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To evaluate long-term outcomes of corneal collagen crosslinking (CXL) using riboflavin and UV-A irradiation and to determine when to repeat CXL. In this retrospective consecutive interventional case series 131 eyes of 131 patients (95 male, 36 female, mean age 29.7 ± 11.4 years) between 2006 and 2016 received standard CXL (Dresden protocol, epithelium-off) for progressive keratoconus. Corrected distance visual acuity (CDVA) and corneal tomography (K 1 , K 2 ,  Kmax ) were repeatedly recorded 1 year ( n  = 103 eyes) to 10 years ( n  = 44) postoperatively. Only one eye per patient was included. Paired  t -test or Wilcoxon matched-pairs signed rank test was used for parametric and nonparametric data, respectively. 1–3 years preoperatively, median K 2  significantly increased by 1.1 D ( p  &lt; 0.001). Postoperatively, median K 2  increased by 0.1 D after 1 year, then decreased over the remaining postoperative period by 0.85 D ( p  = 0.021).  Kmax  fluctuated without significant change. Median apical corneal thickness decreased by 16 µm ( p  = 0.012) after 5 years and then returned to preoperative values. Mean CDVA showed a significant improvement (decrease in logMAR 0.08 after 10 years,  p  = 0.010). CXL non-responders, defined by a postoperative increase in  Kmax &gt;2 D, increased from 16% after 5 to 33% after 10 years. Risk factors for non-response were young age, high astigmatism (&gt;4.3 D), thin cornea (&lt;480 µm), poor initial visual acuity (CDVA ≥0.3 D), and atopic dermatitis. 4 eyes were re-treated 3–4 years after first CXL without complications and keratoconus stabilized thereafter. CXL can slow or stop keratoconus progression. However, as the number of responders declines after 5 years, especially patients with risk factors may require re-treatment.

Long-Term Outcome of Corneal Collagen Crosslinking with Riboflavin and UV-A Irradiation for Keratoconus *