CLINICAL SCIENCE
Keratoconus Corneal Posterior Surface Characterization
According to the Degree of Visual Limitation
Alfredo Vega-Estrada, MD, PhD,*†‡ and Jorge L. Alio, MD, PhD*†‡
Purpose: To characterize posterior corneal surface features in
patients with keratoconus and healthy controls and correlate them
with the severity of the disease according to visual limitation.
Methods: Retrospective, comparative, clinical study including 477
cases, 374 keratoconic eyes and 103 healthy corneas. Patients were
classified according to the degree of visual limitation. The corneal
posterior surface including shape indices and keratoconus screening
indices was evaluated using the rotating Scheimpflug camera and
Placido disc topographer.
Results: Dioptric power of the posterior corneal surface increases
linearly as corrected distance visual acuity deteriorates (r . 0.700; P
, 0.001). A significant correlation was also observed between shape
indices root mean square per unit of area (RMS/A) (posterior surface
irregularity) and corrected distance visual acuity (r = 20.750; P ,
0.001). In addition, keratoconus screening indices such as posterior
corneal aberrations and posterior ectasia vertex (KVb) also showed
significant correlation with the degree of visual limitation (r =
20.687; P , 0.001 and r = 20.789; P , 0.001, respectively).
Receiver operating characteristic curves demonstrate that RMS/A
and KVb showed highest discriminating capabilities between normal
and mild keratoconus cases with an area under the curve of 0.96 and
0.97, respectively, with a sensitivity and specificity of more than
93% for the RMS/A and 89% and 84% for the KVb.
Conclusions: Posterior corneal surface characteristics correlate with
the degree of visual impairment and can be used for classifying patients
with keratoconus. RMS/A, KVb, and posterior corneal aberrations are
the most representative variables of visual function deterioration and are
also useful to differentiate normal from mild keratoconus cases.
Key Words: keratoconus, posterior surface, keratoconus classifica-
tion, corneal ectasia
(Cornea 2019;38:730–736)
C orneal ectatic disorders are composed of a group of
degenerative pathologies characterized by progressive
Received for publication October 18, 2018; revision received January 11,
2019; accepted January 15, 2019. Published online ahead of print March
14, 2019.
From the *Cornea and Refractive Surgery Department, Vissum, Alicante,
Spain; †Keratoconus Unit, Vissum, Alicante, Spain; and ‡Division of
Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
The authors have no conflicts of interest to disclose.
Correspondence: Jorge L. Alio, MD, PhD, Calle Cabañal, 1 Edificio, Vissum,
Alicante 03016, Spain (e-mail: jlalio@vissum.com).
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corneal thinning and alterations in the morphology of the
tissue that negatively affects the patient’s visual function.
Keratoconus is by far the most common disease classified
within this group of pathologies affecting between 4 and 6 of
1000 in the general population.1 Regarding its etiology,
keratoconus is multifactorial in origin with genetic and
environmental factors involved in its pathogenesis.2–4 Inde-
pendent of the mechanism of action involved in the
development of the disease, one of the hypotheses that could
explain the morphological changes observed in the corneal
stroma is the biomechanical alteration of the tissue that occurs
due to the loss in the spatial arrangement of the collagen
fibers.5 However, which area of the cornea is the first to be
affected by those biomechanical changes is still a topic of
debate. There are some investigations that have proposed that
the main morphological alterations in keratoconus begin at
the posterior surface of the cornea, which makes it logical to
suggest that an analysis of these changes may lead to a better
categorization and early detection of the disease.6
Most clinical grading systems used in the classification
of keratoconus are based on morphological variables without
taking into consideration factors directly related to the visual
function of the patients, such as visual acuity. In recent years,
our research group reported the significant impact on therapy
of a keratoconus grading classification that is mainly based on
the patient’s visual acuity limitation.7 In 2016, Belin and
Duncan8 introduced the ABCD grading system, which also
includes into their variables the visual acuity and notes the
importance of using visual function among the factors in
grading the disease.
