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All Rotterdam Study participants with reliable Pentacam scans and no prior corneal refractive surgery were cross-sectionally analysed (<jats:italic>n<\/jats:italic>\u2009=\u20092660). First, we applied a novel evidence-based definition. Suspected keratoconus was defined as having at least one eye with a final D-index (BAD-D)\u2009\u2265\u20092.6. Manifest keratoconus was defined as having at least one eye with: (1) BAD-D\u2009\u2265\u20092.6; and (2) a score of at least 4\/10 on the novel Rotterdam Keratoconus Scale (RKS); and (3) a confirming assessment of the relevant Pentacam maps; and (4) meeting Holladay\u2019s criteria in case of recent contact lens usage. Using this proposed definition, 72 participants (2.71%, 95%CI: 2.16\u20133.40%) had suspected keratoconus, while 10 participants (0.38%, 95%CI: 0.20\u20130.69%) had manifest keratoconus. To assess reproducibility, two specialists independently applied the proposed definition, with a substantial inter-observer agreement (Kappa\u2009=\u20090.74). Interestingly, 6(60%) patients were unaware of having keratoconus. Applying nine alternative definitions from similar screening studies produced prevalence estimates ranging from 0.19 to 9.29% in the same cohort. Moreover, counting solely on a BAD-D cutoff of 2.6 to define keratoconus was unreliable, with a low positive predictive value of 14%. These findings explain partially the large heterogeneity in the reported keratoconus prevalences, underscoring the need for a standardized definition.<\/jats:p>","DOI":"10.1038\/s41598-025-87532-4","type":"journal-article","created":{"date-parts":[[2025,1,28]],"date-time":"2025-01-28T05:36:19Z","timestamp":1738042579000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Different keratoconus definitions can lead to substantial prevalence disparities in population-based studies"],"prefix":"10.1038","volume":"15","author":[{"given":"Hasan","family":"Shabani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bart T. 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