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S H O RT R E P O RT

Trends in Corneal Topography and Tomography

Imaging for Keratoconus Management
Alan W Kong 1 , Tessnim R Ahmad 2 , Marcus L Turner 1 , Jackson Barnett 1 , Gurbani Kaur 1
,
Neel D Pasricha 2,3 , Maanasa Indaram 2
1
School of Medicine, University of California San Francisco, San Francisco, CA, USA; 2Department of Ophthalmology, University of California San
Francisco, San Francisco, CA, USA; 3Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA

Correspondence: Maanasa Indaram, Department of Ophthalmology, University of California San Francisco, 490 Illinois Street, San Francisco, CA,
94158, USA, Email [email protected]

Purpose: To describe trends in the use of corneal topography and tomography for the management of keratoconus patients at a single
academic institution and to identify how these trends may be associated with different procedural interventions.
Patients and Methods: In this retrospective cohort study, keratoconus patients treated from 2012 to 2019 were identified. The
electronic health record was reviewed for the presence of corneal topography or tomography imaging completed within seven days of
the first visit and the highest level of intervention at the first and most recent visit. Patients were grouped as pediatric (<18 years) or
adult (≥18 years). Chi-square tests and linear regressions were used to evaluate trends and to determine which factors were predictive
for receiving corneal collagen cross-linking (CXL) versus other surgical interventions (intrastromal corneal ring segments, lamellar
keratoplasty, or penetrating keratoplasty) by the most recent visit.
Results: A total of 873 keratoconus patients met inclusion criteria. The use of corneal topography at the first visit remained relatively
consistent from 2012 to 2019, while corneal tomography usage at the first visit increased from 3.9% in 2015, when corneal
tomography was introduced, to 52.8% in 2019. Each year was associated with an 11.2% ± 1.9% increase in the use of corneal
tomography at the first visit in pediatric patients and 6.7% ± 0.5% in adult patients. Use of corneal tomography at the first visit was
a significant predictor for receiving CXL procedures (P < 0.001) and a negative predictor for requiring other surgical interventions (P =
0.032) when controlling for the year of the first visit.
Conclusion: Obtaining corneal tomography at the first visit has become the standard of care in keratoconus, especially for pediatric
patients. Moreover, the increase in corneal tomography imaging has coincided with an increase in CXL procedures and decrease in
other surgical interventions.
Keywords: keratoconus, topography, tomography, corneal collagen cross-linking, keratoplasty

Introduction
Keratoconus is a bilateral, progressive corneal ectasia which can result in irregular astigmatism and vision loss.1,2 The
prevalence of keratoconus has been estimated to be between 0.17 per 1000 in the United States Medicare population to
1.38 per 1000 in the total global population,3,4 although additional epidemiological studies have demonstrated that the
prevalence may be even greater than these estimates.5,6 Keratoconus commonly develops in the second or third decade of
life, and associated risk factors include atopic disease, family history of keratoconus, and eye rubbing.4,7,8 Some have
suggested that keratoconus is more prevalent in males,9 but this is not consistent across all studies.3,6 Furthermore,
socioeconomic status has been shown to be a significant predictor of keratoconus severity and progression.10
Early diagnosis and management of keratoconus is imperative to prevent vision loss and improve visual outcomes.
Current diagnostic imaging modalities include corneal topography and tomography, which are used in tandem with corneal
biomechanical measurements and epithelial thickness mapping.11 Corneal topography uses Placido disc reflection to identify
anterior corneal curvature.12 Corneal tomography uses either Scheimpflug imaging or optical coherence tomography (OCT)
to measure both the anterior and posterior elevation, as well as corneal thickness,12 which allows for improved detection of

Clinical Ophthalmology 2022:16 1357–1363 1357

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mild ectasia.13,14 To our knowledge, no prior studies have indicated the prevalence of corneal topography and tomography
usage in ophthalmology practices with keratoconus patients, nor the outcomes associated with using corneal tomography. In
this study, we describe the prevalence of corneal topography and tomography usage and the associated patient outcomes,
namely the need for corneal collagen cross-linking (CXL) or other surgical interventions (intrastromal corneal ring segments,
lamellar keratoplasty, or penetrating keratoplasty), at a single academic institution.