Therefore, the purpose of this study is to analyze and
characterize the features of the posterior corneal surface in
patients with keratoconus and correlate them with the severity
of the disease, taking into account the limitation of the
patient’s visual function. We also aim to compare those
features with those found in a normal population to assess
whether the posterior corneal surface is different in a normal
group and patients with mild keratoconus.
MATERIALS AND METHODS
Patients
This retrospective, comparative, nonrandomized, clini-
cal study evaluated 477 eyes of 335 patients, of which 374
eyes were classified as keratoconus based on Rabinowitz2
topographical pattern. The remaining 103 eyes were consid-
ered to have a healthy cornea with no topographic alterations
and corrected distance visual acuity (CDVA) of 1.00 on
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Cornea  Volume 38, Number 6, June 2019
a decimal scale. Patients with previous ocular surgery or an
active ocular disease other than keratoconus were excluded.
In addition, patients with corneal scars were also excluded
from the present investigation. Ethical committee approval
from our institution was obtained for this investigation. In
addition, informed consent to include clinical information in
scientific studies was obtained from all patients, following the
tenets of the Helsinki declaration.
Clinical Examination Protocol
Patients underwent a complete ophthalmic examination,
including uncorrected distance visual acuity, CDVA, in
decimal notation, manifest refraction, slit-lamp biomicro-
scopy, Goldmann tonometry, fundus evaluation, and corneal
topography (Sirius, CSO, Firenze, Italy). The Sirius combines
the rotating Scheimpflug camera and the Placido disk. The
system measures 35,632 points on the anterior corneal surface
and 30,000 points on the posterior surface. Repeated
measurements have been reported in normal group and
patients with keratoconus.9
The following corneal posterior topographic variables
were analyzed: mean keratometry in the flattest (K1) and
steepest (K2) meridians for 3-, 5-, and 7-mm zones of the
cornea.
• Shape indices (4.5 and 8.0 mm corneal diameter)
• Flat radius (rf): apical radius of the flattest meridian
of the aspherotoric surface, which best approximates
the measured surface.
• Steepest radius (rs): apical radius of the steepest
meridian of the aspherotoric surface, which best
approximates the measured surface.
• Asphericity (Q): conic section that can be described
by the apical radius of curvature in the
meridian studied.
• Root mean square per unit of area (RMS/A):
deviation of the surface being examined from the
aspherotoric best-fit surface, characterized by rf, rs,
Q, and toricity axis. Higher RMS values represent
greater corneal irregularity.
• Keratoconus screening indices (8.0 mm corneal diameter):
• Posterior asymmetry index (Sib): difference of the
mean posterior tangential curvature of 2 circle areas,
center of the vertex, from the superior and
inferior hemisphere.
• Posterior corneal aberrations (BCVb): analysis of
the posterior Zernike components for the coma,
trefoil, and spherical aberrations in the inferotempo-
ral area of the cornea.
• posterior vertex of the ectatic area (KVb): posterior
vertex of the ectatic area.
• ThkMin: minimum thickness.
Keratoconus Grading System
The severity of keratoconus was classified according to
the degree of visual limitation as follows: grade I, patients
with spectacle CDVA of 0.90 or better; grade II, patients with
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Keratoconus Corneal Posterior Surface Characterization
CDVA equal or better than 0.60 and worse than 0.90; grade
III, patients with CDVA equal or better than 0.40 and worse
than 0.60; grade IV, patients with CDVA equal or better than
0.20 and worse than 0.40; and grade Plus, patients with
CDVA worse than 0.20.7
Statistical Analysis
Statistical analyses were performed using the SPSS
statistics software package version 15.0 for Windows (SPSS,
Chicago, IL). Normality of all data samples was evaluated by
means of the Kolmogorov–Smirnov test. When parametric
analysis was possible, the 1-way analysis of variance with
Bonferroni post-hoc comparison procedure was used for the
comparison groups. If variances were not homogeneous
(checked by the Levene test), the Tamhane post-hoc analysis
was used. When the parametric analysis was not possible, the
Kruskal–Wallis test was used to compare the analyzed pa-
rameters between groups. For post-hoc analysis, the Mann–
Whitney test with Bonferroni’s adjustment was used to avoid
the experimental error rate in these cases. For all statistical
tests, the same level of significance was used (P , 0.05).
