Corneal collagen cross-linking at diagnosis in pediatric keratoconus: A prospective study from the Indian Subcontinent

PURPOSE: To assess the one-year visual, refractive, and tomographic outcomes of corneal collagen cross-linking (CXL) performed at diagnosis in Indian children with keratoconus and to evaluate its safety in eyes with controlled vernal keratoconjunctivitis (VKC). METHODS: Thirty-eight eyes of 30 children (9-18 years) diagnosed with keratoconus underwent standard epithelium-off CXL (Dresden protocol). "At diagnosis" was defined as treatment within four weeks of first topographic confirmation. Outcome measures included uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BCVA), mean refractive spherical equivalent (MRSE), keratometric indices (flat K, steep K, apical K), pachymetry, and endothelial cell density. Statistical analysis included paired and adjusted comparisons with 95% confidence intervals (CIs). RESULTS: UCVA improved from 0.72 ± 0.46 to 0.45 ± 0.42 logMAR ( P < 0.001) and BCVA from 0.37 ± 0.30 to 0.21 ± 0.28 logMAR ( P < 0.001). MRSE improved by 1.72 D ( P < 0.001). Steep K and apical K flattened by 2.02 D and 2.26 D respectively ( P < 0.001). Endothelial cell counts were stable. Subgroup analysis showed no difference between VKC and non-VKC eyes. Three patients developed transient sterile infiltrates that resolved with medical therapy. CONCLUSION: Performing CXL at diagnosis is safe and effective in halting pediatric keratoconus progression while improving visual and refractive outcomes. Early treatment is particularly relevant for high-risk ethnic groups such as Indian children, where keratoconus is aggressive and rapidly progressive.