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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*†‡

corneal thinning and alterations in the morphology of the


Purpose: To characterize posterior corneal surface features in tissue that negatively affects the patient’s visual function.
patients with keratoconus and healthy controls and correlate them Keratoconus is by far the most common disease classified
with the severity of the disease according to visual limitation. within this group of pathologies affecting between 4 and 6 of
Methods: Retrospective, comparative, clinical study including 477 1000 in the general population.1 Regarding its etiology,
cases, 374 keratoconic eyes and 103 healthy corneas. Patients were keratoconus is multifactorial in origin with genetic and
classified according to the degree of visual limitation. The corneal environmental factors involved in its pathogenesis.2–4 Inde-
posterior surface including shape indices and keratoconus screening pendent of the mechanism of action involved in the
indices was evaluated using the rotating Scheimpflug camera and development of the disease, one of the hypotheses that could
Placido disc topographer. explain the morphological changes observed in the corneal
stroma is the biomechanical alteration of the tissue that occurs
Results: Dioptric power of the posterior corneal surface increases due to the loss in the spatial arrangement of the collagen
linearly as corrected distance visual acuity deteriorates (r . 0.700; P fibers.5 However, which area of the cornea is the first to be
, 0.001). A significant correlation was also observed between shape affected by those biomechanical changes is still a topic of
indices root mean square per unit of area (RMS/A) (posterior surface debate. There are some investigations that have proposed that
irregularity) and corrected distance visual acuity (r = 20.750; P , the main morphological alterations in keratoconus begin at
0.001). In addition, keratoconus screening indices such as posterior the posterior surface of the cornea, which makes it logical to
corneal aberrations and posterior ectasia vertex (KVb) also showed suggest that an analysis of these changes may lead to a better
significant correlation with the degree of visual limitation (r = categorization and early detection of the disease.6
20.687; P , 0.001 and r = 20.789; P , 0.001, respectively). Most clinical grading systems used in the classification
Receiver operating characteristic curves demonstrate that RMS/A of keratoconus are based on morphological variables without
and KVb showed highest discriminating capabilities between normal taking into consideration factors directly related to the visual
and mild keratoconus cases with an area under the curve of 0.96 and function of the patients, such as visual acuity. In recent years,
0.97, respectively, with a sensitivity and specificity of more than our research group reported the significant impact on therapy
93% for the RMS/A and 89% and 84% for the KVb. of a keratoconus grading classification that is mainly based on
the patient’s visual acuity limitation.7 In 2016, Belin and
Conclusions: Posterior corneal surface characteristics correlate with Duncan8 introduced the ABCD grading system, which also
the degree of visual impairment and can be used for classifying patients includes into their variables the visual acuity and notes the
with keratoconus. RMS/A, KVb, and posterior corneal aberrations are importance of using visual function among the factors in
the most representative variables of visual function deterioration and are grading the disease.
also useful to differentiate normal from mild keratoconus cases. Therefore, the purpose of this study is to analyze and
Key Words: keratoconus, posterior surface, keratoconus classifica- characterize the features of the posterior corneal surface in
tion, corneal ectasia patients with keratoconus and correlate them with the severity
of the disease, taking into account the limitation of the
(Cornea 2019;38:730–736) 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
C orneal ectatic disorders are composed of a group of
degenerative pathologies characterized by progressive
group and patients with mild keratoconus.

Received for publication October 18, 2018; revision received January 11, MATERIALS AND METHODS
2019; accepted January 15, 2019. Published online ahead of print March
14, 2019. Patients
From the *Cornea and Refractive Surgery Department, Vissum, Alicante, This retrospective, comparative, nonrandomized, clini-
Spain; †Keratoconus Unit, Vissum, Alicante, Spain; and ‡Division of cal study evaluated 477 eyes of 335 patients, of which 374
Ophthalmology, Universidad Miguel Hernández, Alicante, Spain. eyes were classified as keratoconus based on Rabinowitz2
The authors have no conflicts of interest to disclose.
Correspondence: Jorge L. Alio, MD, PhD, Calle Cabañal, 1 Edificio, Vissum, topographical pattern. The remaining 103 eyes were consid-
Alicante 03016, Spain (e-mail: jlalio@vissum.com). ered to have a healthy cornea with no topographic alterations
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. and corrected distance visual acuity (CDVA) of 1.00 on