Methods
This study was approved by the Institutional Review Board at the University of California San Francisco (UCSF) and
was conducted in accordance with the Declaration of Helsinki. All accessed data remained in compliance with data
protection and privacy regulations. All patients with an International Classification of Diseases (ICD) diagnosis of
keratoconus (ICD-9 code 371.6, ICD-10 code H18.609) were retrospectively identified and screened for eligibility.
Clinical documentation of keratoconus and complete data on one or more of the study outcomes were required for
inclusion. The retrospective period dated from 2012, when Epic (Verona, Wisconsin) was implemented as the electronic
health record at UCSF, to 2019. The electronic health record was reviewed for clinical characteristics including age, sex,
race, and underlying developmental disability. All characteristics were collected from the first visit for each patient. Age
was categorized into pediatric patients (age <18 years) and adults (age ≥18 years).
The primary outcome was defined as the presence of corneal topography (Tomey TMS-4, Phoenix, AZ) and/or
tomography (Oculus Pentacam, Wetzlar, Germany) imaging within ±7 days of the first and most recent visits. The
decision over which corneal imaging modality was chosen in the evaluation of keratoconus patients was per the attending
physician’s preference. Interventions for keratoconus were defined as no specific intervention, rigid gas permeable (RGP)
or scleral lenses, corneal collagen cross-linking (CXL), intrastromal corneal ring segments (ICRS), lamellar keratoplasty,
and penetrating keratoplasty. The interventions were grouped as nonprocedural (no specific interventions and RGP or
scleral lenses), CXL, and other surgical interventions (ICRS, lamellar keratoplasty, and penetrating keratoplasty) for
statistical analysis.
Statistical analyses were performed using a Chi-square test to evaluate differences between categorical variables,
univariate linear regression to evaluate the association between predictor variables and corneal imaging modality, and
multivariate analysis to identify differences in interventions. Significance was defined as P<0.05. Analyses were
performed using R software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria).

Results
1746 eyes from 1038 individuals were identified with an ICD-9 or ICD-10 diagnosis of keratoconus. Of these
individuals, 873 (84.1%) had clinical documentation confirming the diagnosis of keratoconus and a documented first
visit date. In this cohort, 791 (90.6%) were adults and 82 (9.4%) were pediatric patients at the time of their first visit.
Fifty-seven (6.5%) had a clinical diagnosis of some form of developmental disability, 55 of whom (96.5%) were adults at
the time of their first visit. Additional demographic information is included in Table 1.
Corneal tomography was introduced at this institution in February 2015. The percentage of patients receiving corneal
tomography at the first visit increased from 3.9% in 2015 to 52.8% by the year 2019, whereas the rate of corneal
topography usage at the first visit remained steady (40.4% in 2012 and 37.0% in 2019, see Figure 1). In total, 39.0% of
pediatric patients received corneal tomography imaging within 7 days of the first visit compared to 22.5% of adult
patients (P=0.001). The use of corneal topography imaging at the first visit was more similar between pediatric and adult
patients at 51.2% and 51.6% (P=1.00) respectively. Between 2012 and 2019, there was an 11.2% ± 1.9% increase in
corneal tomography usage per year (P<0.001) for pediatric patients. In adults, corneal tomography usage at the first visit
increased by 6.7% ± 0.5% per year (P<0.001). When comparing rates of imaging in patients with developmental
disabilities, 17.5% had corneal tomography at the first visit compared to 24.6% of those without developmental
disabilities (P=0.30). 50.9% of patients with developmental disabilities had corneal topography, and 51.5% of patients
without developmental disabilities had corneal topography (P=1.00). In patients with developmental disabilities, corneal
tomography at the first visit increased by 7.5% ± 1.8% per year (P<0.001), compared to 7.0% ± 4.6% growth in usage in
patients without developmental disabilities (P<0.001).

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Table 1 Clinical and Demographic Characteristics of Keratoconus Patients

Parameters Total KCN Patients (N=873) Adult KCN Patients (N=791) Pediatric KCN Patients (N=82)

Diagnosis age (years ± SD) 40.3 ± 17.1 43.0 ± 15.7 14.9 ± 2.5
Female (n, %) 295 (33.8) 266 (33.6) 29 (35.4)
Race (n, %)
Caucasian 360 (41.2) 343 (43.4) 17 (20.7)
Black 77 (8.8) 74 (9.4) 3 (3.7)
Asian 67 (7.7) 57 (7.2) 10 (12.2)
Other 244 (27.9) 206 (26.0) 38 (46.3)
Unknown/declined 125 (14.3) 111 (14.0) 14 (17.1)
Developmental disability (n, %) 57 (6.5) 55 (7.0) 2 (2.4)
Tomography first visit (n, %) 210 (24.1) 178 (22.5) 32 (39.0)
Topography first visit (n, %) 450 (51.5) 408 (51.6) 42 (51.2)
Abbreviation: KCN, keratoconus.

