Keratoplasty In Pediatric Keratoconus: 13-Year Review

Corneal transplantation in pediatric patients with keratoconus is indicated for advanced disease with significant visual impairment not amenable to other surgical treatments such as corneal cross-linking or intrastromal segments. Given the aggressive course of pediatric keratoconus and the technical and postoperative challenges associated with corneal transplantation in children, this study aims to evaluate the clinical profile, disease severity, indications, and outcomes of pediatric patients with keratoconus undergoing penetrating keratoplasty (PK), with particular emphasis on the factors leading to corneal transplantation during pediatric age.

Department of Ophthalmology, Unidade Local de Saúde de São João, a tertiary ophthalmic referral centre in Porto, Portugal.

Retrospective observational study including all pediatric patients (≤18 years) who underwent PK due to keratoconus at a tertiary referral hospital between 2011 and 2024 with a minimum 12-month follow-up. Demographic data, keratoconus severity stages, keratometric and pachymetric indices (thinnest pachymetry, Kmax, Kmedium, ARC, PRC, anterior astigmatism, BAD-D index), mid-term visual and graft outcomes were analyzed. Pre- and postoperative best-corrected visual acuity (BCVA) and tomographic parameters were compared.

Seventeen patients (14 male) underwent 21 PKs. Mean age at surgery was 16.3 ± 2.0 years, with a mean follow-up of 88.5 ± 55.7 months. In terms of disease severity, 12 eyes were classified stage IV Amsler-Krumeich and 5 had a history of previous acute corneal hydrops. Mean preoperative thinnest pachymetry was 332.3 ± 88.4 μm and mean Kmax 80.8 ± 7.4 D. BCVA improved significantly from 1.15 ± 0.55 to 0.14 ± 0.10 logMAR (p < 0.001), at last follow-up. All tomographic parameters improved significantly postoperatively (p < 0.001). Only one eye required re-transplantation due to graft–host ectasia.

In this series, penetrating keratoplasty for pediatric keratoconus was reserved for markedly advanced disease, frequently associated with extreme corneal thinning, very steep curvature, or previous acute hydrops. Despite this unfavorable preoperative profile, keratoplasty provided substantial and sustained visual rehabilitation with low complication rates in the mid-term follow-up. These findings underscore the aggressive nature of pediatric keratoconus and highlight the importance of early detection and timely conservative intervention to reduce the need for corneal transplantation during childhood and adolescence.