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Cross-linking in paediatric cases

CXL is safe and effective in children with keratoconus but follow-up is required

Dermot McGrath

Posted: Friday, February 1, 2019

Corneal collagen cross-linking (CXL) may be considered a safe and effective procedure in the paediatric population with progressive keratoconus, although these younger patients require particularly close follow-up, according to Meena Lakshmipathy MD.

“There is a possibility that repeat treatment may be and this needs to be explained to parents. Extra care is also needed as children are more prone to infections and a heightened allergic response,” she told delegates attending the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) subspecialty day at the 36th Congress of the ESCRS in Vienna.

There is a strong rationale for treating progressive keratoconus in a young population, said Dr Lakshmipathy.

“The hope is that by performing CXL we can avoid the need to perform keratoplasty in these young patients. Some studies have shown that it has already halved the indications of keratoplasty in children,” she said.

Dr Lakshmipathy advised seeing patients at least once every six months, with progression determined on the basis of at least two of the following criteria being met: an increase of at least 1.5D in maximum keratometry, an increase of at least 1.5D in the retinoscopic or topographic cylinder or a reduction in thickness of more than 15mm at the thinnest point of the cornea.

Contraindications to performing CXL in paediatric patients include herpetic eye disease, significant scarring, neurotrophic keratopathy, autoimmune disorders, severe dry eye and active vernal keratoconjunctivitis (VKC), she added.

Dr Lakshmipathy’s group, Medical Research Foundation, Sankara Nethralaya, Chennai, India, has already published data in Cornea. Totally, 377 eyes of 336 patients with progressive keratoconus underwent CXL. Of these, 194 patients had a follow-up of two years up to 6.7 years. In that study, patients with a minimum pachymetry of 450mm underwent the standard “epithelium off” Dresden protocol of CXL using 0.1% riboflavin, while eyes with a minimum pachymetry between 350 and 450mm underwent CXL using hypoosmolar riboflavin.

CXL was effective at stabilising the disease and improving visual acuity in a majority of eyes, noted Dr Lakshmipathy.

“We found that there was improvement in best-corrected visual acuity. The K-Maximum readings also showed a significant reduction after CXL treatment,” she said.

The need for long-term follow-up in young patients was emphasised.

“After three months, there was progressive flattening of the cornea up until about two years. If we look at the data after four years, however, there was a clear trend toward steepening of the cornea in 24% of patients and 31% of eyes showed a reduction in visual acuity,” she said.

Meena Lakshmipathy: meepath@hotmail.com