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Rapid keratitis and perforation after corneal collagen cross-linking.

ABSTRACT: Purpose:To describe a case of rapid keratitis and corneal perforation after epithelium off collagen cross-linking. Observations:We report a case of a 17-year-old male who underwent collagen cross-linking with the protocol and device approved by the United States Food and Drug Administration (FDA) that developed a corneal infiltrate 3 days after the procedure. He later developed corneal thinning and perforation on day 5 requiring the use of cyanoacrylate glue and a Kontur lens. Despite initial improvement in the infiltrate with fortified antibiotics he later had leakage of aqueous around the glue and a flat chamber requiring an emergent penetrating keratoplasty on postoperative day 16. Conclusion and importance:While collagen cross-linking has been very effective for treating keratoconus and is being recommended more frequently since FDA approval in the United States, severe complications such as corneal perforation requiring early transplant can still occur.

SUBMITTER: Schear M

PROVIDER: S-EPMC7132167 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Rapid keratitis and perforation after corneal collagen cross-linking.

Schear Matthew M Ragam Ashwinee A Seedor John J Udell Ira I Shih Carolyn C

American journal of ophthalmology case reports 20200313

<h4>Purpose</h4>To describe a case of rapid keratitis and corneal perforation after epithelium off collagen cross-linking.<h4>Observations</h4>We report a case of a 17-year-old male who underwent collagen cross-linking with the protocol and device approved by the United States Food and Drug Administration (FDA) that developed a corneal infiltrate 3 days after the procedure. He later developed corneal thinning and perforation on day 5 requiring the use of cyanoacrylate glue and a Kontur lens. Des ...[more]

PMID: 32274444

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Corneal collagen cross-linking for bacterial infectious keratitis.

Project description: Not available

| S-EPMC7389372 | biostudies-literature

Sterile keratitis after combined riboflavin-UVA corneal collagen cross-linking for keratoconus.

Project description:PurposeTo investigate patient risk factors and to look for potential causes of sterile infiltrates following an unexpected cluster of sterile keratitis after a routine collagen cross-linking (CXL) list.MethodsThe records of all 148 cases of CXL were reviewed retrospectively. The equipment and solutions used and our clinic's standard operating procedure for CXL were reviewed. An in-vitro experiment to explore the variation in ultraviolet A (UVA) irradiance from fluctuations in the working distance of the UVA lamp was conducted.ResultsThe four patients who developed sterile infiltrates had steeper maximum corneal curvatures (68.0±7.3?D) and thinner pachymetry (389.9±49.0??m) than the 144 who did not (57.0±8.2?D, P=0.05; 454.6±45.4??m, P=0.08). A corneal curvature of >60?Dand a pachymetry of <425??m were significant risk factors. All four affected cases obtained a complete resolution with topical antibiotics and steroids. The unaided VA and the maximum K improved from their pre-operative levels in three out of four patients. A 2-mm reduction in distance of the VEGA C.B.M. X-Linker from a treated surface increased irradiance to 3.5-3.7?mW/cm(2), which is above the threshold for endothelial toxicity.ConclusionPatients with thinner and steeper corneas are at an increased risk of developing sterile keratitis. The visual outcomes despite this complication are good.

| S-EPMC4274277 | biostudies-literature

Corneal Perforation After Corneal Cross-Linking in Keratoconus Associated With Potentially Pathogenic ZNF469 Mutations.

Project description:PurposeTo report a case of bilateral and repetitive corneal perforations after corneal cross-linking (CXL) for keratoconus in a woman harboring potentially pathogenic variants in the ZNF469 gene and to characterize the keratoconus phenotype in this woman and her daughter who shared the same ZNF469 mutations.MethodsClinical characterization of the proband and her daughter followed by sequencing of the genes associated with brittle cornea syndrome, ZNF469 and PRDM5, in both individuals.ResultsAn Ashkenazi Jewish woman in her sixth decade presented with diffuse corneal thinning and progressive steepening consistent with keratoconus. After CXL, epithelium-off in the first eye and epithelium-on in the second, she developed spontaneous corneal perforations in each eye. Her daughter in her fourth decade demonstrated a similar pattern of diffuse corneal thinning and progressive corneal steepening but did not undergo CXL and did not develop corneal perforation. Screening of the ZNF469 and PRDM5 genes revealed 3 missense ZNF469 variants (c.2035G>A, c.10244G>C, and c.11119A>G) in cis arrangement on 1 allele of ZNF469 in both proband and her daughter. Although the 3 variants share low (<0.01) global minor allele frequencies, each has significantly higher minor allele frequencies (0.01-0.03) in the Ashkenazi Jewish population, leading to uncertainty regarding a pathogenic role for the identified variants.ConclusionsCXL may be associated with the development of corneal perforation in particular at-risk individuals with keratoconus. Identifying clinical and genetic risk factors, including screening of ZNF469 and PRDM5, may be useful in the prevention of significant complications after CXL.

| S-EPMC6612572 | biostudies-literature

Corneal Collagen Cross-Linking for Keratoconus: Systematic Review.