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

a decimal scale. Patients with previous ocular surgery or an CDVA equal or better than 0.60 and worse than 0.90; grade
active ocular disease other than keratoconus were excluded. III, patients with CDVA equal or better than 0.40 and worse
In addition, patients with corneal scars were also excluded than 0.60; grade IV, patients with CDVA equal or better than
from the present investigation. Ethical committee approval 0.20 and worse than 0.40; and grade Plus, patients with
from our institution was obtained for this investigation. In CDVA worse than 0.20.7
addition, informed consent to include clinical information in
scientific studies was obtained from all patients, following the
tenets of the Helsinki declaration. Statistical Analysis
Statistical analyses were performed using the SPSS
statistics software package version 15.0 for Windows (SPSS,
Clinical Examination Protocol Chicago, IL). Normality of all data samples was evaluated by
Patients underwent a complete ophthalmic examination, means of the Kolmogorov–Smirnov test. When parametric
including uncorrected distance visual acuity, CDVA, in analysis was possible, the 1-way analysis of variance with
decimal notation, manifest refraction, slit-lamp biomicro- Bonferroni post-hoc comparison procedure was used for the
scopy, Goldmann tonometry, fundus evaluation, and corneal comparison groups. If variances were not homogeneous
topography (Sirius, CSO, Firenze, Italy). The Sirius combines (checked by the Levene test), the Tamhane post-hoc analysis
the rotating Scheimpflug camera and the Placido disk. The was used. When the parametric analysis was not possible, the
system measures 35,632 points on the anterior corneal surface Kruskal–Wallis test was used to compare the analyzed pa-
and 30,000 points on the posterior surface. Repeated rameters between groups. For post-hoc analysis, the Mann–
measurements have been reported in normal group and Whitney test with Bonferroni’s adjustment was used to avoid
patients with keratoconus.9 the experimental error rate in these cases. For all statistical
The following corneal posterior topographic variables tests, the same level of significance was used (P , 0.05).
were analyzed: mean keratometry in the flattest (K1) and Correlation coefficients (Pearson or Spearman, depending on
steepest (K2) meridians for 3-, 5-, and 7-mm zones of the whether the normality condition could be assumed) were used
cornea. to assess the correlation between corrected visual acuity and
posterior corneal topographic variables. Receiver operating
• Shape indices (4.5 and 8.0 mm corneal diameter)
characteristic (ROC) curves were established to determine
• Flat radius (rf): apical radius of the flattest meridian
what parameters could be used to classify diseased corneas,
of the aspherotoric surface, which best approximates
calculating: area under the curve, optimal cut-offs, sensitivity,
the measured surface.
and specificity.
• Steepest radius (rs): apical radius of the steepest
meridian of the aspherotoric surface, which best
approximates the measured surface. RESULTS
• Asphericity (Q): conic section that can be described This study comprises a total of 477 eyes of 335 patients,
by the apical radius of curvature in the 374 eyes diagnosed with keratoconus and 103 healthy eyes;
meridian studied. 186 males and 149 females with ages ranging from 8 to 67
• Root mean square per unit of area (RMS/A): years (mean age of 38.6 6 12.4 years). According to the
deviation of the surface being examined from the degree of visual limitation, the patients diagnosed with
aspherotoric best-fit surface, characterized by rf, rs, keratoconus were classified as follows: 184 cases as grade
Q, and toricity axis. Higher RMS values represent I, 78 grade II, 52 grade III, 37 grade IV, and 23 as
greater corneal irregularity. keratoconus grade Plus. Table 1 summarizes the main visual
• Keratoconus screening indices (8.0 mm corneal diameter): and refractive outcomes.
• Posterior asymmetry index (Sib): difference of the
mean posterior tangential curvature of 2 circle areas,
center of the vertex, from the superior and Posterior Keratometry, Shape, and
inferior hemisphere. Keratoconus Indices
• Posterior corneal aberrations (BCVb): analysis of
Dioptric power of the posterior corneal surface was
the posterior Zernike components for the coma,
evaluated at 3, 5, and 7 mm. Table 2 summarizes the results
trefoil, and spherical aberrations in the inferotempo-
of posterior keratometry for the healthy group and each one of
ral area of the cornea.
the keratoconus groups.
• posterior vertex of the ectatic area (KVb): posterior
There was a clear correlation between the magnitude of
vertex of the ectatic area.
the dioptric power of posterior keratometry and the severity of
• ThkMin: minimum thickness.
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).
Keratoconus Grading System For the RMS/A, a correlation between the degree of
The severity of keratoconus was classified according to posterior corneal irregularity and visual impairment of the
the degree of visual limitation as follows: grade I, patients patient was observed. Table 2 summarizes the mean values of
with spectacle CDVA of 0.90 or better; grade II, patients with the RMS/A for a 4.5- and 8-mm corneal area. It was found that

