Optimising Workflow And Efficiency In A Paediatric Keratoconus Service

Paediatric keratoconus is an important but easily missed pathology requiring community optometry vigilance to ensure early and accurate diagnosis, allowing appropriate and timely treatment. In comparison to adult disease, paediatric keratoconus is often both more advanced at diagnosis and more likely to progress over a given time period. A high clinical suspicion in community settings is required to ensure no cases are missed, but this can manifest as a large number of false-positive referrals, leading to increased demand on the corneal or paediatric specialist teams. As such, we looked to assess our current paediatric keratoconus diagnostic pathway, and make modifications to streamline to increase clinical efficiency within the service.

This was performed in the tertiary ophthalmic service in Edinburgh (Princess Alexandra Eye Pavilion, Edinburgh and Royal Hospital for Children and Young People, Edinburgh).

Referral data, clinical information, investigations, diagnosis and outcomes were collected for all patients referred as paediatric keratoconus from the community from January 2024 to January 2025. This was a single-centre study, with patients under the care of multiple specialists. Using “R Studio” (Boston, MA), descriptive statistical analysis of these variables was performed.

19 paediatric patients were referred with possible keratoconus. Mean age of patient was 11.2 years old. Mean LogMAR acuity was 0.04(±0.15) Right and 0.05(±0.12) Left. The mean magnitude of cylinder dioptre was 2.07D (±1.50) with a range of 0.25 to 5.25D. The average axis was 80.9°, with 94% (n=18/19) of cases demonstrating With-The-Rule astigmatism. All children underwent a corneal topography assessment (Pentacam, OCULUS Optikgeräte GmbH). None of the children were diagnosed with keratoconus. 84% (n=16) children were discharged at first review, 11% (n=2) were followed up in clinic for additional pathology (exotropia, and anisometropic amblyopia). 5% (n=1) required follow-up due to inability to access corneal topography on day of review.

With our thorough review of one year of the paediatric keratoconus diagnostic pathway, we demonstrate that we receive a large percentage of false-positive referrals from the community. This reduces the efficiency of the clinic and provides opportunity for improvement. We have already initiated a ‘Topography-Only’ pathway for referrals, allowing asynchronous review of topography by specialists, without the miss-use of clinical resources. This new pathway will shortly be re-assessed and results presented, with potential for facilitation by allied health professionals to further reduce demand on the specialist consultant-led services. Further work could assess similar diagnostic pathways across Scotland to develop a national strategy.