Of the 1746 eyes that met our inclusion criteria, 405 (23.2%) had corneal tomography completed on the first visit.
Multivariate analysis showed that corneal tomography at the first visit was a significant predictor for receiving CXL
(β=9.9%, Standard error 1.8%, P<0.001), while corneal topography was a significant negative predictor for CXL (β=
−2.7%, 1.4%, P=0.047) when controlling for the year of the first visit (Figure 2A and Table 2). Corneal tomography at
the first visit also a significant negative predictor for requiring other surgical interventions (β=−5.4%, 2.5%, P=0.032),
while corneal topography at the first visit was not significantly associated with a change in the rate of requiring other
surgical interventions (β=−3.2%, 1.9%, P=0.088) when controlling for the year of the first visit (Figure 2B and Table 2).
When considering keratometry for patients who had corneal topography and corneal tomography within 30 days from
one another for the first visit (690 eyes, 39.5%), the Km from corneal tomography had a significant correlation with the
AveK from corneal topography with an adjusted R2 = 0.16 (P<0.001, Figure 3A). Likewise, the steep K and flat K from

70

60
Imaging Modality Usage Rate (%)

50

40

30

20 Legend
Corneal Tomography
Corneal Topography
10

2012 2014 2016 2018

Year of First Visit

Figure 1 Change in the rates of corneal topography and corneal tomography usage near the first visit over time. Corneal topography usage at the first visit stayed relatively
constant from 2012 to 2019, whereas corneal tomography usage increased significantly since it was introduced in February 2015. Imaging near the first visit was defined as
having either corneal topography or tomography done ±7 days from the first visit.

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A B Differences in Rates of
Differences in Rates of CXL
Surgical Intervention
25 25
** *

Intervention by the Most Recent Visit

Percentage of Patients with Surgical
Percentage of Patients with CXL 20 20
by the Most Recent Visit
15 15

10 10

5 5

0 0
No Tomography No Tomography
Tomography Tomography

Figure 2 Differences in interventions by the most recent visit for patients who did receive corneal tomography near the first visit compared to those who did not. (A) The
percentage of patients with corneal collagen cross-linking (CXL) was significantly greater in those who did receive corneal tomography imaging near the first visit (P<0.001).
(B) In contrast, the percentage of patients requiring another surgical intervention for keratoconus (defined as having ICRS, lamellar keratoplasty, or penetrating keratoplasty)
was significantly lower in patients who did have corneal tomography near the first visit compared to patients without tomography (P=0.048). Statistics: Multivariate linear
regression controlling for year of the first visit. *P<0.05, **P<0.001.

corneal topography also correlated with the corneal tomography from the K2 (adjusted R2 = 0.21, P<0.001) and K1
(adjusted R2 = 0.04, P<0.001), respectively (Figures 3B and C).

Discussion
Corneal topography is a mainstay in the evaluation of keratoconus with nearly half the patients in this study receiving one
at their first visit and no significant change in its usage over time. However, the use of corneal tomography at
a keratoconus patient’s initial visit has increased dramatically since 2015, when it was acquired at this academic
institution. Interestingly, we have found that pediatric patients are more likely to receive corneal tomography imaging
at their first visit than adult patients. Corneal tomography usage is also predictive of receiving CXL and for not receiving
other surgical interventions needed to treat keratoconus.

Table 2 Association of Imaging Modality and Intervention

Variable CXL (β Coefficient, %) SE (%) P value

Topography first visit −2.7 1.4 0.047*

Tomography first visit 9.9 1.8 <0.001**
Pediatric patient 23.5 2.3 <0.001**
Developmental disability 6.2 2.7 0.022*
Year of first visit 0.004 0.001 <0.001**

Variable Surgical Intervention† (β Coefficient, %) SE (%) P value

Topography first visit −3.2 1.9 0.088

Tomography first visit −5.4 2.5 0.032*
Pediatric patient −11.9 3.2 <0.001**
Developmental disability 0.6 3.7 0.862
Year of first visit −0.006 0.001 <0.001**
Notes: *P<0.05; **P<0.001. †Surgical interventions are defined as intrastromal corneal ring segments, lamellar keratoplasty, or
penetrating keratoplasty.
Abbreviation: CXL, corneal collagen cross-linking.

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A B C
Average K Steep K Flat K

Km (D, Tomography)

K2 (D, Tomography)

K1 (D, Tomography)
75 75 75

50 50
50
25
25 25

40 50 60 70 80 40 50 60 0 20 40 60
AveK (D, Topography) Ks (D, Topography) Kf (D, Topography)

Figure 3 Correlation between keratometry measurements from corneal topography and corneal tomography for patients at their first visit. Patients with corneal
topography and tomography within 30 days from each other were included (N=690 eyes). (A) The correlation between the average keratometry from corneal topography
(AveK) and tomography (Km) had an adjusted R2 of 0.16 (P<0.001). (B) The adjusted R2 value for the correlation between the steep K from corneal topography (Ks) and
tomography (K2) was 0.21 (P<0.001). (C) The adjusted R2 value for correlation between the flat K from corneal topography (Kf) and tomography (K1) was 0.04 (P<0.001).
All K values are in diopters (D).

