A Safe Technique Almost Leads To Oblivion Of Harmful Complications

To describe a case report of an keratoconus patient that underwent collagen cross linking (CXL) of the cornea and complicated with corneal abcess.

Cornea Service, Ophthalmology Department, Centro Hospitalar Lisboa Central, Lisbon

A 24 years old male patient with progressive keratoconus underwent CXL in left eye (LE),  original Dresden Protocol (Epi-off) was applied with all the antiseptic and safety measures being adopted before and after the procedure. The procedure underwent without intraoperative complications. 2 days after CXL the epithelium was healing properly but not completely and the eye showed no significant inflammatory signs so therapeutic contact lens (TCL) was left and the patient was medicated with ofloxacin and artificial tears. Day 4 post-procedure the patient went to the emergency room with decreased visual acuity in LE.  In slit-lamp examination it was possible to detect corneal abcess with hypopyon and fibrin in anterior chamber, the visual acuity was hand movements, ultrasonography showed no posterior segment involvement. The patient was admitted to ward, cultures of the lesion were performed and he started empyrical fortified ceftazidime and vancomycin drops 1/1h. Culture results were positive to methicillin-susceptible Staphylococcus aureus sensitive to gentamicin so ophtalmic antibiotic drops were started 4/4h. 3 days after ward admition the cornea perfurated and the perfuration was tamponed by the iris keeping anterior chamber formed, TCL was left and oral doxycicline was introduced and a penetrating keratoplasty was performed. Two weeks post transplant the visual acuity with +4.00 x 0 is 0.6 (decimal).

CXL is a safe procedure with few complications however we must not forget the rare and harmful complications of this technique already described. These patients must be closely monitored to detect complications early and treat according to the need through the various therapeutic modalities.