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To examine the relative merits of apical support and apical clearance fitting of rigid gas-permeable contact lenses for keratoconus.After an historic review of fitting approaches for keratoconus, a case report is described in which an adventitious apical clearance fitting for early keratoconus might have been associated with accelerated progress of the ectasia.The hypothesis that apical clearance fittings increase the risk of accelerating ectasia progression in early keratoconus is examined in counterpoint to the hypothesis that apical support fittings increase the risk of apical scarring. Reference is made to the responses of normal corneas to apical clearance fitting and to apical contact fittings used in orthokeratology fittings. The tendency for corneas to mold to contact lens curvature is reviewed. The possibility that reduced corneal thickness or tissue softening and associated changes to the biomechanical properties of the cornea in keratoconus may facilitate molding with apical clearance fitting is examined.Known and putative risk factors for fitting complications that are associated with apical clearance and apical touch contact lens fitting are given as a basis for the reader to draw conclusions about the management of contact lens fitting for keratoconus. The possibility of symptomless adverse responses is a strong indication for frequent routine aftercare reviews.