Correlation coefficients (Pearson or Spearman, depending on
whether the normality condition could be assumed) were used
to assess the correlation between corrected visual acuity and
posterior corneal topographic variables. Receiver operating
characteristic (ROC) curves were established to determine
what parameters could be used to classify diseased corneas,
calculating: area under the curve, optimal cut-offs, sensitivity,
and specificity.
RESULTS
This study comprises a total of 477 eyes of 335 patients,
374 eyes diagnosed with keratoconus and 103 healthy eyes;
186 males and 149 females with ages ranging from 8 to 67
years (mean age of 38.6 6 12.4 years). According to the
degree of visual limitation, the patients diagnosed with
keratoconus were classified as follows: 184 cases as grade
I, 78 grade II, 52 grade III, 37 grade IV, and 23 as
keratoconus grade Plus. Table 1 summarizes the main visual
and refractive outcomes.
Posterior Keratometry, Shape, and
Keratoconus Indices
Dioptric power of the posterior corneal surface was
evaluated at 3, 5, and 7 mm. Table 2 summarizes the results
of posterior keratometry for the healthy group and each one of
the keratoconus groups.
There was a clear correlation between the magnitude of
the dioptric power of posterior keratometry and the severity of
keratoconus. Specifically, there was an increase in the dioptric
power of all keratometric readings together with a steeper slope
in the mean that the visual acuity became worse (Fig. 1).
For the RMS/A, a correlation between the degree of
posterior corneal irregularity and visual impairment of the
patient was observed. Table 2 summarizes the mean values of
the RMS/A for a 4.5- and 8-mm corneal area. It was found that
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Vega-Estrada and Alio Cornea  Volume 38, Number 6, June 2019

TABLE 1. Visual and Refractive Outcomes of Normal Group and Patients with Keratoconus Classified According to the Visual
Limitation
UDVA CDVA Sphere (D) Cylinder (D) Spherical Equivalent (D)
Min Max Mean STD Min Max Mean STD Min Max Mean STD Min Max Mean STD Min Max Mean STD
Normal 0.01 1.20 0.53 0.41 1.00 1.20 1.10 0.10 212.00 8.50 20.33 3.27 25.75 0.00 20.65 0.80 212.00 8.13 20.65 3.20
Group
Grade I 0.00 1.50 0.52 0.35 0.90 1.50 1.01 0.09 214.50 3.50 21.19 2.67 25.50 0.00 21.74 1.28 216.63 1.50 22.05 2.73
Grade II 0.01 0.86 0.25 0.23 0.60 0.88 0.74 0.08 212.00 5.00 22.31 3.45 29.00 0.00 23.40 1.98 214.00 3.63 23.99 3.58
Grade III 0.00 0.46 0.14 0.13 0.40 0.56 0.45 0.05 220.00 4.50 24.48 4.78 210.00 0.00 23.27 2.17 221.00 1.75 26.12 4.85
Grade IV 0.00 0.26 0.08 0.08 0.20 0.38 0.27 0.05 218.00 5.00 23.43 5.45 217.00 0.00 24.64 3.59 220.00 4.00 25.75 5.65
Grade 0.01 0.15 0.03 0.04 0.01 0.17 0.09 0.06 220.00 3.00 27.26 8.26 28.50 0.00 22.63 2.68 221.75 0.00 28.58 8.01
Plus
D, diopter; Max, maximum; Min, minimum; STD, standard deviation; UDVA, uncorrected distance visual acuity.