Project description:To evaluate the efficacy of collagen cross-linking (CXL) one year after treatment for keratoconus compared to no treatment by summarizing randomized controlled trials (RCTs) using a systematic review.Trials meeting the selection criteria were quality appraised, and the data were extracted by two independent authors. The outcome parameters included maximum keratometry (Kmax), corneal thickness at the thinnest point, best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), spherical equivalent (SE) refraction, and cylindrical refraction one year after CXL. We compared the changes in the above parameters with the control group.We identified five RCTs involving 289 eyes that met the eligibility criteria for this systematic review. The changes in BSCVA from baseline to one year exhibited a significant difference between the two groups. There was no statistically significant difference between the two groups for changes in corneal thickness and cylindrical refraction. We did not conduct a meta-analysis in Kmax, UCVA, and SE refraction because their I2 values were greater than 50%.According to the systematic review, CXL may be effective in halting the progression of keratoconus for one year under certain conditions, although evidence is limited due to the significant heterogeneity and paucity of RCTs.

| S-EPMC5485290 | biostudies-other

Epithelium-on Corneal Collagen Cross-Linking with Hypotonic Riboflavin Solution in Progressive Keratoconus.

Project description:IntroductionEpithelium-off cross-linking (epi-off CXL) has long been established as the gold standard treatment for progressive keratoconus. Several protocols for epithelium-on (epi-on) CXL have been proposed to help reduce post-operative pain and facilitate visual recovery, but there is no epi-on treatment approach that is currently approved in the United States. The hydrophilic and macromolecular characteristics of conventional epi-off riboflavin formulations may create clinical challenges for absorption through an intact epithelium. This study investigates the clinical efficacy of a dextran-free hypotonic riboflavin ophthalmic solution (Photrexa, Glaukos, Burlington, MA, USA), approved for epi-off CXL, in a novel epi-on CXL protocol.MethodsTwenty-five eyes of 17 patients were treated in this prospective, single-arm study using a hypotonic riboflavin formulation without dextran and low irradiance UVA (3mW/cm2) for epi-on CXL. Visual acuity, as well as refractive and keratometry outcomes, were observed over 12 months.ResultsAt 12 months, Kmax was stable with no clinically or statistically significant change from a mean pre-op of 55.4D to 55.9D (p=0.13). Uncorrected and best corrected logMAR visual acuity significantly improved from 0.77 to 0.62 and from 0.17 to 0.12, respectively. There were no significant adverse safety events.ConclusionPatients who underwent epi-on CXL with dextran-free hypotonic riboflavin demonstrated improvements in uncorrected and best corrected visual acuity with stable keratometry at 12 months post-operatively. The efficacy is consistent with other epi-on studies to date but remains lower than standard epi-off CXL. New technologies, including supplemental oxygen and transepithelial riboflavin ophthalmic solutions, are currently under clinical evaluation and may offer a path forward for epi-on CXL in the USA.

| S-EPMC8273905 | biostudies-literature

Comparing the effects of two different contact lenses on corneal re-epithelialization after corneal collagen cross-linking.

Project description:To investigate whether keratoconus (KC) patients who applied the corneal collagen cross-linking (CXL) and two different contact lens (CL) showed any differences in complaints and findings following the CXL.This prospective, comparative, double-blind clinical study involved 60 eyes of 60 patients (38 female and 22 male). At the end of the CXL procedure, CL (Balafilcon A) was inserted in 29 patients (Group-1) while CL with different material content (Hioxifilcon A) designed for therapeutic/bandage purposes were inserted in 31 patients (Group-2).On the 1st and 3th day after the CXL, there were no statistically significant differences between the groups in terms of the postoperative symptoms. On the 3th day after the CXL, all cases of both two groups were found to complete the corneal re-epithelialization. There was more PE ratio in the patients who had allergic conjunctivitis.With the use of Balafilcon A and Hioxifilcon A lens materials, KC patients who underwent the CXL were found to have similar symptoms and clinical findings after the CXL. However, epithelial staining and PE were observed more in KC cases accompanied by allergic conjunctivitis.

| S-EPMC5510126 | biostudies-other

Corneal collagen cross-linking epithelium-on vs. epithelium-off: a systematic review and meta-analysis.

