We studied 162 keratoconus patients in an attempt to clarify the role of hard contact lens wear in the development of keratoconus. Forty-three (26.5%) of these 162 patients developed keratoconus while wearing hard contact lenses. In a group of 1,248 controls who were fitted for soft contact lenses and observed by us from one year to six years, only one patient developed keratoconus. We demonstrated a circumstantial association between hard contact lens wear and the development of keratoconus, but no cause-effect relationship can be drawn from the existing data. However, we concluded that hard contact lenses do not retard or halt progression of the cone. Hard contact lens wear could not be ruled out as the specific environmental risk factor triggering keratoconus in 26.5% of the patients. If we identify the genetic risk present in this subpopulation, eliminating environmental risks would be an effective means of preventing keratoconus in those predisposed individuals.