corneal irregularity, as represented by the RMS/A, increases
according to the degree of visual limitation; thus, the worse the
visual acuity, the greater the posterior corneal irregularity
(Fig. 2). It was also observed that the mean values of other
shape indices, rs, rf, and asphericity at 4.5 and 8 mm, were also
worse when the corrected visual acuity deteriorated (Table 2).
In relation to the keratoconus screening indices, it was
found that with the exception of grade IV and grade Plus, all
patients showed an increase in the posterior corneal surface
inferosuperior difference as represented by the Sib index
(Table 2 and Fig. 3). In addition, BCVb and KVb also
increased as the visual function deteriorated (Table 2 and
Fig. 3). Finally, corneal thickness (ThkMin) decreased as the
severity of keratoconus worsened (deteriorated) according to
the degree of visual limitation (Table 2 and Fig. 3).
Spearman Correlations and ROC Curves
A statistical correlation was performed between the
CDVA and each one of the variables under analyses to assess
the level of relationship among them and also to determine
which of those variables played a significant role in visual
acuity degradation. We observed a strong and statistically
significant direct correlation with the posterior keratometries

TABLE 2. Posterior Keratometries, Shape, and Screening Indices of Normal Group and Patients with Keratoconus Classified
According to the Degree of Visual Limitation
Normal Group Grade I Grade II Grade III Grade IV Grade Plus
Mean STD Mean STD Mean STD Mean STD Mean STD Mean STD P*
Posterior keratometry
K2 3 mm (D) 26.37 0.26 26.79 0.61 27.56 1.03 28.92 1.89 29.77 3.21 211.69 4.46 ,0.001
K2 5 mm (D) 26.34 0.24 26.63 0.46 27.18 0.73 28.17 1.28 28.63 1.67 29.91 2.10 ,0.001
K2 7 mm (D) 26.28 0.23 26.51 0.36 26.89 0.53 27.66 1.04 27.96 1.43 28.80 1.39 ,0.001
KM 3 mm (D) 26.15 0.22 26.32 0.50 26.72 0.97 27.57 2.20 27.93 1.90 28.54 2.58 ,0.001
KM 5 mm (D) 26.14 0.21 26.30 0.40 26.60 0.76 27.48 0.91 27.48 1.44 28.26 1.89 ,0.001
KM 7 mm (D) 26.12 0.20 26.25 0.33 26.46 0.58 27.16 0.74 27.05 1.43 27.73 1.34 ,0.001
Posterior shape indices
rf 4.5 mm (D) 25.99 0.22 26.13 0.52 26.62 1.11 27.93 1.51 28.23 2.32 29.41 2.73 0.350
rs 4.5 mm (D) 26.34 0.26 26.68 0.68 27.47 1.23 28.80 1.72 29.52 2.73 210.31 3.32 ,0.001
Q 4.5 mm 20.14 0.26 0.05 1.13 20.53 1.39 21.34 1.52 20.71 2.35 20.52 2.28 .0.100
RMSA 4.5 mm (mm/mm2) 0.09 0.03 0.36 0.30 0.57 0.34 0.90 0.92 1.48 1.77 1.16 0.48 ,0.001
rf 8 mm (D) 26.06 0.23 26.26 0.44 26.70 0.95 27.81 1.25 28.38 1.95 210.01 2.72 0.030
rs 8 mm (D) 26.33 0.25 26.65 0.54 27.29 1.05 28.46 1.45 29.26 2.27 211.15 3.40 ,0.001
Q 8 mm 20.29 0.18 20.37 0.44 20.72 0.73 21.21 0.75 21.43 0.92 21.51 0.92 .0.100
RMSA 8 mm (mm/mm2) 0.14 0.05 0.34 0.54 0.57 0.87 0.80 1.20 1.40 1.95 1.25 1.03 ,0.001
Screening indices
Sib (D) 0.03 0.12 0.91 0.97 1.39 1.18 1.89 1.25 2.53 2.06 1.97 1.64 ,0.001
BCVb (D) 0.19 0.24 1.66 1.73 2.94 2.32 4.48 2.94 6.14 4.47 6.83 3.72 ,0.001
KVb (mm) 10.65 3.08 38.59 30.35 66.54 37.20 95.30 51.60 134.73 69.16 164.77 72.88 ,0.001
ThkMin (mm) Ø = 8 mm 541.58 32.22 486.93 39.06 459.14 55.70 424.74 56.49 396.78 75.94 360.91 53.97 ,0.001
*P value comparing normal group from patients with grade I keratoconus.
