Purpose: To report the trends in the clinical presentation, diagnosis, and management of keratoconus (KC) in patients presenting to a multitier hospital network over 33 years. Methods: This retrospective study included patients with KC presenting from 1987 to 2020. Patients with KC in at least 1 eye were included. The data of 20,576 patients included in this study were retrieved from the electronic medical record database. Data on patient demographics, ocular diagnosis, contact lens usage, and surgical history were collected and exported for analysis. Descriptive statistics and chi square test were used for statistical analysis. Results: A total of 20,576 KC cases were seen from 1987 to 2020. Mean age at diagnosis reduced from 29.3 years (1987–1991) to 22.2 years (2016–2020). Adults (76.64%) were commonly affected with a majority being male (61.25%). Use of contact lenses increased from 4.34% (2002–2006) to 11.23% (2016–2020). Of the total number of surgical interventions, collagen crosslinking (CXL) constituted more than 1/5th (22.28%) between 2007 and 2011, which increased to more than half between 2012 and 2016 (53.61%) and almost 3/4th (72.53%) between 2017 and 2020. Advances in lamellar surgery have led to more patients undergoing deep anterior lamellar keratoplasty (DALK) as compared with penetrating keratoplasty. In the last 8 years, 17.2% patients underwent surgery and the most common was CXL (14.77%) followed by DALK (1.72%) and penetrating keratoplasty (1.04%). Conclusions: We report the trends in the clinical presentation and management of KC over 3 decades. In the last 33 years, advances in diagnostics have helped diagnose KC earlier. Contact lenses and advances in CXL have reduced the number of keratoplasties in KC, DALK being more common.