Revisiting the oil droplet sign in keratoconus: Utility for early keratoconus diagnosis and screening

PURPOSE: An annular dark shadow (ADS) reflex has been observed while performing direct ophthalmoscopy on subjects with keratoconus. This study describes a method that may serve as a diagnostic technique for early keratoconus and may be used as a quantitative measure of severity. METHODS: Healthy keratoconic subjects and keratoconus suspects underwent corneal tomography and a full ocular examination. Keratoconus severity was graded based on Belin ABCD criteria. An iPhone camera was connected to a direct ophthalmoscope to take a picture of the eye. The height of the ASD was measured using the AutoCAD software. Differences between subject groups were evaluated by chi‐squared and Mann–Whitney tests. Spearman correlation compared ocular parameters and the height of the ADS. A multiple stepwise linear regression was used to predict the height of the ADS based on clinical parameters. RESULTS: Fifty‐eight subjects participated in this study: 37 healthy controls (37 eyes) and 21 keratoconics or keratoconus suspects (37 eyes). The ADS was present in all keratoconic and keratoconus‐suspect eyes but in none of the controls. The height of the ADS was significantly correlated with keratoconus severity. Front corneal surface root mean square of higher order aberrations, sphere and anterior radius of curvature from the front apex curve are significant predictors of the height of the ADS. CONCLUSIONS AND RELEVANCE: The ADS may be a useful method to diagnose keratoconus and keratoconus‐suspect cases and serve as a grading and follow‐up method for tracking disease severity.