RING INFILTRATES ON THE FIRST POSTOPERATIVE DAY AFTER CORNEAL COLLAGEN CROSSLINKING.

Corneal collagen crosslinking is a common practice for managing keratoconus and considered safe and effective. As with any other surface corneal procedures, a variety of complications can occur. We will explore the differential diagnosis for a ring infiltrate and/or keratitis postoperatively with guidelines for management.

A 21 year-old male with progressive keratoconus (Grade 1) in the right eye and stable keratoconus suspect in the left eye, underwent corneal collagen crosslinking in the right eye. Because the patient had G6PD deficiency, he was started on Maxitrol eyedrops four times per day (fluoroquinolones are contraindicated). Oxybuprocain 0.04% was given three times a day as needed for pain. On the first postoperative day, he was noted to have a ring infiltrate in the right eye surrounding the epithelial defect and with diffuse infiltrates in the anterior one third of the stroma within the area of the defect. Viral and bacterial cultures were taken. Oxybuprocain eyedrops was stopped and hourly topical fortified vancomycin (25mg/ml) and gentamycin (14mg/ml) were started every 1 hour. Oral valacyclovir 1g three times/day was started. Topical prednisolone acetate 1% was increased to every hour. Three days postoperatively, eye cultures grew Streptococcus pneumoniae. After prolonged treatment, the corneal epithelial surface healed but with significant scarring and neovascularization.

Aggressive infectious keratitis uncommonly presents on postoperative day one and other entities should be kept in mind and addressed initially. However, keeping in mind an infectious etiology is essential to prevent progression with further complications.