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Risk factors for microbial keratitis after corneal collagen cross-linking with epithelial debridement

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Session Details

Session Title: Cornea
Session Date/Time: Friday 09/02/2018 | 08:30-10:00
Paper Time: 09:27
Venue: Annex A

First Author: A.Tzamalis UK
Co Author(s): V. Romano  R. Cheeseman  R. Vinciguerra  C. Willoughby  M. Batterbury  S. Kaye  

Abstract Details


To identify common risk factors for microbial keratitis after epithelium-off corneal collagen cross-linking.


St Paul’s Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK


All patients undergoing collagen corneal cross-linking between February 2011 and July 2017 for the management of progressive keratoconus were identified through a systematic search in the electronic database and enrolled in a retrospective cohort study. Their medical records were thoroughly reviewed and cases of microbial keratitis were identified and further analysed. Possible risk factors for the development of microbial keratitis were recorded by all cases and included in a separate analysis.


1273 eyes of 964 patients were identified and included in the analysis. 9 eyes of 8 patients (0.71% of treated eyes) developed microbial keratitis 1 to 5 days after CXL. A greater proportion of patients developing microbial keratitis were atopic (75%). Staphylococcus aureus was the only pathogen identified, being isolated from the cornea in 4 patients, from the conjunctiva in 2 patients and the nose in 3 patients. After modifying postoperative treatment protocol to exclude the use of bandage contact lens and topical steroids before complete epithelial healing, no further cases of microbial keratitis were detected in 957 eyes, yielding a statistical significant difference (p<0.0001) in comparison to the incidence of microbial keratitis before modification (9/316, 2.8%).


This large retrospective case analysis shows that commensal organisms in sites contiguous with the cornea may pose an infection risk to patients undergoing epithelium-off corneal collagen crosslinking, particularly those with a history of atopic disease. The postoperative use of bandage contact lens and topical steroids before epithelial healing are identified as main risk factors for the development of microbial keratitis after CXL.

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