Systematic navigation through keratoconus landscape: the crucial role of ocular surface

This comprehensive systematic review addresses how concurrent ocular surface diseases (OSDs) in patients with keratoconus (KC) affect KC's development, progression, diagnostic evaluation, and management, as well as KC's effect on ocular surface disturbance. This review integrates ocular surface findings to bridge the gap between KC pathophysiology and practical clinical management, ultimately offering a structured framework for optimizing KC treatment.

This systematic review represents the effort to integrate existing knowledge on the interplay between OSDs and KC, yielding practical clinical guidance. OSDs are not only recognized contributors to KC onset but are also major factors in treatment failure, making their evaluation critical in KC management.

A systematic search was conducted in Scopus, PubMed, Cochrane, Embase, and Web of Science for studies published up to February 2025. Studies were included regardless of language, provided they met predefined relevance and quality criteria. Exclusion criteria included replies, commentaries, case studies, retracted studies, ex vivo investigations, and studies scoring low on the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) checklist. This systematic review is registered with PROSPERO (ID: CRD42025644883).

Initially, 9572 records were identified; 5337 duplicates were removed, leaving 4235 for screening. After title and abstract review, 576 full texts were assessed, with 372 excluded based on AMSTAR scores or study type, leaving 204 studies. Findings highlight that OSDs significantly affect KC pathogenesis and clinical management. Nonectatic conditions such as dry eye and tear film instability are increasingly included in the differential diagnosis of KC, emphasizing the need for a multidisciplinary approach. OSDs not only contribute to KC progression but also complicate diagnostic interpretations and influence treatment efficacy.

The ocular surface plays a pivotal role not only in KC pathogenesis but also in treatment success or failure. Thus, it is important to address concurrent OSDs in patients with KC because they can complicate its course. This is a vital consideration for treatment strategies. However, more studies on the causal link between KC and OSD are needed to help clinicians diagnose and manage these conditions better.