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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 Fig. 3). Finally, corneal thickness (ThkMin) decreased as the
according to the degree of visual limitation; thus, the worse the severity of keratoconus worsened (deteriorated) according to
visual acuity, the greater the posterior corneal irregularity the degree of visual limitation (Table 2 and Fig. 3).
(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). Spearman Correlations and ROC Curves
In relation to the keratoconus screening indices, it was A statistical correlation was performed between the
found that with the exception of grade IV and grade Plus, all CDVA and each one of the variables under analyses to assess
patients showed an increase in the posterior corneal surface the level of relationship among them and also to determine
inferosuperior difference as represented by the Sib index which of those variables played a significant role in visual
(Table 2 and Fig. 3). In addition, BCVb and KVb also acuity degradation. We observed a strong and statistically
increased as the visual function deteriorated (Table 2 and 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 Cornea  Volume 38, Number 6, June 2019

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 nus could be evaluated by the progression in the steepening
inferosuperior value and posterior corneal height were the of the posterior surface, which agreed with the results of the
best variables in differentiating a normal group from patients current investigation, as we observed a strong correlation
with keratoconus and also useful in grading the severity of between increased posterior curvature and keratoconus
the disease, which is in concordance with the findings of the severity.
current work.16 In addition, other authors who have Regarding shape and keratoconus indices, it was found
analyzed the posterior corneal surface in patients with that most of the variables showed a linear correlation with the
keratoconus using anterior segment optical coherence degree of corrected vision of the patients. Thus, the poorer
tomography technology have also found the significant the value of the shape and keratoconus indices, the worse the
importance of posterior surface in differentiating normal patient’s visual acuity. Statistical correlations also showed
from mild keratoconus cases, and evaluating the progression the relationship among the aforementioned variables and the
of the disease.17 Fujimoto et al using the CASIA SS-1000 degree of visual limitation. This way, posterior corneal
found that the rate of progression in patients with keratoco- 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
FIGURE 4. ROC curves of corneal posterior variables with the cases. Other studies that have compared normal groups and
highest discrimination capabilities between normal group and keratoconic patients have also found that variables in the
patients with mild (grade I) keratoconus. posterior corneal surface are useful to differentiate normal

