Long-term outcomes of corneal crosslinking for keratoconus across pediatric, adolescent, and adult populations in a diverse U.S. population.

Abstract

Purpose: To evaluate long-term outcomes of epithelium-off corneal crosslinking (CXL) on keratoconus progression and visual function across pediatric, adolescent, and adult cohorts in a diverse U.S. population over a 5-year follow-up period.

Setting: Tertiary care ophthalmology center in the United States.

Design: Retrospective cohort study conducted between January 2017 and October 2025 of patients treated between January 2017 and May 2023. Inclusion criteria required a diagnosis of progressive keratoconus and ≥12 months of follow-up.

Methods: 243 eyes from 193 patients were analyzed, including 80 eyes from pediatric patients (32.9%) younger than 18 years of age. All eyes underwent standard epithelium-off CXL for progressive keratoconus. Clinical parameters, including corrected distance visual acuity (CDVA), maximum keratometry (Kmax), minimum central corneal thickness (CCTmin), and wavefront aberrations (root mean square error), were recorded preoperatively and at 12-month postoperative intervals through 60 months.

Results: CXL was associated with significant and sustained visual and structural improvements. Mean CDVA improved significantly from baseline and remained improved through 60 months ( P < .05). The greatest mean corneal flattening (Kmax) occurred within the first 2 years, with stability maintained through 48 months ( P < .05). Postoperative CCTmin overall declined from preoperative baseline, demonstrating a trend of gradual rethickening consistent with stromal remodeling after 24 months, while remaining below baseline ( P < .05). Wavefront aberrations remained stable, and adverse events were minimal.

Conclusions: CXL is associated with long-term safety and sustained improvements in visual and tomographic outcomes across pediatric, adolescent, and adult patients in a diverse U.S. cohort, supporting timely intervention in progressive keratoconus.