The Corneal Time Bomb: Managing The Risk Of Bilateral Corneal Melting After Crosslinking For Keratoconus With Pseudomonas Aeruginosa Infection

We present a case of a 23-year-old young woman with a history of intrastromal ring implantation who underwent corneal CXL epi off with bilateral corneal melting associated with pseudomonas aeruginosa infection.

Clinica Oftalmologica Colsubsido, Cundinamarca, Bogotá, Colombia 

A 23-year-old woman with keratoconus and intrastromal ring implantation in both eyes 5 years ago was recommended for corneal cross-linking (CXL) due to progression of keratoconus (OD: K: 52.8X55.7X44.5°; pachymetry 452um, OS: K: 48.7X50.3X79.6°; pachymetry 434um). CXL was performed under the accelerated Dresden protocol, with post-op checks revealing contact lenses and intrastromal rings in position, healing epithelium, no haze, and no infection signs. Eight days later, the patient presented with burning, tearing, redness, and yellow discharge in both eyes, likely due to poor medication adherence. Contact lenses were removed, and cultures confirmed pseudomonas aeruginosa in the right eye (OD). Biomicroscopy showed corneal melting in OD (50% superior to intrastromal ring) and 20% in OS. Vancomycin and ceftriaxone were started, and emergency tectonic transplant was discussed. After 72 hours, progressive corneal melting in OD was confirmed, with positive Seidel's sign. A manual trepanation and tectonic transplant were performed on OD. The patient’s follow-up showed stable grafts with no infection. Two months later, an optic transplant was performed. Post-op, the graft was centered, and no signs of rejection or infection were observed, with best corrected visual acuity (BCVA) of 20/80 at two months.

Refractory infectious keratitis and deep corneal ulcers require urgent intervention to prevent vision loss. Tectonic keratoplasty is an effective emergency treatment when fresh tissue is unavailable, stabilizing the eye's structure, controlling infection, and preparing for future procedures. In the presented case, it managed a severe corneal infection, providing temporary stabilization until fresh tissue became available for a definitive optic transplant. Tectonic keratoplasty is also valuable for corneal thinning or perforation, restoring eye integrity and enabling visual rehabilitation. It is especially useful in donor shortages, efficiently managing tissue resources in emergencies.