Project description:BackgroundThe purpose of the study was to determine the advantages and disadvantages of epi-on corneal cross-linking (CXL) techniques compared with standard epi-off CXL.MethodsWe searched MEDLINE and EMBASE for randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) and we evaluated the selected papers according to the Cochrane risk of bias tool. We considered, as primary outcomes, average Kmax flattening, changes in uncorrected and corrected distance visual acuity (UDVA and CDVA); as secondary outcomes, we considered changes in pachymetry values and endothelial cell density (ECD). We also investigated adverse events related to the treatments and treatment failure. Meta-analysis was conducted with a fixed or random-effects model using weighted mean difference (MD) with 95% confidence interval (CI) as the effect size.ResultsA total of 15 studies were included and among these 15 trials, 9 were RCTs and 6 were NRSIs, but only 4 studies showed no high risk of bias and were included in this meta-analysis. Our analysis revealed significant postoperative differences in CDVA (MD = 0.07; 95% CI 0.04 to 0.10; P < 0.001), and no significative differences in UDVA, Kmax, central corneal thickness (CCT) and ECD (P > 0.05). Epi-on CXL protocol was found to be significantly less prompt to have risks of delay in epithelial healing (P = 0.035) and persistent stromal haze (P = 0.026).ConclusionEpi-on CXL is as effective as epi-off CXL. Except for a higher significant improvement in CDVA with current epi-on protocols, our meta-analysis demonstrates that epi-on and epi-off CXL have comparable effects on visual, topographic, pachymetric, and endothelial parameters. Epi-on CXL has clinical advantages in terms of comfort and avoidance of complications as it reduces the risk of developing delay in epithelial healing and persistent stromal haze.

| S-EPMC8465763 | biostudies-literature

Corneal Collagen Crosslinking Treatment in a Case with Pneumococcal Keratitis.

Project description:Bacterial keratitis is a serious ocular infectious disease that can threaten vision. The disease generally progresses rapidly and can lead to corneal scar, stromal abscess formation, perforation, and dissemination to adjacent tissues if not treated properly. Recent studies showed that corneal collagen crosslinking (CCC) using ultraviolet-A/riboflavin is effective in the treatment of bacterial keratitis refractory to topical antibiotic treatment. In addition to being bactericidal, CCC also decreases risk of perforation by strengthening the corneal collagen structure. Herein, we report a male patient with Streptococcus pneumonia keratitis 6 months after a keratoplasty procedure, which did not respond to fortified topical antibiotic therapy and was treated successfully with riboflavin/ultraviolet-A CCC. His pain decreased remarkably in a few days. The corneal epithelial defect healed and infiltration regressed within 2 weeks after CCC. His vision improved significantly from hand movement to 20/400. CCC might be used as adjuvant treatment in bacterial keratitis refractory to medical treatment.

| S-EPMC5468530 | biostudies-other

Protection of Corneal Limbus from Riboflavin Prevents Epithelial Stem Cell Loss after Collagen Cross-Linking.

Project description:To investigate whether the protection of corneal limbus from riboflavin exposure during collagen cross-linking (CXL) prevents limbal epithelial stem cell (LESC) loss.Ten New Zealand white rabbits received an epithelium-off CXL using an accelerated protocol. Seven days before procedure, 5-bromo-2-deoxyuridine (BrdU) was intraperitoneally injected. During procedure, riboflavin was applied to the corneal surface within a 9?mm diameter retention ring in 5 rabbits, thereby preventing the limbus from riboflavin exposure. In other 5 rabbits, riboflavin was instilled every 2?min, allowing the spillover to the limbus. One day after UVA irradiation, corneas were subjected to histological and molecular assays.There were no differences in corneal thickness and epithelial healing between the groups. The numbers of BrdU-labelled and p63+ limbal epithelial cells were markedly reduced in the group without a ring, but significantly increased when a ring was used. Robust expression of CK3/12 was observed in the limbal epithelium in the group with a ring. The mRNA levels of ABCG2, FGF2, IL-1?, and IL-6 were significantly increased in the corneas with a ring.Protection of limbus from riboflavin during CXL was effective in preserving LESCs. However, inflammation was increased in the cornea treated with riboflavin using a ring.

| S-EPMC6008863 | biostudies-other

Corneal collagen cross-linking with and without epithelial removal: a contralateral study with 0.5% hypotonic riboflavin solution.

Project description:Our main purpose was to compare safety and efficacy in the treatment of progressive keratoconus with "epithelium-on" and "epithelium-off" corneal collagen cross-linking (CXL). Our secondary purpose was to evaluate efficacy of CXL when hypotonic 0.5% riboflavin is used as photosensitizer.One eye of 20 patients with bilateral progressive keratoconus was randomly treated for "epithelium-on" CXL (group 1) while the fellow eye underwent "epithelium-off" CXL (group 2). Hypotonic 0.5% riboflavin was used in both groups. Visual acuity, refraction, corneal topography, and wavefront aberrometry were evaluated at baseline and after 1, 6, and 12 months. Specular microscopy was performed on 10 patients preoperatively and after 12 months. Postoperative pain was evaluated using a patient questionnaire.Uncorrected and corrected distance visual acuity improved significantly in both groups. Refraction, topography, and aberrometry showed nonsignificant changes from the preoperative status throughout the 12-month follow-up in both groups. Moreover, the outcomes between the groups were comparable at all follow-up points. Endothelial cell-count was stable. Postoperative pain length was shorter in group 1 (P < 0.001)."Epithelium-on" and "epithelium-off" CXL using hypotonic 0.5% riboflavin were equally safe and effective in stabilization of keratoconus. Topography and aberrometry outcomes in both groups failed to show any significant improvements. This study is registered at ClinicalTrials.gov: NCT01181219.

| S-EPMC4090564 | biostudies-literature

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