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Outcomes at baseline and 1, 3, 6, and 12\u00a0months included corrected distance visual acuity (CDVA), maximum keratometry (Kmax), minimum corneal thickness (MCT), computerized non-invasive\u00a0tear break-up time (cBUT), Ocular Surface Disease Index (OSDI), and tear MMP-9 (point-of-care test). In vivo qualitative confocal microscopy (IVCM) investigation provided supportive imaging. Paired t-tests were used and results reported with 95% confidence intervals (CI).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      CDVA improved to 0.09 logMAR at 12\u00a0months (\u2248 0.81 decimal; 95% CI: 0.10\u20130.08 logMAR;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.001). Kmax decreased from 55.00 to 53.75 D (95% CI: 53.55\u201353.95 D; \u0394\u2009=\u2009\u2009\u2212\u20091.25 D;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.001), indicating ectasia stabilization. cBUT increased from 10.11 to 14.41\u00a0s (95% CI: 14.11\u201314.71;\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.01). OSDI decreased to 12.15 (95% CI: 11.65\u201312.65). Tear MMP-9 levels diminished from 64.79 to 16.15\u00a0ng\/mL (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.0001) and the proportion\u2009&lt;\u200938.6\u00a0ng\/mL reached 86.7% of the study cohort at 12\u00a0months. IVCM documented disappearance of inflammatory infiltrates. No postoperative persistent adverse events occurred.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Epi-off ACXL stabilized ectasia, improving visual and ocular\u00a0surface outcomes, markedly lowering tear MMP-9 levels. Although exploratory, these findings are consistent with a potential ocular\u00a0surface anti-inflammatory and neuromodulatory role of ACXL, meriting validation in studies involving inflammatory DED beyond keratoconus.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40662-025-00469-7","type":"journal-article","created":{"date-parts":[[2026,1,3]],"date-time":"2026-01-03T07:14:00Z","timestamp":1767424440000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Anti-inflammatory and dry eye benefits of accelerated epi-off corneal cross-linking in pediatric keratoconus with allergic ocular surface disease and elevated MMP-9"],"prefix":"10.1186","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1829-9288","authenticated-orcid":false,"given":"Cosimo","family":"Mazzotta","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caterina","family":"Gagliano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabiana","family":"D\u2019Esposito","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Cappellani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos Rocha","family":"De Lossada","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davide","family":"Borroni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Meduri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Ferrise","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,2]]},"reference":[{"key":"469_CR1","doi-asserted-by":"publisher","first-page":"297","DOI":"10.1016\/S0039-6257(97)00119-7","volume":"42","author":"YS Rabinowitz","year":"1998","unstructured":"Rabinowitz YS. 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Middle East Afr J Ophthalmol. 2019;26(2):95\u2013100.","journal-title":"Middle East Afr J Ophthalmol"}],"container-title":["Eye and Vision"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40662-025-00469-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s40662-025-00469-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40662-025-00469-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,3]],"date-time":"2026-01-03T18:07:01Z","timestamp":1767463621000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s40662-025-00469-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,2]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["469"],"URL":"https:\/\/doi.org\/10.1186\/s40662-025-00469-7","relation":{},"ISSN":["2326-0254"],"issn-type":[{"value":"2326-0254","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,2]]},"assertion":[{"value":"30 July 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"7 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 January 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval for this study was obtained from the Institutional Review Board of the Siena Cross-linking Center, Monteriggioni, Siena, Italy (CXLMMP-9-P1). All procedures were conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all subjects and, for pediatric participants, from their parents or legal guardians.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"2"}}