This study assessed the facility-based proportion, demographic profile, clinical characteristics, and factors associated with KC among patients attending tertiary referral refraction clinics in Malawi. A retrospective cross-sectional review of clinical records was conducted at Malawi's four national referral eye hospitals. Records of patients aged 10-45 years who attended refraction services between January 2014 and December 2018 were reviewed. KC cases were ascertained using predefined clinical criteria. Analyses were performed using R version 4.5.1 (R Foundation for Statistical Computing). Of the 1,400 targeted records, 1,180 (84.3%) were successfully retrieved. The facility-based proportion of KC was 5.7% (67/1180; 95% CI: 4.4-7.2%). KC was most common among individuals aged 18-35 years (p = 0.001) and varied significantly by facility and region (p < 0.005). Blurred vision was the predominant presenting complaint (88.1%), while diagnosis relied primarily on retinoscopy, slit-lamp examination, and keratometry. Significant inter-eye differences were observed for best-corrected visual acuity and astigmatic axis (p < 0.005), but not for keratometric measurements. Median visual acuity improved from 0.2 to 0.6 following refractive correction. In multivariable analyses, cylindrical refractive error remained independently associated (AUC ≈ 0.88) with KC, whereas age and gender were not. Sensitivity analyses produced findings consistent with the primary results. Keratoconus represents a substantial clinical burden within Malawi's tertiary eye-care system and is associated with considerable visual impairment. Strengthening early detection, access to corneal imaging, specialised rehabilitation services, and clinical information systems may improve diagnosis, management, and visual outcomes.

This study assessed eye care practitioners’ competencies, clinical practices, and barriers related to KC diagnosis and management in Malawi. A national cross-sectional study was conducted among eye care practitioners in Malawi. Data were collected using a structured questionnaire assessing demographics, self-reported competency in KC diagnosis and management, clinical practices, service availability, and barriers to care. Data analysis was conducted using Stata version 15 and R version 4.5.1. A total of 110 practitioners participated (response rate: 58.5%). The mean age was 35.4 ± 7.4 years, and optometrists constituted 60.9% of respondents. Diagnostic competency scores were consistently higher than management competency scores across knowledge, skills, and experience domains. Higher educational attainment was independently associated with diagnostic competency, with undergraduate (aOR = 3.3; 95% CI: 1.13–9.63) and postgraduate practitioners (aOR = 6.6; 95% CI: 1.91–22.62) demonstrating greater odds of competency than diploma holders. Equipment shortages were significantly associated with facility type (p = 0.035), while other barriers showed no significant variation across regions or levels of care. Eye care practitioners in Malawi reported moderate competency in KC diagnosis and management, with stronger confidence in diagnosis than management. Strengthening practitioner training, improving access to diagnostic technologies, and enhancing affordability of contact lens services may improve KC care delivery and visual outcomes.