Vision-Related Quality of Life in Iraqi Keratoconus Patients: A Comparative Analysis of Surgical and Nonsurgical Interventions

PURPOSE: To compare vision-related quality of life (QoL) between surgical and nonsurgical interventions in Iraqi patients with unilateral keratoconus (KC) and to identify independent clinical predictors of QoL outcomes. METHODS: This multicenter cross-sectional study enrolled 490 patients with unilateral KC. Participants were stratified into surgical (n = 240; intracorneal ring segments [ICRS], deep anterior lamellar keratoplasty [DALK], or penetrating keratoplasty [PKP]) and nonsurgical (n = 250; corneal collagen crosslinking [CXL], rigid gas-permeable, or scleral lenses) groups. Clinical assessments included best-corrected visual acuity (BCVA), maximum keratometry (Kmax), spherical equivalent, and disease stage. QoL was measured using the validated 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Subgroup analyses, pairwise comparisons, and multivariate regression were conducted to identify determinants of QoL. RESULTS: Surgical patients demonstrated significantly higher NEI-VFQ-25 composite and subscale scores than nonsurgical patients (p < 0.001), with marked improvements in general vision, mental health, and daily activities. Subgroup analyses confirmed that ICRS provided superior outcomes in mild-to-moderate KC compared to CXL and contact lenses, while DALK and PKP yielded comparable benefits in advanced disease. Stratified analyses revealed sex-based and age-related differences, with females and older patients reporting better QoL. Multivariate regression analysis identified surgical treatment, BCVA ≤0.3 logMAR, patient satisfaction with surgery, and mild KC as independent positive predictors of QoL, whereas advanced stage, male sex, higher Kmax, and increasing age were identified as negative predictors. A treatment-age interaction indicated that younger patients benefited more from timely surgery. CONCLUSIONS: Surgical interventions, particularly ICRS and PKP, are associated with superior QoL compared with nonsurgical options in Iraqi patients with KC. These findings underscore the importance of incorporating patient-reported outcomes into clinical decision-making and support individualized, stage-based surgical referral, especially in resource-limited settings.