D, diopter; K, keratometry; K2, steepest keratometry; KM, mean keratometry; STD, standard deviation.

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Cornea  Volume 38, Number 6, June 2019 Keratoconus Corneal Posterior Surface Characterization

classified as grade I (mild keratoconus). It was found that

from the different indices those that showed an area under the
curve (AUROC) above 0.89 were as follows: RMS/A 4.5 and
8 mm, Sib, KVb, and BCVb (Fig. 4); among these, RMS/A
4.5 and KVb showed the highest AUROC, 0.96 and 0.97,
with a level of sensitivity and specificity of more than 93%
for the RMS/A 4.5 and a cut-off value of 0.12 mm/mm2, and
a sensitivity and specificity of 89% and 84%, respectively, for
the KVb with a cut-off value of 13.5 mm.

DISCUSSION
This study aims to describe the main posterior surface
characteristics of patients with keratoconus classified accord-
ing to the degree of visual limitation; in addition, it was
determined that it is the main posterior corneal features
that differentiate a normal group from patients with
mild keratoconus.
Over the last few years, the increasing knowledge of
corneal ectatic disorders together with advances in technol-
ogy of diagnostic tools brought us to closely look for
alterations in the posterior corneal surface. Several efforts
have been made by different groups of investigators to
identify subtle changes on the posterior surface related to
ectatic disorders, thus avoiding complications in corneal
refractive surgery.6,10–12
In this study, an increasing posterior corneal dioptric
power related to the degree of severity in the visual function
was observed; thus, the steeper the posterior corneal surface,
the worse the visual acuity of the patient. These findings
were confirmed with the correlation observed between the
keratometric variables and the CDVA. Similar published
results in the literature have reported higher levels of
posterior elevation in patients with keratoconus and kerato-
conus suspects.10,13,14 Safarzadeh and Nasiri,14 using the
Sirius, found that posterior corneal elevation showed the
highest discrimination capabilities between normal and
suspect keratoconus eyes. Kamiya et al15 evaluated changes
in the posterior corneal surface according to the severity of
keratoconus and also found that posterior corneal height
increased linearly with the severity of the disease. Du et al
FIGURE 1. Dioptric power of the posterior corneal surface in
normal group and patients with keratoconus classified ac-
cording to the degree of visual limitation.

at 3, 5, and 7 mm (r . 0.700; P , 0.001), and some of the

posterior shape indices: RMS/A 4.5 mm and 8 mm (r .
20.750; P , 0.001), rs at 4.5 and 8 mm (r . 0.650; P ,
0.001), and rf at 4.5 and 8 mm (r . 0.575; P , 0.001). An
indirect and significant correlation was observed with kera-
toconus screening indices evaluated over a posterior surface
area of 8 mm: BCVb (r = 20.687; P , 0.001), KVb (r =
20.789; P , 0.001), and Sib (r = 20.580; P , 0.001). In
addition, a direct correlation was observed between corneal
thickness reduction and visual acuity of the patients (r = 0.722 FIGURE 2. RMS/A at 4.5 and 8 mm of corneal diameter
P , 0.001). showing how the posterior corneal surface irregularity in-
ROC curves were established, aiming to determine the creases according to the degree of visual impairment in pa-
discrimination capabilities between normal group and those tients with keratoconus.

