The Second Global Consensus on Keratoconus

Ten years after the landmark publication of the First Global Consensus on Keratoconus and Ectatic Disease, an updated Second Global Consensus is now available.

Organised by José Álvaro Gomes MD, PhD; Renato Ambrósio Jr, MD, PhD; and Farhad Hafezi MD, PhD, the new document brings together experts from 12 international societies across 6 continents. The project aims to distil the collective judgement of the world’s leading cornea specialists.

As Professor Hafezi explained, the project is a momentary snapshot of the current opinion of international leaders in the field. Using a modified Delphi methodology, only statements reaching at least two-thirds (66%) agreement were accepted. “That threshold ensures the conclusions represent a broad consensus rather than individual preferences,” he observed.

And its impact extends well beyond academic debate. “The Second Global Consensus on Keratoconus is [essentially] a guidelines document that provides clinicians with a practical framework for diagnosis and management, as well as helping societies and health systems to harmonise their standards of care,” said Prof Gomes. “By consolidating expertise into clear, evidence-based recommendations, the Consensus influences not only clinical practice but also training and even policy decisions around corneal health.”

The organisers shared several important updates during a Cornea Day session during the 2025 ESCRS Annual Congress in Copenhagen on new developments in keratoconus and cross-linking. Immediate treatment of children upon diagnosis, adoption of the Belin ABCD for staging and monitoring, new protocols such as ELZA-sub400 for thin corneas, and new techniques and technology such as ELZA-PACE, SLAK, and CAIRS were all presented and discussed.

“These updates reflect the continuous evolution and paradigm shift in keratoconus care,” Prof Ambrósio noted. “The Second Consensus expanded beyond stabilisation, integrating multimodal diagnostics for individualised management, ectasia prevention, vision rehabilitation, and guidance in therapeutic, elective, and refractive cataract surgery.”

The Cornea Day programme featured a structured overview of the Consensus. Prof Hafezi introduced the initiative, followed by Michael Belin MD presenting “Highlights of the Consensus, part 1,” which focused on diagnostic definitions and staging. Cosimo Mazzotta MD then delivered “part 2,” covering CXL protocols and treatment strategies.

Prof Hafezi noted that behind these highlights lies the work of seven expert panels, each addressing a major theme: definition and staging, non-invasive treatment, cross-linking, invasive visual rehabilitation, keratoplasty, refractive surgery, and cataract in keratoconus. The forthcoming publication will detail both the agreements and the open debates that remain, he said.

If the First Consensus in 2015 helped establish cross-linking as the standard of care, the 2025 update reflects a broader ambition. “We can now move beyond stabilising the disease,” Prof Hafezi said. “With techniques such as PRK combined with CXL, PACE, CAIRS, and SLAK, we can offer patients meaningful visual rehabilitation. For many, that means not just stopping progression but regaining quality of life.”

As a result, the Second Global Consensus is expected to serve as both a practical roadmap for clinicians and a benchmark for future innovation in corneal surgery—an internationally representative document to guide the field until the next update.

Farhad Hafezi MD, PhD, FARVO is Medical Director at the ELZA Institute of Dietikon, Switzerland.

Renato Ambrósio Jr, MD, PhD is Adjunct Professor of Ophthalmology at the Federal University of the State of Rio de Janeiro, Brazil.

José Álvaro Pereira Gomes MD, PhD is Adjunct Professor at the Federal University of São Paulo, Brazil.