Sterile keratitis after uneventful corneal collagen cross-linking in a patient with Axenfeld-Rieger syndrome

Retrospective Analysis of Sterile Corneal Infiltrates in Patients with Keratoconus after Cross-Linking Procedure

Background: This paper’s objective is to analyze patients with keratoconus who developed sterile infiltrate after corneal collagen cross-linking (CXL), and to evaluate possible risk factors for their occurrence. Methods: 543 medical histories of patients after cross-linking (Epi-off, Epi-on) procedure performed according to the Dresden protocol were analyzed retrospectively. Results: Sterile corneal infiltrates occurred in four men (0.7%) in the age range (16–28) years, the average age being 20.3. The average time from procedure to onset of symptoms was 3.5 days (2–5 days). Inflammatory infiltration resolved in all patients, leaving scars on corneal stroma in two patients. Corneal healing time ranged from 4–12 weeks. In vivo confocal microscopy (IVCM), round inflammatory cells, and Langerhans cells in the epithelium and Bowman’s layer were observed at the site of infiltration. The Optical coherence tomography (OCT) shows hyperreflective lesions of various sizes which decreased over time. The corneal topographic parameters and Best-corrected visual acuity (BCVA) improved after the CXL procedure in all of the described cases. Conclusions: Most likely, damage to the epithelium and the phototoxic effect of the procedure is of significant importance in the formation of sterile corneal infiltrates. Appropriate classification and selection of CXL procedures in combination with protective measures in people at risk may have an overwhelming impact on the incidence of this complication.

Infectious keratitis after corneal crosslinking: systematic review

Corneal crosslinking is a U.S. Food and Drug Administration--approved therapy to stiffen the cornea and prevent progression of corneal ectasia in patients with keratoconus. The standard procedure involves removal of the corneal epithelium (epithelial-off) prior to treatment. Variations to the standard procedure include accelerated crosslinking and transepithelial procedures. This study reviewed what is known regarding the risk for infection after epithelial-off crosslinking, the spectrum of pathogens, and clinical outcomes. 26 publications were identified. All eyes were fit with a bandage contact lens postoperatively. Available data indicate that the overall frequency of infectious keratitis after epithelium-off crosslinking is low. Bacterial infections are the most common, with a mean time of presentation of 4.8 days postoperatively. The use of steroids and bandage contact lenses in the immediate postoperative period and/or a history of atopic or herpetic disease were associated with infection. These patients require intense postoperative care with prophylactic antiviral therapy when appropriate.

The diagnosis and phacoemulsification in combination with intraocular lens implantation for an Axenfeld-Rieger syndrome patient with small cornea: a case report

BACKGROUND

Axenfeld-Rieger syndrome (ARS) is a congenital disease with a series of developmental abnormalities, and no case of ARS with cataract and small cornea has been reported in previous studies. In the present report, we aimed to describe the diagnosis and phacoemulsification of an ARS patient with small cornea.

CASE PRESENTATION

A 58-year-old Han Chinese male patient who was referred to Eye Center of the Second Affiliated Hospital of Zhejiang University Medical College was diagnosed with ARS. Systemic and ophthalmic examination and genetic testing were performed. The slit-lamp microscopic examination of anterior segment showed obvious nuclear cataract, iris lesions, and the abnormal cornea of both eyes with small transversal and longitudinal diameters. ARS with bilateral complicated cataract and small cornea was diagnosed. Microincision-phacoemulsification in combination with intraocular lens implantation was performed on his left eye. After successful surgery of his left eye, the best-corrected visual acuity (BCVA) was obviously improved from 2 to 0.5 (LogMAR). A transient elevation of intraocular pressure (IOP) was controlled with medication.

CONCLUSIONS

Through genetic testing, a known pathogenic mutation NM_153427.2:c.272G > A was detected on the PITX2 gene; and an unknown mutation NM_001453.2:c.1063C > T was detected on FOXC1 gene. For the ARS patient with complicated cataract, the visual acuity was increased by phacoemulsificasion in combination with microincision.

Corneal crosslinking in a case with Axenfeld-Rieger syndrome and unilateral pellucid marginal degeneration

A 31-year-old male patient presented with the complaint of progressive vision loss in his left eye. Slit-lamp examination showed posterior embryotoxon, iris hypoplasia, and iridocorneal adhesion in both eyes, corectopia in the right, and peripheral inferior thinning and ectasia in the left eye. Corneal topography showed slightly asymmetric bowtie pattern in the right eye and crab-claw pattern in the left eye. Topographic examination was compared with his previous topography. The comparison showed 1.6-D steepening of maximum keratometry (K_max) and 22-µm decrease of thinnest corneal pachymetry. Corneal crosslinking treatment was performed on the left eye. At the postoperative 28-month follow-up visit, K_max decreased from 54.1 to 53.0 D and corrected distance visual acuity improved to 20/20 with scleral lens. This is the first reported a case with Axenfeld–Rieger syndrome and pellucid marginal degeneration association. We suggest that corneal crosslinking can be useful for management of pellucid marginal degeneration and longer follow-up might be needed in order to corroborate the effectiveness of the corneal crosslinking procedure.