Long Term Follow-up of Corneal Collagen Cross-Linking in Pediatric Keratoconus

Abstract Purpose: To evaluate the long-term outcomes of epithelium-off corneal collagen cross-linking using the Dresden protocol in pediatric keratoconus patients. Methods: This retrospective case series included pediatric patients who underwent standard collagen corneal cross-linking at a single site. Clinical assessment comprised visual acuity, refraction, and Scheimpflug tomography. A minimum follow-up of 60 months was required. The protocol consisted of UVA irradiation at 3 mW/cm² for 30 minutes (total dose 5.4 J/cm²). Postoperative management included topical antibiotics until re-epithelialization and corticosteroids for 2 weeks. Results: Twenty-three eyes of 13 patients (mean age 15.35 years; range: 12–17.5) were analyzed with a mean follow-up of 12.18 ± 2.92 years. Uncorrected distance visual acuity improved from 0.70 ± 0.44 to 0.41 ± 0.40 logMAR (p < 0.001), while corrected distance visual acuity improved from 0.26 ± 0.22 to 0.09 ± 0.16 logMAR (p < 0.001). Mean flat and steep keratometry remained stable (p > 0.05), while maximum keratometry decreased significantly from 53.88 ± 8.05 D to 52.43 ± 6.97 D (p = 0.009). Only one eye (4.3%) progressed by > 1 D in maximum keratometry. No permanent corneal haze was observed Conclusions: Standard epithelium-off corneal cross-linking using the Dresden protocol is safe and effective in halting keratoconus progression in pediatric patients. Long-term follow-up demonstrated durable disease stabilization, significant visual improvement, and minimal complications, supporting early intervention as the standard of care in this high-risk population.