Keratoconus is a progressive corneal disorder which is frequently asymmetric. The aetiology of keratoconus remains unclear, and the concept of keratoconus as an ectatic disorder has been challenged recently. We carried out a retrospective study in 160 eyes of 80 patients, to evaluate and compare interocular differences in corneal diameter and surface area in patients with unilateral or highly asymmetric keratoconus (UHAKC). Calculations were performed using raw topographic elevation data derived from topographic measurements using Orbscan II, and we extrapolated surface areas up to measured corneal diameter. We also evaluated inter-eye correlation, and correlation between corneal surface area, corneal diameter and keratoconus severity. Our results showed a statistically significant but not clinically important greater corneal diameter (12.14 mm and 12.17 mm; p = 0.04), and corneal surface area (paired t-test, p < 0.0001; p = 0.0009 respectively) in more affected eyes. Inter-eye comparison revealed corneal diameter, anterior chamber depth, and corneal surface area were strongly correlated between eyes. Corneal surface area remained strongly correlated, and Bland-Altman analysis also showed strong inter-ocular agreement. Our results show that in patients with UHAKC the interocular difference in corneal diameter and corneal surface area is clinically insignificant, and are consistent with a redistribution, rather than increase, of corneal surface area with keratoconus progression.