Redesigning Regional Keratoconus Care: Using Real World Service Data To Develop A Virtual, Community Integrated Model For Early Detection And Timely Collagen Cross Linking

Published 2026 - 44th Congress of the ESCRS

Reference: POCOR370 | Type: Free paper | DOI: 10.82333/cw04-0h34

Authors: Dr Thomas W Mcnally* ¹ , Mr Mohamed Hegab ¹ , Dr Salmaan Ferrand ¹ , Mr Ankur Mehta ¹

¹Ophthalmology,Sunderland Eye Infirmary,Sunderland,United Kingdom

Purpose

To quantify service burden and time-to-treatment across the current regional keratoconus pathway and to use audit data to inform the development of a virtual, community and optometry integrated model of care.

The three-pathway service will include community hub virtual keratoconus screening and diagnosis, optometry-led monitoring, and a nurse-delivered collagen cross-linking (CXL) service in the local region.

The overarching aim is to improve early keratoconus detection, reduce preventable disease progression, and shorten time‑to‑collagen cross‑linking (CXL) for newly diagnosed patients thereby improving visual outcome, reducing contact lens burden, and improving vision-associated quality of life.

Setting

A regional tertiary ophthalmology service in the United Kingdom providing specialist corneal care for a mixed urban-rural population. The project was registered locally and embedded within a broader service‑redesign initiative involving hospital‑based ophthalmologists and optometrists, community optometrists, an established community hub and digital pathway leads.

Methods

A retrospective audit was performed for all new referrals between 1st January and 31st December 2024. Medical records were reviewed to extract demographic and clinical data.

Findings were used to refine pathway design, define eligibility criteria for community‑based monitoring, and model the expected impact on time‑to‑CXL for new keratoconus diagnoses. The proposed service redesign includes:

1. Community optometrist‑led screening using traffic-light referral criteria

2. Hospital optometry-led virtual triage and monitoring clinics modelled on validated frameworks and a structured escalation protocol for timely CXL listing

3. Nurse-led collagen cross-linking with formal training pathway

4. Consultant-led clinics for complex and surgical patients

Results

1156 patients were referred with suspected corneal pathology, of which 86 were diagnosed with keratoconus. For patients with keratoconus, mean age was 33.2 years (SD 11.4. range 17-40), 72% were male, 52% had a history of eye rubbing, 30% of atopy and 6% of learning disability. 56% of cases were bilateral at presentation and mean UCVA was 0.61logMAR.

32 patients were listed for CXL, most of whom (69%) were listed at their first appointment, with 25% listed at their second. A substantial contact lens burden was observed, with 440 patients undergoing CL re-fitting during 2024.

Significant delays were observed. Median referral-to-assessment time was 114 days (IQR 72) and median listing-to-CXL time was 64 days (IQR 86).

Conclusions

This audit demonstrates substantial service burden and clinically meaningful delays in the current regional keratoconus pathway, with late presentation and diagnosis a key factor.

The proposed community‑integrated pathway aims to reduce time from referral to clinical decision to 8 weeks. Evidence‑based protocols will reduce inappropriate referrals and guide decision making.

The service will be audited against established virtual and nurse‑led pathways for keratoconus screening, monitoring and CXL, and a cost‑benefit analysis undertaken. This will be a novel community‑integrated virtual, optometry‑ and nurse‑led pathway from screening to CXL in the UK, positioned as a template for regional and national expansion.