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Vega-Estrada and Alio
FIGURE 3. Keratoconus screening
indices (Sib, BCVb, KVb, and
ThkMin) showing the correlation
with the reduction in the visual
acuity of the patients with
keratoconus.
observed that some variables such as posterior surface
inferosuperior value and posterior corneal height were the
best variables in differentiating a normal group from patients
with keratoconus and also useful in grading the severity of
the disease, which is in concordance with the findings of the
current work.16 In addition, other authors who have
analyzed the posterior corneal surface in patients with
keratoconus using anterior segment optical coherence
tomography technology have also found the significant
importance of posterior surface in differentiating normal
from mild keratoconus cases, and evaluating the progression
of the disease.17 Fujimoto et al using the CASIA SS-1000
found that the rate of progression in patients with keratoco-
FIGURE 4. ROC curves of corneal posterior variables with the
highest discrimination capabilities between normal group and
patients with mild (grade I) keratoconus.
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Cornea  Volume 38, Number 6, June 2019
nus could be evaluated by the progression in the steepening
of the posterior surface, which agreed with the results of the
current investigation, as we observed a strong correlation
between increased posterior curvature and keratoconus
severity.
Regarding shape and keratoconus indices, it was found
that most of the variables showed a linear correlation with the
degree of corrected vision of the patients. Thus, the poorer
the value of the shape and keratoconus indices, the worse the
patient’s visual acuity. Statistical correlations also showed
the relationship among the aforementioned variables and the
degree of visual limitation. This way, posterior corneal
variables perform with a high degree of accuracy when
classifying the severity of keratoconus according to the visual
limitation. Variables such as RMS/A, KVb, and BCVb
showed the highest level of correlation with the degree of
visual impairment. This means that posterior corneal surface
irregularity, as represented by the RMS/A, posterior corneal
elevation (height of posterior vertex), as represented by the
KVb, and posterior corneal aberrations, as represented by the
BCVb, are the most representative alterations when defining
the severity of keratoconus. These findings suggest that
corneal posterior surface irregularity and corneal aberrations
play a major role in the visual function of the patient, thus,
making them excellent indices in grading the severity of
the disease.
A comparison of the posterior shape and keratoconus
variables was also performed between a normal group and
patients with mild keratoconus, grade I. We observed that
those variables that showed the highest AUROC were the
RMS/A and the KVb with a level of 0.96 and 0.97,
respectively. Similarly, posterior corneal irregularity and
posterior corneal vertex elevation were the most representa-
tive variables when comparing normal and mild keratoconus
cases. Other studies that have compared normal groups and
keratoconic patients have also found that variables in the
posterior corneal surface are useful to differentiate normal
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Cornea  Volume 38, Number 6, June 2019
from pathological subjects. Kamiya et al15 found that
posterior elevation showed a sensitivity of 92.1% and
a specificity of 95.2% when comparing normal and kerato-
conic eyes. de Sanctis et al13 found significant AUROC of the
posterior elevation for keratoconus and subclinical keratoco-
nus with a level of 0.99 and 0.93, respectively. Miháltz et al18
found an AUROC of 0.97 for posterior corneal elevation
when comparing a normal group and patients with keratoco-
nus. Moreover, Du et al found an AUROC of 0.88 with
a specificity of 93.8% for the posterior elevation value
comparing patients with subclinical keratoconus and a normal
group.16 Using the Sirius, Safarzadeh and Nasiri14 reported
that variables with the highest discriminating accuracy
between normal cases and keratoconus suspects were poste-
rior corneal elevation and BCVb. All the aforementioned
studies are in agreement with our findings and note the
importance of the posterior corneal surface in differentiating
normal from keratoconic patients.
To the best of our knowledge, this is the first study that
attempts to correlate posterior corneal surface alterations and
the degree of visual impairment in patients with keratoconus.
