Long-term Results of Cross-linking in Children with Keratoconus

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1 Long-term Results of Cross-linking in Children with Keratoconus Beatrice Frueh,MD Professor of Ophthalmology

2 Financial Disclosure No finantial interests

3 8-year-old Progression in 6 months

4 Keratoplasty in children with keratoconus Only few studies dealing with keratoplasty (lamellar or penetrating) in children with keratoconus The vast majority describe results in children of various ages and with different diagnoses. In fact, only few children need keratoplasty for keratoconus

5 Why is this so? Usually, keratoconus becomes manifest in the late teens Most patients are already adults when they need keratoplasty (PK or DALK)

6 Severity of keratoconus in children Retrospective study 216 patients, 49 < 15-years-old, 167 > 27-years-old at diagnosis In the children, KC was significantly more severe at diagnosis and progression was faster Léoni-Mesplié et al, AJO 2012

7 Keratoplasty for Keratoconus Prognosis is excellent in adults In children, more complications are likely: -more cases of preop hydrops -compliance not always optimal (esp in Down s syndrome) -more suture-related problems (atopy, eye-rubbing)

8 Corneal cross-linking (CXL) is the only available method of arresting keratoconus progression

9 To Clarify There are various techniques for execuiting CXL (some only experimental), but the best established approach is the original Dresden protocol Dresden protocol: epi-off, riboflavin with dextran, 30 min of 3mW/cm 2 UVA irradiation

10 Pediatric CXL: Long-Term Follow-Up of Visual, Refractive, and Topographic Outcomes Forty eyes of 40 patients, age years Follow-up (up to?) 4 years Standard Dresden protocol Uçakhan et al, Cornea 2016

11 Pediatric CXL: Long-Term Follow-Up Uçakhan et al, Cornea 2016

12 Corneal Cross-linking for Pediatric Keratoconus: Long-Term Results 54 eyes, 36 patients (mean age 14.8 years, range 11-17), mean KMax preop 59.1D Standard Dresden protocol Follow-up up to 5 years (9 eyes) Progression in 12 eyes (22%) at the last visit, without losing a single Snellen line (in either UDVA or CDVA) No retreatment or keratoplasty performed Godefrooij et al, Cornea 2016

13 Corneal Cross-linking for Pediatric Keratoconus: Long-Term Results Godefrooij et al, Cornea 2016

14 CXL in Children, 6-Year Results Prospective study (Univ. of Bern), 70 eyes included Minimum follow-up 6 years 23 eyes (18 patients) Standard Dresden protocol Mean age 14.4±3.6 years (4-17), mean follow-up 7.4+/-0.5 years

15 CXL in Children, 6-Year Results No cases of scarring or haze Two cases of peripheral infiltrates Progression: one case at 3 years and one at 2 years (both were retreated, stable 3 and 2 years after re- CXL) CDVA: unchanged in 16, better (>2 lines) in 5, and worse (2 lines) in 2

16 Average Keratometry D AvK pre AvK 1 y AvK 2 Y AvK 3 Y AvK 4 Y AvK 5 Y AVK 6 Y n=22 n=21 n=22 n=22 n=19 n=21 n=18 p<0.005 at all time points

17 Cylinder D preop 1yr 2yrs 3yrs 4yrs 5yrs 6yrs n=23 n=22 n=23 n=23 n=20 n=22 n=19

18 Spherical Equivalent D preop 1 yr 2 yrs 3yrs 4 yrs 5yrs 6yrs n=23 n=21 n=22 n=22 n=20 n=21 n=18

19 Pachymetry 550 μm Preop 1yr 2yrs 3yrs 4yrs 5yrs 6yrs n=21 n=20 n=20 n=20 n=19 n=20 n=15 p<0.001 at all time points

20 KMax D Preop 1yr 2yrs 3yrs 4 yrs 5yrs 6yrs n=16 n=15 n=15 n=16 n=15 n=15 n=13 p<0.001 at all time points

21 Conclusions I Standard CXL is effective in arresting KC progression in children, and is as safe as in adults Progression after CXL in children is rare, but can occur years after the procedure Retreatments are possible and seem to be effective

22 Conclusions II In our 6-year follow-up study of epi-off standard CXL, the corneas flattened and thinned. Topographic indices improved or remained unchanged In cases of scarring or extreme ectasia, CXL is not indicated and keratoplasty (lamellar or penetrating) should be performed

23 Preoperative 3 years 5 years 8 years