Comparative effectiveness of accelerated and standard corneal cross-linking in pediatrics: a systematic review and meta-analysis.

PURPOSE: We aim to evaluate the efficacy and safety of accelerated corneal collagen cross-linking (CXL) compared with standard CXL in pediatric keratoconus.

METHODS

We conducted comprehensive search of PubMed, Scopus, Embase and Web of Science until September 2025. Studies comparing accelerated (9 mW/cm² × 10 min or 18 mW/cm² × 5 min) with standard (3 mW/cm² × 30 min) epithelium-off CXL in patients < 18 years were included. Primary outcomes were spherical equivalent (SE), uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA) and maximum keratometry (K-max). Data was pooled using a random-effects model and risk of bias was assessed with ROB-2 and NOS.

RESULTS

Eight studies were included involving 571 eyes and 464 patients. No significant differences were found between accelerated and standard CXL in mean SE (MD = - 0.02, P = 0.84), UCVA (MD = - 0.06, P = 0.08) BCVA (MD = - 0.02, P = 0.47) or K-max (MD = 0.28, P = 0.72). Heterogeneity was low for SE, UCVA and BCVA but high for K-max. Sensitivity analyses confirmed robustness of results.

CONCLUSIONS

Accelerated CXL provides visual and topographic outcomes equivalent to standard CXL while offering significantly shorter procedure times. These findings suggest that accelerated epithelium-off CXL may be a feasible short- to mid-term alternative in selected pediatric patients, but long-term safety and durability require further confirmation.