High-Fluence Epithelium-off Accelerated Pulsed Corneal Cross-linking (15 mW/cm2; 7.2 J/cm2) for Pediatric Keratoconus: A 3-Year Retrospective Analysis

J Refract Surg. 2024 Mar;40(3):e148-e155. doi: 10.3928/1081597X-20240208-01. Epub 2024 Mar 1.


Purpose: To assess the safety and efficacy of treatment and secondarily determine the topographic changes, visual outcomes, and demarcation line depth after high-fluence pulsed light accelerated cross-linking (ACXL) in pediatric patients (younger than 18 years) with progressive keratoconus.

Methods: This retrospective analysis included 32 eyes (25 children, aged 11 to 18 years), with progressive keratoconus treated with high-energy epithelium-off pulsed light ACXL (7.2 J/cm2, 15 mW/cm2, 12 minutes, 2 seconds on/1 second off). Corrected distance visual acuity (CDVA), Scheimpflug tomography, and anterior optical coherence tomography measurements were recorded preoperatively and 1, 2, and 3 years postoperatively.

Results: A total of 32 eyes were included. Significant CDVA improvement, pachymetry, and maximum keratometry reduction were found at all follow-up visits. Mean keratometric values remained stable, and astigmatism showed a mild worsening (< 0.25 D) with statistical significance at 1 and 3 years. Total aberration showed discordant results and coma aberration had a slight improvement without statistical significance. The demarcation line depth was 265 ± 26 μm. Three patients developed mild haze without visual acuity loss. None of the patients underwent a second CXL procedure.

Conclusions: In pediatric patients, high-fluence epithelium-off pulsed light ACXL appears to be a safe and effective procedure to halt the progression of keratoconus, slightly improving the CDVA and keratometric values. [J Refract Surg. 2024;40(3):e148-e155.].

MeSH terms

  • Child
  • Collagen / therapeutic use
  • Corneal Cross-Linking
  • Corneal Topography
  • Cross-Linking Reagents / therapeutic use
  • Epithelium
  • Humans
  • Keratoconus* / drug therapy
  • Photochemotherapy* / methods
  • Photosensitizing Agents / therapeutic use
  • Retrospective Studies
  • Riboflavin / therapeutic use
  • Ultraviolet Rays


  • Photosensitizing Agents
  • Riboflavin
  • Cross-Linking Reagents
  • Collagen