A proper grading system and description of the main
characteristics of the disease, according to its severity, is
necessary to provide the best therapeutic approach. In a pre-
vious study performed by our research group, we demon-
strated the importance of grading keratoconus according to
the visual function as success and failure rates of intracorneal
ring segment implantation was closely related to the degree of
patient’s visual impairment.7,8 In addition, variables related to
corneal posterior surface irregularity and posterior surface
corneal aberrations not only play a major role in the visual
function of the patient but also show high discrimination
capabilities between normal group and patients with mild
keratoconus, which can help in early diagnosis of the disease
and refine screening of patients for corneal refractive surgery.
An additional topic related to this investigation that is
worth mentioning is the ability of posterior corneal surface
variables to assess keratoconus progression. Even when the
progression of the disease should be evaluated in time, in this
study we analyzed different degrees of keratoconus severity
that may indirectly represent the evolution of the disease. In
this line, those posterior surface variables that performed well
in grading the severity of the disease may also be useful to
assess the progression pattern of keratoconus. In fact, a recent
study by Tellouck et al19 evaluated more than 40 variables to
determine a progression pattern of keratoconus, the authors
found that just 2 of these variables, posterior maximum
keratometry and vertical corneal coma, were the best
indicators of keratoconus progression and the onset of the
changes related to those variables occurred earlier when
compared with the anterior corneal analysis. Similarly,
Fujimoto et al20 also found that corneal posterior steepening
can be used for measuring the rate of progression in
keratoconus cases. Thus, it seems that posterior corneal
variables may also be useful to determine keratoconus
progression. However, this should be better confirmed with
long-term longitudinal studies.
This study enrolled a large number of keratoconic
patients, including a control group of subjects without any
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Keratoconus Corneal Posterior Surface Characterization
pathology, and evaluated the features of the posterior corneal
surface according to visual function severity. Nevertheless,
the retrospective nature of the investigation and the fact that
we describe the posterior corneal surface variables related to
patients with keratoconus using just one diagnostic device are
the main limitations of this investigation. Another drawback
is that we did not include a group of patients with subclinical
or forme fruste keratoconus in our cohort. A fact that will be
of a major relevance and was not assessed in the current work
is the analysis of those cases with posterior surface changes
and normal anterior corneal surface to evaluate the screening
capabilities of the posterior corneal surface in the subclinical
forms of the disease. It has to be pointed out that keratoconus
is a multifactorial disease with a wide range of clinical
presentations and a diagnostic challenge in its early form;
thus, the variables presented in this study cannot be taken
independently, but rather as an adjuvant tool in the diagnosis
and management of patients with keratoconus.
Finally, the findings of the current study may also help
in better understanding the pathogenesis of the disease to
provide the best treatment alternative in patients with
keratoconus. In a recent study conducted by Seiler et al, it
was suggested that due to epithelial modeling that can affect
both corneal curvature and pachymetry, the most sensible
area to assess the weakest point of the cornea will be better
evaluated in the posterior surface, and thus the best area to be
treated with customized corneal collagen cross-linking.21
Future technologies such as Brillouin microscopy for
in vivo biomechanical corneal analysis may confirm the
argument of this hypothesis.22
In conclusion, the posterior corneal surface character-
istics are closely related to the degree of visual limitation and
can be correctly used for classifying the severity of the
disease. Posterior surface irregularity, height of the posterior
corneal vertex, and BCVb are the most representative
variables of visual function deterioration and are also useful
to differentiate normal from mild keratoconus cases.
ACKNOWLEDGMENTS
This study has been carried out in the framework of the
Red Temática de Investigación Cooperativa en Salud
(RETICS), reference number RD16/0008/0012, financed by
the Instituto Carlos III: General Subdirection of Networks
and Cooperative Investigation Centers (R&D&I National
Plan 2008–2011) and the European Regional Development
Fund (Fondo Europeo de Desarrollo Regional FEDER).
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