Table A5: Complication Case Reports for Corneal Collagen Cross-Linking*.
| Author, Year | Indication | Complication Event | Outcome |
|---|---|---|---|
| Angunawela R, 2009 (83) | Case Report, 40-year-old patient with progressive KC treated with CXL. | Non-infective keratitis, treated with preservative-free levofloxacin and dexamethasone 0.1% followed by prednisone acetate 1% and topical agents | Complete resolution of infiltrates but with residual marginal corneal thinning |
| Gokhale N, 2010 (84) | Case report, 19-year-old male with progressive bilateral KC treated bilaterally with CXL | 1 week postoperatively presented with redness, watering, pain, loss of vision in his right eye. On exam right eye diffuse conjunctivitis, central corneal melt with severe thinning and perforation with adjacent edema. | A temporary cyano-acrylate glue applied bandage contact lens was applied until a donor cornea was available. A therapeutic keratoplasty was performed 5 days later. Histologic examination of the corneal button revealed central area of stromal loss with perforation. Stains for fungus and bacteria were negative. |
| Hafezi F, 2008 (87) | Case report, 33-year-old female. Post LASIK developed iatrogenic bilateral keratectasia during first pregnancy treated with CXL and resulting in exacerbation of keratectasia during second pregnancy | Bilateral iatrogenic keratectasia exacerbated during pregnancy | Not reported |
| Koppen C, 2009 (89) | Case report, 28-year-old female with bilateral progressive KC underwent CXL in right eye | On second postop day presented with redness, increasing pain and milky vision. On exam strong ciliary flush and presence of white superficial infiltrates. Cultures were negative and presumptive diagnosis of sterile keratitis that responded to high dose of topical corticosteroids. | At 1 year there was central and superior scarring in superficial stroma leading to a decreased visual acuity. |
| Koppen C, 2009 (89) | Case report, 17-year-old male with bilateral rapidly progressing KC underwent CXL in the left eye | On the second postop day presented with strong ciliary flush, white superficial infiltrates, and iritis with keratic precipitates. Cultures were negative. The epithelium defect healed slowly over 2 weeks. Iritis and keratitis responded to topical steroids. | At 7 months scar formation in the central stroma of the central cornea persisted leading to a decreased visual acuity resulting in subsequent keratoplasty. |
| Koppen C, 2009 (89) | Case report, 23-year-old male with KC and intolerant to RGP lenses underwent CXL in right eye | On fourth postop day, strong ciliary flush, white superficial infiltrates over the treated zone. Responded to treatment involving sub-conjunctival injection of steroids and changed antibiotics to ofloxacin. | At 6 months visual acuity returned to baseline. The other eye did not undergo CXL. |
| Koppen C, 2009 (89) | Case report, 31-year-old male with bilateral KC underwent successful CXL in the right eye 3 months previous to the CXL in the left eye | At the first postop day, signs of pronounced inflammation, corneal edema, irregular epithelium and corneal infiltrates. Treated with sub-conjunctival injection of steroids. | At 5 months post op, visual acuity was reduced over baseline |
| Kymionis G, 2007 (78) | Case report, 21-year-old female with bilateral KC treated by CXL in right eye and planned penetrating keratoplasty in left eye | Herpetic keratitis with iritis On day 5 geographic epithelial defect, stromal edema and cells in the anterior chamber treated initially with topical steroids then to acyclovir with diagnosis herpes simplex virus | Decrease in stromal edema, presence anterior chamber cells and at 2 months a mild central corneal opacity remained |
| Kymionis G, 2007 (88) | Case report, 27-year-old male, CXL 4 years post LASIK for iatrogenic ectasia | Diffuse lamellar keratitis On first postoperative day inflammation with infiltrates covering the interface including the central cornea | After an intensive course every 2 hours of corticosteroid (dexamethasone 1%) inflammation responded rapidly and by 9th day infiltrates had resolved |
| Labiris G, 2011 (85) | Case report, 23-year-old male with bilateral progressive KC underwent CXL in the left eye | During the first postoperative day developed intense photophobia, watering and a nonspecific ocular discomfort. Intensive examination for autoimmune and infectious diseases were all within normal limits. Repeated cultures from the cornea and contact lens were negative. | Cornea presented slow re-epithelialization and progressive thinning resulting in descemetocele and perforation in the second month and underwent successful penetrating keratoplasty. Concluded that nonspecific irreversible damage to keratocytes resulting in corneal melting had occurred. |
