Crosslinking Safe in Children, Adolescents With Keratoconus

Alice Goodman

November 28, 2013

NEW ORLEANS — Pediatric responses after corneal collagen crosslinking are similar to those in adults, and the technique appears to be safe in this younger age group, report researchers. Responses, however, might not be as long lasting in children and adolescents, and longer follow-up is needed to verify this trend.

The study showed that progression of keratoconus occurred in 88% of the pediatric population, suggesting that immediate treatment is needed once the diagnosis is made.

"In children and adolescents, once the diagnosis of keratoconus is evident, do not wait for confirmation to treat," emphasized Farhad Hafezi, MD, from Geneva University Hospitals and the Doheny Eye Institute at the University of Southern California in Los Angeles.

Dr. Hafezi spoke at a what's hot session here at the American Academy of Ophthalmology 2013 Annual Meeting.

Corneal collagen crosslinking is now used clinically in more than 100 countries around the world, but most studies of the procedure have focused on adults.

Crosslinking with riboflavin and UV-A is used to stop the progression of postoperative ectasia and keratoconus, explained Dr. Hafezi. The age of the patient with postoperative ectasia depends on the age at surgery; however, keratoconus starts in the teenage years and progresses most aggressively in the second and third decades of life.

In children and adolescents, once the diagnosis of keratoconus is evident, do not wait for confirmation to treat.

Dr. Hafezi and his team performed a retrospective cohort study of patients 8 to 19 years of age to look at the clinical outcome of crosslinking in younger patients. They also assessed the percentage of children and adolescents showing keratoconus progression after initial diagnosis.

"At the initial visit, progressive keratoconus is seen quickly. If we wait to treat, it may be too long. I see my very young patients 4 weeks after crosslinking so I don't miss progression," he said at the meeting.

The study involved 42 children and adolescents with confirmed keratoconus. The main outcome measures were refraction, slit lamp exam, Placido-based corneal topography, and postoperative imaging at 6 and 12 months. Investigators followed patients for 36 months.

In both children and adolescents, flattening was observed 3 months after crosslinking. The effect of flattening 12 months after linking in children was similar to that typically seen in adults. Significant flattening was observed at 12 and 24 months in children and adolescents, but the significance was lost 36 months after the procedure.

Dr. Hafezi said that previous research involving children and adolescents showed a loss of flattening at 36 months, whereas another study showed persistent flattening at 3 years.

"Three years is the most susceptible period," he noted. "These findings suggest that crosslinking might not be a cure. It may only be effective for 2 to 3 years."

More worrisome is that 52 of the 59 eyes (88%) seen in the study showed progression of keratoconus.

"In light of these findings, crosslinking seems efficient in children and adolescents, but we need to pay attention to long-term effects," Dr. Hafezi added.

Commenting on this study, session chair Bonnie Henderson, MD, from Ophthalmic Consultants of Boston and Tufts University School of Medicine, noted that this study "supports the treatment of pediatric keratoconus immediately after diagnosis, rather than waiting for evidence of progression. Even after treatment with crosslinking, keratoconus appears to progress in children."

Dr. Hafezi has disclosed no relevant financial relationships. Dr. Henderson reports financial ties with Alcon Laboratories, Bausch + Lomb, and the Massachusetts Eye and Ear Infirmary.

American Academy of Ophthalmology 2013 Annual Meeting. Presented November 16, 2013.


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