Prior to the mainstream introduction of corneal collagen cross-linking (CXL) in the late 2000s, there was no effective treatment to prevent progression of keratoconus, other than corneal grafting procedures, which may in some cases just serve to delay progression.1 Over the last 15 years, however, there has been a significant shift in paradigm, with CXL emerging as an effective modality to prevent progression of ectatic disease. Whilst there is a significant body of evidence to support the scientific and clinical outcomes of CXL, we feel it is prudent to be mindful of the risks we expose our patients to, and it is important to be aware that whilst well-designed protocols do exist for CXL, it is still largely carried out in an unregulated manner.2

The presentation, rate, and end stage of keratoconus can vary greatly between affected individuals, though severity and age at presentation are recognised to be important. The risk factors for development of keratoconus are well described with ethnicity, family history, genetic susceptibility, eye rubbing, and syndromic associations all recognised to contribute to the development of keratoconus. The involvement of eye rubbing is supported by scientific literature, with an underlying hypothesis of trauma induced injury, subsequent involvement of inflammatory mediators in the wound-healing response, and an increased rate of keratocyte apoptosis.3, 4

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