Paediatric cornea crosslinking current strategies: A review

Pawan Prasher; Ashok Sharma; Rajan Sharma; Vipan K Vig; Verinder S Nirankari

doi:10.1016/j.aopr.2022.11.002

Paediatric cornea crosslinking current strategies: A review

Adv Ophthalmol Pract Res. 2022 Nov 25;3(2):55-62. doi: 10.1016/j.aopr.2022.11.002. eCollection 2023 May-Jun.

Authors

Pawan Prasher¹, Ashok Sharma², Rajan Sharma², Vipan K Vig³, Verinder S Nirankari⁴

Affiliations

¹ Department of Ophthalmology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India.
² Cornea Centre, SCO 2463 - 2464, Sector 22 C, 160022, Chandigarh, India.
³ Amritsar Eye Hospital, GNDU Shopping Complex, Amritsar, Punjab, India.
⁴ Department of Ophthalmology, University of Maryland, USA.

Abstract

Background: In the general population, 1 in 2000 people has keratoconus. Indians and other people from Southeast Asia have a higher incidence of keratoconus. Children with keratoconus typically present earlier in life and with a more severe disease. Rubbing the eyes has been identified as a risk factor. Children have a higher incidence and a faster rate of keratoconus progression. Visual rehabilitation in children with keratoconus is challenging. They have a low compliance with contact lens use. Many of these children require penetrating keratoplasty at an early age. Therefore, stopping the progression of keratoconus in children is of paramount importance.

Main text: Compared to treatment, keratoconus progression prophylaxis is not only preferable, but also easier. Corneal collagen cross-linking has been shown to be safe and effective in stopping its progression in children. The Dresden protocol, which involves central corneal deepithelization (7-9 mm), saturation of the stroma with riboflavin (0.25%), and 30 min UV-A exposure, has proven to be the most successful. Two significant disadvantages of the typical Dresden regimen are the prolonged operating time and the significant post-operative pain. Accelerated-CXL (9 mW/cm² x 10 min) has been studied to reduce operative time and has been shown to be equally effective in some studies. Compared to accelerated CXL or traditional CXL, epi-off procedures, transepithelial treatment without the need for de-epithelialization and without postoperative discomfort, have been shown to be safer but less effective. Corneal crosslinking should only be performed after treating children with active vernal keratoconjunctivitis. Corneal opacity, chronic corneal edema, sterile infiltrates, and microbial keratitis have been reported after cross-linking of corneal collagen.

Conclusions: The "Dresden protocol", also known as the conventional corneal cross-linking approach, should be used to halt the progression of keratoconus in young patients. However, if the procedure needs to be completed more rapidly, accelerated corneal crosslinking may be considered. Transepithelial corneal cross-linking has been proven to be less effective at stabilizing keratoconus, although being more safer.

Keywords: Corneal collagen cross-linking; Corneal transplant; Keratoconus; Pediatric keratoconus.

Publication types

Review