A Decade Later, Keratoconus Has a New Consensus
Ten years after the first global effort to define the field, the publication of the Global Consensus on Keratoconus and Ectatic Diseases – Edition 2 in the journal, Cornea, marks a clear change in how keratoconus is understood and managed. This is not a cosmetic revision of terminology. It is a broader reappraisal of diagnosis, progression, and treatment in a field that has matured substantially over the past decade. The new document brings together a wider international panel and a broader clinical perspective, including both corneal and refractive surgeons from 12 societies across six continents. Last, but not least, two ELZA team members, Prof. Farhad Hafezi and Dr. Mark Hillen were co-authors.
What emerges is a more modern picture of keratoconus. The disease is no longer framed simply through anterior curvature changes or isolated topographic findings. Instead, the new Consensus reflects the reality of current practice: clinicians increasingly rely on multimodal assessment, integrating tomography, epithelial thickness mapping, and, where available, biomechanical evaluation to characterize disease and risk more precisely. The attached manuscript makes this shift explicit, describing a diagnostic framework that moves beyond surface shape alone and toward a more complete understanding of ectasia susceptibility and manifestation.
For patients, this matters because earlier and more accurate detection changes what is possible. At ELZA, this same logic underpins our work in keratoconus research and our clinical approach to corneal cross-linking. The earlier a cornea at risk can be identified, the greater the opportunity to stabilize it before vision declines further.
The Second Global Consensus: From single parameters to clinical judgment
One of the most important themes in the new Consensus is the move away from overreliance on single indices. In particular, the panel takes a more cautious view of Kmax. Although Kmax remains widely used, the document recognizes its limited repeatability and reproducibility, especially in more advanced disease. In its place, the Consensus favors a broader and more severity-aware interpretation of change over time, incorporating regional curvature, posterior corneal changes, pachymetric progression, and visual function. That is a more demanding approach, but also a more clinically honest one.
The accompanying editorial adopts the same tone. It does not present the new Consensus as doctrine. Instead, it presents it as a carefully constructed statement of what can currently be agreed upon, while acknowledging where evidence remains incomplete. That distinction matters. Consensus is not certainty. It is a disciplined way of defining where the field stands now.
Cross-linking remains central, but treatment is no longer one-size-fits-all
The new (second) Global Consensus reaffirms corneal cross-linking for keratoconus is the cornerstone of disease stabilization. At the same time, it reflects the reality that treatment decisions have become more individualized. Age, corneal thickness, progression pattern, and clinical context all shape management. In younger patients, particularly those at higher risk of rapid progression, the document supports the view that waiting for prolonged observation may not always be appropriate.
That evolution in thinking also creates space for newer approaches aimed not only at stabilizing the cornea, but at improving its regularity. At ELZA, one example is ELZA-PACE customized cross-linking, which reflects the broader trend toward more individualized corneal treatment. The Consensus itself is careful not to overstate what newer strategies can yet claim. But its overall direction is unmistakable: keratoconus management is becoming more personalized, more imaging-driven, and more structurally informed.
Beyond stabilization
The field has also moved beyond the idea that stopping progression is the only meaningful endpoint. The new Consensus places visual rehabilitation within the same overall management framework, bringing contact lenses, corneal reshaping procedures, intrastromal implants, keratoplasty, refractive surgery, and cataract planning into a more coherent whole. That breadth is one of the document’s strengths. Keratoconus is no longer treated as a narrow corneal problem. It is managed across the full arc of a patient’s visual life.
This is also where the document feels most contemporary. It reflects a field that has expanded from identifying disease to stratifying risk, from halting progression to planning visual rehabilitation, and from isolated procedure choices to long-term decision-making.
A broader Second Global Consensus, not a final word
What gives the second Global Consensus particular weight is not only its content, but its scope. According to the manuscript, 128 experts participated in the process, with representation spanning 12 international societies and six continents. That breadth does not eliminate disagreement, but it does strengthen the document as a global clinical reference point rather than a local or subspecialty statement.
Like all Delphi-based work, however, it remains a snapshot in time. The editorial is right to stress that its value lies not in claiming permanence, but in defining what is sufficiently supported to guide practice today. That is what makes the 2026 Consensus important. It does not close the debate on keratoconus. It raises the level at which the debate now takes place.
Citation:
Gomes JAP, Hafezi F, Ambrósio R, et al. Global consensus on keratoconus and ectatic diseases-edition 2. Cornea. Published online May 21, 2026. doi:10.1097/ICO.0000000000004170
