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Background: This retrospective cross-sectional study aims to analyse the keratoconus (KC) stage distribution at different ages within the Homburg Keratoconus Center (HKC)., Methods: 1917 corneae (1000 patients) were allocated to decades of age, classified according to Belin's ABCD KC grading system and the stage distribution was analysed., Results: 73 per cent (n=728) of the patients were males, 27% (n=272) were females. The highest KC prevalence occurred between 21 and 30 years (n=585 corneae, 294 patients). Regarding anterior (A) and posterior (B) curvature, the frequency of A was significantly higher than B in all age groups for stage 0, 1 and 2 (A0>B0; A1>B1; A2>B2; p<0.03, Wilcoxon matched-pairs test). There was no significant difference between the number of A3 and B3, but significantly more corneae were classified as B4 than A4 in all age groups (p<0.02). The most frequent A|B combinations were A4|B4 (n=451), A0|B0 (n=311), A2|B4 (n=242), A2|B2 (n=189) and A1|B2 (n=154). Concerning thinnest pachymetry (C), most corneae in all age groups were classified as C0>C1>C2>C3>C4 (p<0.04, Wilcoxon matched-pairs test). For the best distance visual acuity (D), a significantly higher number of corneae were classified as D1 compared to D0 (p<0.008; D1>D0>D2>D3>D4)., Conclusion: The stage distributions in all age groups were similar. Early KC rather becomes manifest in the posterior than the anterior corneal curvature whereas advanced stages of posterior corneal curvature coincide with early and advanced stages of anterior corneal curvature. Thus, this study emphasises the necessity of posterior corneal surface assessment in KC as enabled by the ABCD grading system., Competing Interests: Competing interests: KX, SCG, SR, EZ, LH, TJ, UK, AL and BS declare that they do not have any financial disclosures in medicine. EF has received a travel grant to the Second and Third Ophthalmology Cystinosis Forum (Orphan Europe, Ulm, Germany) and an invitation to a seminar on presentation training organised by the Santen GmbH (Munich, Germany). TE was a member of the Institute of Experimental Ophthalmology, Saarland University Medical Center (Homburg, Germany), at the time of data collection and is now an employee of the Amiplant GmbH (Schnaittach, Germany)., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)