September 8



Cornea Cross Linking or CXL in Children with keratoconus has been performed at our Keratoconus treatment centers in Los Angles since 2010.

Lets look at the disease process in kids to understand who needs intervention.

Paeditric keratoconus or Keratoconus disorder in children

The child is usually normal and healthy. Keratoconus eye disorder is associated withthe following Syswtemic diseases.

  1. Downs Syndrome
  2. Mitral valve prolapse
  3. Brittle Bone or Ehlers Danlos syndrome
  4. Marfans
  5. Leber Congenital amaurosis

Keratoconus is associated with some eye conditions like:

  1. Atopic vernal conjunctivits
  2. Anterior polar cataract
  3. Retinitis Pigmentosa

Detection of Keratoconus in Children

The child may complain of poor vision even with glasses. You may notice that the kid rubs his eyes frequently. a frequent change in glasses should definitely arouse suspicion of corneal problem.

The clinician may notice scissoring on streak retinoscopy. Inability to refract to 20/20 and presence of high astigmatism are tell tale sign. On slit lamp exam thinning, apical protrusion, prominent corneal nerves, Vogt striae, Fleischer rings, and/or anterior stromal opacifications may be detected. Diagnosis of keratoconus is confirmed with topography and pachymetry map

Porgression of keratoconus in children

There is a lot of variability of the criteria used to define keratoconus progression in different studies. Some use thinning more than 10 microns in 3months. Others look at steepening of the cornea by 1 to 1.5 D. The consensus is that the progression may proceed rapidly so children need to be examined frequently.

StudyVisual acuityRefractionKeratometryPachymetryTopographyConsiderations
Caporossi et al. [30]UCVA/BSCVA decrease ≥ 1 Snellen lineΔSph or ΔCyl > 0.5 DΔK mean > 0.5 DDecrease in thinnest pachymetry ≥ 10 μmΔSAI/SI > 0.5 DAt least 2 parameters in 3 months

Caporossi et al. [31]UCVA/BSCVA decrease ≥ 1 Snellen lineΔSph or ΔCyl > 0.5 DΔK max⁡ > 1 DDecrease in thinnest pachymetry ≥ 10 μmΔSAI/SI > 0.5 DAt least 3 parameters (1 clinical and 2 instrumental) in 3 months

Vinciguerra et al. [32] Change in Sph or Cyl ≥ 3 DΔK mean ≥ 1.5 D on 2 consecutive topographiesDecrease in CCT ≥ 5% on 3 consecutive tomographies Any parameter in 3 months

Zotta et al. [33] ΔSE > 0.75 DΔK max⁡ of cone apex > 0.75 D  Any parameter in 6 months

Chatzis and Hafezi [34]  ΔK max⁡ > 1 D  Follow-up period of maximum 12 months

Bakshi et al. [35] ΔCyl ≥ 1.5 DΔK max⁡ ≥ 1.5 D  Any parameter at 3 time points in 12 months

Magli et al. [36] ΔCyl > 1 DΔK max⁡ of cone apex > 1 D  Any parameter in 6 months

Shetty et al. [3237]  ΔK max⁡ > 1–1.5 D with corresponding change in refractionDecrease in thinnest pachymetry ≥ 5% Any parameter in 6 months

Zotta et al. [33] ΔCyl ≥ 1 D and ΔSE ≥ 0.5 DΔK max⁡ ≥ 1 D  All 3 parameters on consecutive examinations

UCVA: uncorrected visual acuity, BSCVA: best spectacle corrected visual acuity, Sph: sphere, Cyl: cylinder, SAI: surface asymmetry index, SI: symmetry index, CCT: central corneal thickness, SE: spherical equivalent, and Δ: increase in.

CLEK study showed that one in five pediatric patients with this bulging eye disease become worse with time. Keratoconus experts opine that the advantages of cornea cross linking with riboflavin or C3R may outweigh the risks. Hence it is safer to cross link all kids suffering from keratoconus rather than let the eye deteriorate.

Cornea Cross Linking or CXL in Children with keratoconus

One of the more unusual, yet devastating forms of blindness is known as Keratoconus. This disease occurs when the cornea of the eye becomes thinner and eventually bulges out to cause serious vision impairment. For several years, the only recommended treatments were either gas permeable contact lenses or a full corneal transplant. Gas permeable contact lenses are only effective during the early stages of Keratoconus as the bulge in the cornea will eventually keep the lenses from staying on the eye. Plus, the gas permeable type of contacts are often far more expensive than normal, “soft” contact lenses. A full cornea transplant is rarer and can be expensive, such extreme measures are used when there is no other option and when suitable corneas are available.

Fortunately, there is a new, more effective treatment known as cornea cross linking that has helped thousands of people in restoring their vision around the world and in the Los Angeles area as well. Cornea cross linking uses riboflavin or CXL to help anchor the cornea in place and keep it from bulging outwards. Essentially, instead of artificial anchors being used, the natural anchors of the eye itself which are CXL are increased which helps anchor down the cross linking aspects of the cornea. This does not require and for most patients a one-time event, resulting in the prevention of vision loss for over 95% of the patients in which it is performs with upwards of 70% actually reporting improved vision.

This remarkable method was recently developed and is now becoming a very popular treatment to Keratoconus. The details of such a treatment are pretty simple. The patient is starts by adding non-preservative sterile artificial tears to help water up the eyes that are going to be treated. This in essence prepares the eyes for the additional treatment when they arrive at the office. When the treatment starts, eye drops containing Riboflavin are added every few minutes along with drops that help numb the eye and more artificial tears. To help seal in the Riboflavin, ultraviolet light is then applied at 10 to 15 second intervals for up to 30 minutes depending on the patient and the reaction to the additional crosslinking. Although ultraviolet light is invisible to the naked eye, there is still an effect which will feel like burning though no real damage is being done.

After the CXL treatment is over, the patient is then sent home to rest. The burning sensation will subside over a short period of time and additional artificial tears are then added by the patient. In most cases, the cornea cross linking treatment has been highly successful for stopping the gradual progression of the bulging of the cornea and has in many cases caused the vision to improve. While there are no guarantees, many patients have gone from 20/400 due to the Keratoconus to a mere 20/40 which corrective lenses can easily address. Side effects the CXL include a dryness of the eyes which can be treated by artificial tears. You can learn more about Cornea Cross Linking or CXL in Children with keratoconus at our Keratoconus Seminars.


c3r, cxl, pediatric

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