Corneal tomography employs Scheimpflug imaging to create a three-dimensional structure of the cornea, which
allows providers to evaluate the posterior surface and corneal pachymetry in addition to the anterior surface. This gives
providers a more adept detection of even mild corneal ectasia.13,14 In addition, the inclusion of the Belin-Ambrosio
enhanced ectasia display on the Oculus Pentacam has also been shown to be more sensitive at detecting early
keratoconus and mild progression.15,16 While prospective, longitudinal studies are required to fully evaluate the long-
term outcomes of using corneal tomography, this study suggests that corneal tomography can be used to provide earlier
CXL intervention to minimize keratoconus progression and later need for more invasive surgical intervention.
This study also demonstrates a good correlation between corneal topography and tomography measurements.
Although the usage of Placido disc corneal topography generates a more accurate topographical representation of the
anterior surface of the cornea,12,17 our study demonstrated a significant correlation between the average keratometry
measures taken by corneal topography (AveK) versus tomography (Km) and between the steep and flat keratometry
readings across both imaging modalities. A previous study showed good agreement between corneal topography and
tomography, although topography tended to underestimate the steep K, flat K, and the AveK in eyes with keratoconus.18
Currently, one of the most widely used keratoconus grading systems, the Amsler-Krumeich classification system,19 relies
solely on corneal topography. Newer proposed grading systems, such as the ABCD from Belin & Duncan,16,20 take into
account best spectacle corrected visual acuity, both the anterior and posterior corneal surfaces, and corneal pachymetry,
which can only be evaluated using corneal tomography. Thus, further work is required to better define keratoconus
classification that incorporates advances in technology as well as limitations of both corneal topography and tomography.
At our institution, both corneal topography and tomography are billed under the same Current Procedural Treatment
(CPT) code (92025). Therefore, disparities in healthcare coverage and fees did not contribute to the choice of one
imaging modality over the other. However, these socioeconomic factors could prevent some patients from receiving
timely diagnosis, which may result in delayed keratoconus treatment.10 As such, future studies should compare the cost-
benefit of receiving corneal topography versus tomography.
One limitation in our study is that it describes the trends at only a single academic institution, limiting its general-
izability. Furthermore, the data were collected retrospectively, which makes it difficult to fully appreciate changes in
patients over time, as we have only two time points (first and last visit), and some patients were lost to follow up. In
addition, the retrospective nature of this study limits our ability to make conclusive causal-effect relationships between
imaging modalities and patient outcomes. We found patients who received corneal tomography imaging were more likely
to undergo corneal collagen cross-linking, which may have contributed to the lower need for keratoplasties in this
group.21–24 We believe this is because corneal tomography incorporates software to facilitate with earlier decision
making for intervention, such as the Belin-Ambrosio enhanced ectasia display.16 However, the positive change in attitude
towards CXL over the last decade, especially with shown benefit for early intervention in pediatric and developmentally

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delayed populations may have also contributed to this association.25,26 Longitudinal studies may evaluate whether
improved corneal imaging provided by corneal tomography has allowed for quicker access to CXL.
In summary, corneal tomography has increasingly become the standard of care for keratoconus patients. We
demonstrate that use of corneal tomography was associated with fewer invasive surgical interventions. Even though
CXL usage also gained in popularity during this the study period due to evidence of its efficacy and safety, we also show
a correlation between increased corneal tomography and CXL procedure. Finally, we highlight the correlation between
metrics obtained by corneal topography and tomography to illustrate that future efforts to re-classify and define
keratoconus should consider the strengths and limitations of both imaging modalities, as well as the cost to patients,
to accurately diagnose keratoconus and to initiate proper treatment plans.

Acknowledgments
This project received funding from the University of California San Francisco (UCSF) Inquiry Funding Office and was
supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-
CTSI Grant Number UL1 TR001872. Its contents are solely the responsibility of the authors and do not necessarily
represent the official views of the NIH. This project was also made possible in part by unrestricted grant funding from the
All May SeeTM Foundation (San Francisco, CA) and Research to Prevent Blindness (New York, NY) to the University of
California San Francisco, Department of Ophthalmology.

Disclosure
Dr Neel D Pasricha reports consulting fees from iota Biosciences, outside the submitted work. The authors report no
other conflicts of interest in this work.

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