When Prevention Turns Into Emergency: Severe Early Complications After Epithelium-Off Corneal Cross-Linking

To report and analyze severe early postoperative complications occurring after epithelium-off corneal cross-linking (CXL) performed for progressive keratoconus in young patients, and to highlight the potential progression from inflammatory or infectious corneal damage to structural compromise requiring therapeutic keratoplasty. Through three clinical cases, we aim to emphasize that although CXL is considered a preventive and stabilizing procedure, it may exceptionally lead to sight-threatening outcomes demanding aggressive medical and surgical intervention.

Department of Ophthalmology, Tertiary Referral Center for Corneal Diseases and Keratoplasty, Hospital Cheikh Zaïd, Rabat, Morocco. The center manages advanced keratoconus cases and complex postoperative corneal complications referred from regional institutions, including severe infectious keratitis and corneal melting requiring urgent surgical management.

We retrospectively analyzed three patients aged 15 to 19 years referred between postoperative day 2 and day 4 after epithelium-off CXL. All presented with intense ocular pain and marked visual acuity decrease. Clinical assessment included BCVA measurement, slit-lamp examination documenting corneal infiltrates, necrosis, neovascularization or perforation, anterior chamber evaluation, and microbiological sampling. Intensive topical fortified antibiotics and systemic therapy were initiated. Surgical intervention was indicated in cases of progressive corneal melting, structural instability, or uncontrolled infection.

The first patient developed acute corneal necrosis with vision limited to light perception, requiring urgent tectonic keratoplasty, achieving BCVA 7/10 at 8 months. The second patient presented a near-total corneal abscess with 360° neovascularization and athalamia; despite intensive therapy, penetrating keratoplasty became necessary. The third patient developed severe keratitis progressing to total opacification, central perforation, and inflammatory cataract; combined keratoplasty and cataract surgery restored anatomical integrity. Microbiological cultures were negative in all cases, likely due to prior antibiotic use.

Although epithelium-off CXL is widely regarded as safe and effective for progressive keratoconus, early postoperative infectious or necrotic complications may occur and severely threaten ocular integrity. Negative cultures do not exclude infection. Prompt diagnosis, aggressive antimicrobial treatment, and timely surgical intervention are critical to preserve vision. A procedure intended to prevent ectatic progression may, in rare cases, evolve into a complex therapeutic challenge requiring corneal transplantation.