UV collagen cross-linking viable option for pediatric patients

Because the progression of keratoconus is rapid at this age, the procedure should be performed as early as possible.

UV collagen cross-linking can be an alternative to corneal transplantation in pediatric keratoconus patients from the ages of 10 years to 16 years, according to a specialist.

Keratoconus is not infrequent in this age group and has an extremely rapid progression, said Michele Fortunato, MD, of the Pediatric Hospital “Bambin Gesù” in Rome and president of AIERV (Association Internationale pour l’Enfance et la Réhabilitation Visuelle).

“In no time, you find yourself dealing with an eye where it is too late to do lamellar transplantation and where the only option you have is [penetrating keratoplasty]. And we know very well that at this age, the risk of rejection with a full thickness graft is very high,” Dr. Fortunato told Ocular Surgery News in a telephone interview.

Regular examinations

In the presence of a suspect keratoconus, it is mandatory at this age to do regular, frequent pachymetry and topography examinations at monthly intervals. The 6-month schedule of the average adult case is too long, he said. Such a close monitoring allows the specialist to immediately detect the signs of keratoconus progression: modifications of the topography map, visual acuity loss and contact lens intolerance.

“As soon as you see these signs, you should offer a cross-linking treatment, and do it as early as possible,” he said.

In all patients, the corneal thickness must be at least 400 µm.

Results are better than in adult patients

Dr. Fortunato performed UV cross-linking in 16 pediatric patients and had rewarding results.

“Keratoconus progression was halted in all the cases. We also had a reduction of the ectasia and a nice regularization of the surface that is not commonly seen in adults. Young corneas are so elastic that they respond very well to the reinforcing and reshaping stimulus of UV light on the collagen fibers. A remarkable gain of visual acuity lines was also observed and seems to be stable over time,” he said.

“The follow-up is not long, but also in our 2-year case, we haven’t seen any changes, and this is very promising if we consider how rapidly this, like other degenerative diseases, tends to progress at this age,” Dr. Fortunato said.

As far as the procedure is concerned, Dr. Fortunato said no variations are required from the standard modality that is used in adult patients. Only in some cases, when the child is uncooperative and unable to lie still for half an hour, is general anesthesia advisable. – by Michela Cimberle

Michele Fortunato, MD, can be reached at Via Polibio 4, 00136 Rome, Italy; +39-06-397-42614; e-mail: micfortunato@hotmail.com.

This study confirms that keratoconus in pediatric age has a different and dramatically faster progression than in adult eyes, despite the high elasticity of young corneas. We all know how frequently and violently graft rejection occurs in these young patients. Therefore, a minimally invasive therapy that delays and doesn’t preclude corneal transplantation at a later stage is as precious as gold. The author, who can rely on a wide personal experience in one of the most important centers for pediatric ophthalmology in Europe, also noted that no adaptation or variation of the standard treatment protocol is necessary. This is precious and reassuring advice for all those who want to try this procedure in young patients.

- Filippo Simona, MD

President of the Swiss Society of Ophthalmology