Retrospective Analysis of Sterile Corneal Infiltrates in Patients with Keratoconus after Cross-Linking Procedure

Abstract

Background: This paper’s objective is to analyze patients with keratoconus who developed sterile infiltrate after corneal collagen cross-linking (CXL), and to evaluate possible risk factors for their occurrence. Methods: 543 medical histories of patients after cross-linking (Epi-off, Epi-on) procedure performed according to the Dresden protocol were analyzed retrospectively. Results: Sterile corneal infiltrates occurred in four men (0.7%) in the age range (16–28) years, the average age being 20.3. The average time from procedure to onset of symptoms was 3.5 days (2–5 days). Inflammatory infiltration resolved in all patients, leaving scars on corneal stroma in two patients. Corneal healing time ranged from 4–12 weeks. In vivo confocal microscopy (IVCM), round inflammatory cells, and Langerhans cells in the epithelium and Bowman’s layer were observed at the site of infiltration. The Optical coherence tomography (OCT) shows hyperreflective lesions of various sizes which decreased over time. The corneal topographic parameters and Best-corrected visual acuity (BCVA) improved after the CXL procedure in all of the described cases. Conclusions: Most likely, damage to the epithelium and the phototoxic effect of the procedure is of significant importance in the formation of sterile corneal infiltrates. Appropriate classification and selection of CXL procedures in combination with protective measures in people at risk may have an overwhelming impact on the incidence of this complication.

Keratoconus: exploring fundamentals and future perspectives – a comprehensive systematic review

“…Steroids should only be administered after considering the increased risks of cataracts, glaucoma, and a weakened immune system. 51 …”

Severe Complications after Corneal Collagen Cross-Linking (CXL)

“…Amongst the pathogens, Acanthamoeba and Pseudomonas species, both ubiquitous germs, are reported to cause the most severe courses of keratitis after CXL, potentially aggravated by atopic disease 14 , 15 . Noninfectious keratitis after epi-off CXL is known and reported to respond well to topical steroids 20 , 21 , 22 , 23 . Cases of sterile corneal melting are described without being able to clearly identify predictive risk factors 24 , 25 , 26 .…”

Immediate postoperative keratitis caused by Rhizopus species following standard CXL for keratoconus: A case report and literature review

“…Bacterial infections are much more common than fungi following CXL due to the entrapment of microbes from the conjunctival cul-de-sac under the static tear pool of BCL. [2][3][4] In tropical countries like India, Mycotic keratitis (MK) is higher, ranging between 14-40% causing fulminant infections. Rhizopus sp are opportunistic human pathogens known to cause a rapid, fatal disease called Mucormycosis.…”

“…The risk factors identified are non-healing epithelial defects (ED), initiation of topical steroids before ED completely heals, and associated co-existing conditions such as allergic eye disease and atopy. [2][3][4] Management of MK is challenging due to the rapid spread of organisms into the deeper stroma. We describe the first case report of corneal ulcer caused by Rhizopus sp, post-CXL, in the immediate postoperative period in a healthy young male.…”