The introduction of corneal collagen cross-linking (CXL) in routine clinical practice has changed the management of keratoconus (KC) in the adult population. Due to its success in adult patients, CXL is now being utilized to stop or slow the progression of KC in the pediatric age group (< 18 years old) as well.

Early CXL intervention can minimize and/or prevent the typical sequelae of events leading to corneal thinning, penetrating keratoplasty, and reduced acuity (Panos et al, 2017; Kankariya et al, 2013). Additionally, it may eliminate the overall need for specialty contact lenses and/or glasses (Panos et al, 2017; Kankariya et al, 2013).

Although KC is most frequently diagnosed after adolescence, the corneal ectasia process starts at a younger age (Kankariya et al, 2013). KC presents at a higher rate of progression (88%) and is more aggressive (seven-fold higher risk of requiring corneal grafting) in pediatric patients as compared to the adult KC progression rate (25%). Due to this high rate of progression and severity in the pediatric population, some practitioners have proposed that awaiting documented progression is not mandatory and that CXL should be performed in children and adolescents as soon as the diagnosis is made (Chatzis and Hafezi, 2012; Cimberle, 2017; Buzzonetti et al, 2017; Eisenberg, 2012). In fact, this approach is becoming the standard of care in many European countries.

A New Approach

We believe that a team approach can provide the highest level of care for KC patients. Ideally, patients should have access to a centralized practice in which there is collaboration among optometrists, ophthalmologists, technicians, and support staff focused on KC diagnosis and treatment. The eyecare center should be equipped with a tomographer and aberrometer as well as be able to provide CXL and other surgical services related to KC (e.g., intrastromal rings, different types of corneal transplants, etc.).

With this focus, children could be screened for KC, and early intervention with CXL could prevent further progression and poor outcomes. Current KC patients could also be managed properly with optical and, if needed, surgical solutions.


  • Family history of KC
  • Frequent eye rubbing (allergies)
  • Down syndrome
  • Excessive changes in prescription, especially astigmatism
  • Unexplainable uncorrectable vision to 20/20
  • Extreme sensitivity to bright lights, halos, or glare
  • African-American, Hispanic, and Middle Eastern descent

Our Role

Given that more than 70% of patients who have KC first present to eyecare practices, practitioners can play an important role in early detection (Eisenberg, 2012).

When examining children at risk for KC, counsel the parents and recommend that siblings also be screened. Also perform tomography. If unavailable in your office, establish a relationship with another practice that has the technology for early detection and treatment. If you are providing care for adults who have KC, recommend that their children be screened as well.


Early intervention with CXL is important, because patients are not candidates for CXL once corneal thickness is under 400μm (Krader, 2011). In addition, if the keratoconus is not treated early, it may lead to progressive visual impairment in pediatric patients, which can also affect their social and educational development and, thus, negatively affect their quality of life (Kankariya et al, 2013). Our failure to embrace this new standard of care will reduce the quality of life for children at risk for KC. CLS

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