The immunopathology of keratoconus: tear film biomarkers and immune pathways

Purpose of review This review explores established risk factors for keratoconus and current insights into tear film immune biomarkers, with a focus on the role of chronic low-grade inflammation in disease pathogenesis and emerging targeted therapies. Recent findings Growing evidence supports immune dysregulation as a key driver in the onset and progression of keratoconus. Genetics establish a foundation for a dysregulated inflammatory response in the ocular surface and corneal microenvironment, which sustains and accelerates disease progression. Elevated tear levels of IL-1, IL-6, TNF-α, HMGB1, and MMP9 reflect these inflammatory changes. Chronic inflammation and repeated mechanical trauma from eye rubbing, especially in adolescents and young adults, are major risk factors for disease progression. Timely screening and regular corneal topography in adolescents with allergic or atopic disorders are essential for early diagnosis and prevention of vision loss. Summary The tear film and corneal microenvironment contain valuable immune markers that shed light on keratoconus pathophysiology. Advances in precision and predictive medicine hold promise for safer, more effective strategies to halt disease progression.