| Mangioris G, 2010 (86) | Case report. 25-year-old female with bilateral KC underwent CXL. | Presented 5 days post CXL with multiple deep infiltrates in periphery of cornea near limbus. Corneal scraping and secretions were negative for organisms | At 2 months some nebulae remained in the central cornea and visual acuity was reduced. |
| Perez-Santonja J, 2009 (79) | Case report, 29-year-old female with progressive bilateral KC. CXL in right eye for stage 1 KC and 1 month later ICRS implants in the left eye for stage 11 KC. | Microbial keratitis, photophobia and blurring in the CXL treated right eye, culture proven Staphylococcus epidermidis treated with topical ofloxacin 0.3% and tobramycin at 1-hr intervals. | Ocular inflammation and corneal infiltrates improved rapidly and at 5 months postop a mild haze was detected |
| Pollhammer M, 2009 (80) | Case report, 42-year-old patient with KC treated with CXL and postoperatively experiencing pain and progressive reduction in visual acuity | Stromal infiltrates and anterior chamber inflammation due to bacterial infection with Escherichia coli | Infection successfully treated after several weeks with tobramycin and cephazolin eye drops Resulted in avascularized corneal scar and permanent reduction of visual acuity |
| Rama P, 2009 (81) | Case report, 32-year-old man with bilateral KC treated with CXL in the left eye reported conjunctival redness and discharge 3 days postoperatively | Progressive corneal involvement with corneal opacification and despite intensive oral and topical antibiotics and steroids for infection with Acanthamoeba, persisting severe inflammation with corneal ectasia and subtotal de-epithelialization | Corneal ulceration with melting and cornea perforation on day 11 followed by penetrating keratoplasty. At 2 months the graft was clear with no sign of infection |
| Rodriguez-Ausin P, 2011 (76) | Case reports, 21-year-old patient with bilateral progressive grade 111 KC treated with CXL in the left eye and 9 months later CXL in the right eye. Referred for slight pain and low visual acuity in right eye 48 hours postoperatively | Corneal infiltrates with ulcer and despite 3 weeks intensive oral and topical antibiotic treatment (cultures were negative or bacteria or fungi) stromal opacities persisted at 3 weeks and at 2 months corneal leucomas and inferior thinning | At one year, KC stabilization was reported and a bilateral toric ICL implantation significantly improved bilateral visual acuity |
| Rodriguez-Ausin P, 2011 (76) | Case report, 11-year-old male with grade 3 to 4 KC treated initially with contact lenses to improve visual acuity and subsequently treated with CXL for bilateral progressive KC | After CXL 48 hours sterile corneal infiltrates (cultures negative for bacteria, fungi or parasites) and after intensive antibiotic and steroid treatment at 3 months detected in right eye stromal haze and stromal inflammatory infiltrates | At 12-month F-up the right eye showed progression, worsening of best corrected visual acuity with contact lens (1 line lost) and grade 2 para-central scarring |
| Sharma N, 2010 (82) | Case report, 19-year-old female with KC underwent CXL in the right eye and on fourth postop day presented with 3-day history of pain, redness and decreasing vision in the right eye | On exam corneal infection along with a corneal ulcer with central infiltrates with epithelial defect involving 90% of the corneal depth. Corneal scrapings were positive for Pseudomonas aeruginosa which responded to antibiotic treatment | At 2 months infiltrates decreased in size and a leucomatous corneal opacity remained with greatly reduced visual acuity. An optical keratoplasty is planned for visual rehabilitation. |
| Zamora K, 2009 (77) | Case report, 32-year-old male with KC underwent CXL in the left eye and presented on the third postop day with a 1-day history of red painful eye. | On exam conjunctival infection, severe keratitis with central corneal epithelial defect, ring of infiltrates and dense fibrin reaction throughout the anterior chamber. Cultures from the contact lens were positive for Streptococcus salivarius and S oralis. And corneal scrapings were positive for Staphylococcus sp. | At 2 months, residual central corneal stromal haze and a sub-epithelial scar in a ring-like configuration remained |
*
CXL indicates corneal cross-linking; ICRS indicates intrastromal corneal ring segment; KC indicates keratoconus; RGP indicates rigid gas permeable.