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We read with great interest the work of O'Brart and associates regarding the efficacy of riboﬂavin/ultraviolet-A corneal collagen cross-linkage to halt the progression of keratoconus.1 There has been enough literature published to establish the efficacy of collagen cross-linking, but prospective randomised clinical trials to establish the cause–effect relationship are lacking. Hence the intention to find such association is praiseworthy.
It is important to consider the natural course of the disease in any study relating to the efficacy of intervention in modifying the disease course. However, it seems this was not considered in the present study. Also, keratoconus is a bilateral asymmetrical disease with varying rates of progression. Hence, is taking the fellow eye as control for a clinical trial perfect?
The mean …