Keratoconus is a disease of young people and is most common and most aggressive in children and adolescents (8 to 19 years). It is therefore very important to carry out regular follow-up checks here. Above all, the children of adult patients with keratoconus should also be examined.
Our group has one of the longest international experiences in the treatment of children and adolescents. This particular age group requires special care and attention because the risk of postoperative complications such as infection can be greatly increased.
Unlike adults, children and adolescents are immediately cross-linked as soon as the keratoconus is clearly diagnosed. So there are no historical controls planned to prove the deterioration.
This is because one of the first major studies of CXL in children (in 2012) clearly showed that keratoconus worsened in 88% of all children and adolescents aged 8 to 19. This study comes from our research group. These results made it clear that if the disease worsens in 9 out of 10 children and adolescents, there should be no hesitation in treating the condition immediately.
The results of cross-linking in children and adolescents are as excellent as they are in adults: the disease can be stopped with a high rate of success. In adults, we usually have to wait six months to see if the CXL treatment has succeeded, but in children and adolescents we can often determine success after just three months.
We often see children react more clearly and more strongly than adults. The topography below shows a remarkable result early after crosslinking the right eye: the cornea not only stabilized, but also underwent a flattening of more than 5 diopters after 7 months.
7 months after CXL
A 15-year-old boy with a decrease in visual acuity in his right eye that started 3 months before the first consultation. The patient and his parents were asked to come to a follow-up after 4 weeks. Unfortunately, they did not reappear until 3 months later. The right picture shows the massive deterioration after just 3 months.
Cross-linking in children and adolescents is exactly the same as for adults. Because the treatment is painless, we can also treat children over the age of 9 under local anaesthesia. For children under the age of 9 years, if necessary, we will perform the treatment under general anaesthesia: our anaesthetists will discuss this with you separately.
This is a difficult decision in children. CXL requires the second layer of the cornea, the stroma, to be saturated with riboflavin. Unfortunately, the first layer of the cornea, the epithelium, stops riboflavin from penetrating into the stroma.
Therefore, CXL usually involves removing the epithelium in the center of the cornea so that riboflavin can penetrate into the stroma directly. This technique is called “epi-off CXL”, because the epi(thelium) is taken off. Epi-off CXL exists since 2002.
A major disadvantage of epi-off CXL is that removal of the epithelium can cause substantial pain: children tend to rub their eyes immediately after surgery, which increases the risk for (dangerous) corneal infection.
In epi-on CXL, the epithelium is not removed. Special eye drops (penetration enhancers) are used to get the riboflavin through the epithelium into the stroma. The infection risk is virtually null and there is no pain, just a slight discomfort, but the effectiveness might be slightly lower than epi-off CXL. Successful epi-on CXL exists since 2019, .
– Epi-off CXL has 20 years of data showing effectiveness and it has the greatest chance of stopping keratoconus progression, but it is a little riskier.
– Epi-on CXL is approaching the effectiveness of epi-off CXL, makes the immediate period after surgery more comfortable for the child and decreases the risk for infection.
Therefore, we will decide individually by assessing each child. If there are doubts that a child will cope well with the post-surgical eye drop and bandage contact lens wearing regimen, then we may propose using epi-on CXL.