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Purpose: To determine the prevalence of keratoconus (KC) in relation to ethnicity in N. Macedonia. Methods: This was a cross-sectional, interventional retrospective study. Chart reviews were performed for all new patients attending between January 2016 and January 2020 at the Sistina Ophthalmology Hospital in Skopje. All patients were screened, KC diagnosis and classification was based on the corneal topography. Ethnicity and gender classifications were according to patients’ self-opinions. Results: A total of 2812 patients charts reviewed. The mean age was 31.71 years (SD, ±9.73), 1209 (43%) were male. 2050 (72.9%) declared themselves as Macedonians, 649 (23.1%) Albanians, 76 (2.7%) Turks and 37 (1.3%) in other ethnicities. Differences in age between the ethnic groups was statistically significant (𝑥2=90.225, p<0.001). KC was diagnosed in 343 patients (12.2%), 9 were KC suspects and 6 were pellucid marginal degeneration. KC was more frequent in males (n=246, 71.7% of total) and skewed towards younger patients. Increasing patients’ age decreased the odds of KC diagnosis by 3.7%(95% CI:1.8%-4.4%) per annum. Males were 4 times more likely to be diagnosed with KC (AOR=4.01;95% CI:3.12–5.16). In comparison with Macedonian patients, Turks were more likely to be diagnosed with KC (AOR=4.09;95%CI:2.47–6.78). There was no difference between Macedonians and Albanians (p=0.08). Conclusion: The prevalence of KC at a refractive surgery practice in N.Macedonia is much higher compared with general population and similar to the prevalence in Middle East Asia. Nationwide screening programs are needed to diagnose the disease earlier.