Clinical Evaluation and Validation of the Dutch Crosslinking for Keratoconus Score

Robert P. L. Wisse*, Rob W. P. Simons, Martijn J. B. van der Vossen, Marc B. Muijzer, Nienke Soeters, Rudy M. M. A. Nuijts, Daniel A. Godefrooij

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


ImportanceDefining keratoconus progression is fundamental in clinical decision making because crosslinking treatments are indicated when the disease is considered progressive. Currently, there is no consensus which parameters should be used to define progression. ObjectiveTo assess and validate a novel clinical scoring system as an easy-to-use assessment tool for crosslinking treatment in patients with keratoconus. Design, Setting, and ParticipantsProspective cohort study at 2 academic treatment centers. Patients with keratoconus referred between January 1, 2012, and June 30, 2014, with 2-year follow-up were included. Analysis began March 2017. InterventionsThe Dutch Crosslinking for Keratoconus (DUCK) score is based on changes in 5 clinical parameters that are routinely assessed: age, visual acuity, refraction error, keratometry, and subjective patient experience. The DUCK score is derived by scoring 0 to 2 points per item, and cutoffs were determined by clinical experience. We compared the DUCK scores to the conventional 1.0-diopter increase in maximum keratometry criterion, within the last 12 months, in a longitudinal discovery and a validation cohort. Sensitivity analyses and intraitem correlations were performed. Main Outcomes and MeasuresOverall treatment rate reduction and the duly withheld treatment rate. ResultsA total of 504 eyes of 388 patients were available for analysis on disease progression in the course of 12 and 24 months. Baseline patient characteristics of the discovery cohort and the validation cohort were comparable in terms of age (mean [SD], 26.8 [8.3] years vs 26.3 [9.1]), sex (216 of 332 [65%] vs 123 of 172 [72%] men), and maximum keratometry (mean [SD], 53.5 [7.1] vs 52.7 [6.3]). Adhering to the DUCK score, rather than maximum keratometry, was associated with a reduction in overall treatment rate by 23% (95% CI, 18%-30%), without increasing the risk of disease progression (ie, the rate of progression for both groups was equal; 0%). The DUCK score appears to better identify eyes that were duly withheld treatment by 35% (95% CI, 22%-49%). Conclusions and RelevanceThese results provide validation of the DUCK score as a tool to determine whether a crosslinking treatment might be warranted. Compared with the conventional maximum keratometry criterion of more than 1.0 diopter, the DUCK score may better select patients who might benefit from crosslinking treatment. Potentially, it may prevent unnecessary treatments, reduce exposure to treatment risks, and improve the cost effectiveness of crosslinking.

Original languageEnglish
Pages (from-to)610-616
Number of pages7
JournalJAMA Ophthalmology
Issue number6
Publication statusPublished - Jun 2019




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