Official ESCRS | European Society of Cataract & Refractive Surgeons


Sterile corneal infiltrates after riboflavin–UVA collagen cross-linking in keratoconus: a two-case report

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Session Details

Session Title: Presented Poster Session: Corneal Cross-Linking

Venue: Poster Village: Pod 3

First Author: : C.Garcia Arumi Fuste SPAIN

Co Author(s): :    S. Martin Nalda   L. Bisbe Lopez   R. Martin Pujol   D. Aragon Roca   M. Berges Marti           

Abstract Details


Corneal collagen cross-linking (CXL) is a safe and effective treatment protocol used to halt the progression of keratoconus (KC). Although rare, complications like haze, infectious and sterile keratitis, corneal melting, and diffuse lamellar keratitis have been reported after CXL. The main hypothesis about the mechanism that triggers these infiltrates is the phototoxic effect on the corneal stroma. Alterations in antigenicity that occur in native proteins after CXL could also stimulate the occurrence of these infiltrates. We report 2 cases of sterile corneal infiltrates that occurred after uneventful CXL surgery procedure for progressive keratectasia.


Hospital Vall d’Hebron, Barcelona (Spain)


Two patients who presented progressive keratoconus documented underwent corneal CXL that was performed with the application of 0’1% riboflavin every 2 minutes for 20 minutes, and exposure to UVA light (18 mW/cm for 5 min, radiant exposure 5.4 J/cm) for 5 minutes. In case 1 corneal desepithelization was underwent before CXL and case 2 received transepithelial CXL.


After uneventful surgery, both patients presented with severe photophobia, redness of the eye and decreased vision 4 days (case 1) and 1 month (case 2) following the procedure. Slit-lamp examination showed anterior multiple superficial stromal infiltrates in the peripheral (case 1) and central (case 2) cornea with overlying epithelium defect. Due to the lack of pain and absence of any pathogen from corneal samples, a diagnosis of sterile keratitis was considered. A combination of topical antibiotic and corticosteroid regimen was administered. Three months after CXL slit-lamp examination showed a mild stromal scar, which did not decrease visual acuity.


Cross-linking associated with sterile keratitis is an unusual entity of unknown etiology, which can lead to stromal scarring. The inflammatory response of UVA irradiation during CXL and its role in the individual immune mechanisms of the cornea deserve further investigation. The visual outcomes despite this complication are good. The treatment of these sterile infiltrates after CXL is with high dose of corticosteroids but in some cases it can also be useful topical cyclosporine and tacrolimus.

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