Cross‐linking in children with keratoconus: a systematic review and meta‐analysis

Abstract

Keratoconus can behave more aggressively in pediatric than in adult patients. We systematically reviewed the literature to determine the effectiveness of corneal collagen cross‐linking (CXL) in children. For this study, MEDLINE® and Cochrane databases were searched for all studies examining the effects of standard, trans‐epithelial or accelerated CXL protocols in patients age 18 years or younger. Primary outcomes were; uncorrected visual acuity (UCVA) and maximum keratometry (Kmax) and secondary outcomes were; best‐corrected visual acuity (BCVA), mean refractive spherical equivalent (MRSE), central corneal thickness (CCT) and endothelial cell density (ECD). Standardized mean differences (SMD) and 95% confidence intervals were calculated, comparing baseline values with those at 6, 12 and 24 months. A total of 13 papers, published between May 2011 and December 2014 examining 490 eyes of 401 patients with a mean age of 15.25 (±1.5) years, were included in the qualitative analysis in this review. Nine papers were included in the meta‐analysis, showing significant improvement in UCVA and BCVA and stable Kmax at 12 months, and stable UCVA, improved BCVA and improved Kmax at 24 months in the standard protocol group UCVA, BCVA and KMax were stable at 12 months in the trans‐epithelial group. Mean refractive spherical equivalent (MRSE), CCT and ECD remained stable in both groups. In conclusion it was found that standard CXL may be effective in halting progression of keratoconus in pediatric patients at 1 year. However, larger, more long‐term studies are required to ascertain its effectiveness.

Corneal Ectasia Preferred Practice Pattern®

“…Longer-term studies are needed to evaluate its ultimate effectiveness. 101 The plethora of international clinical data supports the use of CXL in the early…”

Long-Term Follow-up of Intrastromal Corneal Ring Segment Implantation in Pediatric Keratoconus

“…Regarding disease stabilization, in light of the results published, it appears that cross-linking (CXL) is effective in slowing down progression in the pediatric population, [6][7][8] although some patients (around 20% 8 ) might require retreatment. An important question to consider is whether this procedure should be carried out in all cases of pediatric keratoconus.…”

Corneal Crosslinking: The Standard Protocol

“…(28) Recent studies confirm the treatment's effectiveness, as well as the significant improvement of topographic features and visual acuity. [29][30] However, further monitoring suggests that despite initial improvement, pediatric patients may present long-term progression. 31 Additional studies are still needed and should focus on the development of appropriate techniques and protocol, not only to obtain lasting and effective results, but principally to ensure the safety of patients in pediatric age.…”