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

from pathological subjects. Kamiya et al15 found that pathology, and evaluated the features of the posterior corneal
posterior elevation showed a sensitivity of 92.1% and surface according to visual function severity. Nevertheless,
a specificity of 95.2% when comparing normal and kerato- the retrospective nature of the investigation and the fact that
conic eyes. de Sanctis et al13 found significant AUROC of the we describe the posterior corneal surface variables related to
posterior elevation for keratoconus and subclinical keratoco- patients with keratoconus using just one diagnostic device are
nus with a level of 0.99 and 0.93, respectively. Miháltz et al18 the main limitations of this investigation. Another drawback
found an AUROC of 0.97 for posterior corneal elevation is that we did not include a group of patients with subclinical
when comparing a normal group and patients with keratoco- or forme fruste keratoconus in our cohort. A fact that will be
nus. Moreover, Du et al found an AUROC of 0.88 with of a major relevance and was not assessed in the current work
a specificity of 93.8% for the posterior elevation value is the analysis of those cases with posterior surface changes
comparing patients with subclinical keratoconus and a normal and normal anterior corneal surface to evaluate the screening
group.16 Using the Sirius, Safarzadeh and Nasiri14 reported capabilities of the posterior corneal surface in the subclinical
that variables with the highest discriminating accuracy forms of the disease. It has to be pointed out that keratoconus
between normal cases and keratoconus suspects were poste- is a multifactorial disease with a wide range of clinical
rior corneal elevation and BCVb. All the aforementioned presentations and a diagnostic challenge in its early form;
studies are in agreement with our findings and note the thus, the variables presented in this study cannot be taken
importance of the posterior corneal surface in differentiating independently, but rather as an adjuvant tool in the diagnosis
normal from keratoconic patients. and management of patients with keratoconus.
To the best of our knowledge, this is the first study that Finally, the findings of the current study may also help
attempts to correlate posterior corneal surface alterations and in better understanding the pathogenesis of the disease to
the degree of visual impairment in patients with keratoconus. provide the best treatment alternative in patients with
A proper grading system and description of the main keratoconus. In a recent study conducted by Seiler et al, it
characteristics of the disease, according to its severity, is was suggested that due to epithelial modeling that can affect
necessary to provide the best therapeutic approach. In a pre- both corneal curvature and pachymetry, the most sensible
vious study performed by our research group, we demon- area to assess the weakest point of the cornea will be better
strated the importance of grading keratoconus according to evaluated in the posterior surface, and thus the best area to be
the visual function as success and failure rates of intracorneal treated with customized corneal collagen cross-linking.21
ring segment implantation was closely related to the degree of Future technologies such as Brillouin microscopy for
patient’s visual impairment.7,8 In addition, variables related to in vivo biomechanical corneal analysis may confirm the
corneal posterior surface irregularity and posterior surface argument of this hypothesis.22
corneal aberrations not only play a major role in the visual In conclusion, the posterior corneal surface character-
function of the patient but also show high discrimination istics are closely related to the degree of visual limitation and
capabilities between normal group and patients with mild can be correctly used for classifying the severity of the
keratoconus, which can help in early diagnosis of the disease disease. Posterior surface irregularity, height of the posterior
and refine screening of patients for corneal refractive surgery. corneal vertex, and BCVb are the most representative
An additional topic related to this investigation that is variables of visual function deterioration and are also useful
worth mentioning is the ability of posterior corneal surface to differentiate normal from mild keratoconus cases.
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 ACKNOWLEDGMENTS
this line, those posterior surface variables that performed well This study has been carried out in the framework of the
in grading the severity of the disease may also be useful to Red Temática de Investigación Cooperativa en Salud
assess the progression pattern of keratoconus. In fact, a recent (RETICS), reference number RD16/0008/0012, financed by
study by Tellouck et al19 evaluated more than 40 variables to the Instituto Carlos III: General Subdirection of Networks
determine a progression pattern of keratoconus, the authors and Cooperative Investigation Centers (R&D&I National
found that just 2 of these variables, posterior maximum Plan 2008–2011) and the European Regional Development
keratometry and vertical corneal coma, were the best Fund (Fondo Europeo de Desarrollo Regional FEDER).
indicators of keratoconus progression and the onset of the
changes related to those variables occurred earlier when
compared with the anterior corneal analysis. Similarly, REFERENCES
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Vega-Estrada and Alio Cornea  Volume 38, Number 6, June 2019

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