Severe microbial keratitis and associated perforation after corneal crosslinking for keratoconus

Rana, Mrinal; Lau, A.; Aralikatti, Anil; Shah, Sunil

doi:10.1016/j.clae.2014.10.004

Cited by 32 publications

(28 citation statements)

References 14 publications

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“…Especially the significant bacterial overgrowth induced by the 0.1% Ce6 PDI treatment at day 3 of regimen I is a matter of concern, although this bacterial overgrowth was not seen when Ce6 concentrations ≤0.05% were utilized. This finding is supported by previous clinical case reports, indicating an increased risk of microbial infections as a complication that may be induced by corneal crosslinking29303132333435363738.…”

Section: Discussionsupporting

confidence: 90%

“…corneal crosslinking with riboflavin and ultraviolet light, is nowadays commonly applied as a treatment for corneal ectatic diseases24. A small number of clinical case reports indeed suggest that corneal crosslinking might be used as a therapy option for bacterial keratitis25262728, while other case reports indicated an increase in microbial infections as a complication of this therapy form when treating corneal ectatic diseases29303132333435363738. To date, only little experimental evidence is provided, whether PDI is a useful option to fight bacterial keratitis.…”

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confidence: 99%

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Chlorin e6 mediated photodynamic inactivation for multidrug resistant Pseudomonas aeruginosa keratitis in mice in vivo

Deichelbohrer

Tschernig

et al. 2017

Sci Rep

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Following corneal epithelium scratches, mouse corneas were infected with the multidrug resistant (MDR) P. aeruginosa strain PA54. 24 hours later, 0% (for control group), 0.01%, 0.05% or 0.1% Chlorin e6 (Ce6), a second generation photosensitizer derived from chlorophyll, was combined with red light, for photodynamic inactivation (PDI). 1 hour or 2 days later, entire mouse eyes were enucleated and homogenized for counting colony forming units (CFU) of P. aeruginosa. For comparison, 0.1% Ce6 mediated PDI was started at 12 hours post infection, and 0.005% methylene blue mediated PDI 24 hours post infection. Clinical scores of corneal manifestation were recorded daily. Compared to the control, CFU 1 hour after PDI started 24 hours post infection in the 0.01% Ce6 and 0.05% Ce6 groups were significantly lower (more than one log10 reduction), the CFU 2 days post PDI higher in the 0.1% Ce6 group, clinical score lower in the 0.1% Ce6 group at 1 day post PDI. These findings suggest that PDI with Ce6 and red light has a transient efficacy in killing MDR-PA in vivo, and repetitive PDI treatments are required to fully resolve the infection. Before its clinical application, the paradoxical bacterial regrowth post PDI has to be further studied.

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Section: Discussionsupporting

confidence: 90%

mentioning

confidence: 99%

Chlorin e6 mediated photodynamic inactivation for multidrug resistant Pseudomonas aeruginosa keratitis in mice in vivo

Deichelbohrer

Tschernig

et al. 2017

Sci Rep

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“…Interestingly, as previously reported in the infectious keratitis survey promoted by ASCRS, evaluating trends of infectious keratitis following keratorefractive procedures, the most common organism cultured was MRSA, with an incidence of 1 infection in every 1102 procedures [ 39 ]. However, despite the high rate of association between keratoconus and atopic dermatitis, a review of existing literature showed few cases of MRSA infection following UVA/CXL [ 14 , 16 , 30 ]. This finding should be related to the sterilizing effect of UVA irradiation used during CXL procedure on the central cornea.…”

Section: Discussionmentioning

confidence: 99%

“…The onset of stromal edema and transient corneal haze are typical postoperative findings, with a tendency to decrease and eventually disappear in the following months [ 4 , 5 ]. The most frequently observed complications are represented by corneal scarring, sterile infiltrates [ 6 – 8 ], and delayed epithelial healing, whereas infectious keratitis, although rare, seems to be the most serious complication [ 9 – 16 ].…”

Section: Introductionmentioning

confidence: 99%

Methicillin-ResistantStaphylococcus aureusOcular Infection after Corneal Cross-Linking for Keratoconus: Potential Association with Atopic Dermatitis

Fasciani

Agresta

Caristia

et al. 2015

Case Reports in Ophthalmological Medicine

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Purpose. To report the risk of methicillin-resistant Staphylococcus aureus (MRSA) ocular infection after UVA-riboflavin corneal collagen cross-linking in a patient with atopic dermatitis. Methods. A 22-year-old man, with bilateral evolutive keratoconus and atopic dermatitis, underwent UVA-riboflavin corneal cross-linking and presented with rapidly progressive corneal abscesses and cyclitis in the treated eye five days after surgery. The patient was admitted to the hospital and treated with broad-spectrum antimicrobic therapy. Results. The patient had positive cultures for MRSA, exhibiting a strong resistance to antibiotics. Antibiotic therapy was modified and targeted accordingly. The intravitreal reaction is extinguished, but severe damage of ocular structures was unavoidable. Conclusion. Riboflavin/UVA corneal cross-linking is considered a safe procedure and is extremely effective in halting keratoconus' progression. However, this procedure is not devoid of infectious complications, due to known risk factors and/or poor patients' hygiene compliance in the postoperative period. Atopic dermatitis is a common disease among patients with keratoconus and Staphylococcus aureus colonization is commonly found in patients with atopic dermatitis. Therefore, comorbidity with atopic dermatitis should be thoroughly assessed through clinical history before surgery. A clinical evaluation within three days after surgery and the imposition of strict personal hygiene rules are strongly recommended.

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“…The results from an increasing number of long-term studies have recurrently demonstrated that this is a safe method but there are also various different complications observed after CXL treatments [ 30 , 31 ], as summarized in Table 1 . One major problem is the increased risk of infective keratitis due to delayed reepithelialisation, [ 14 , 15 , 18 , 32 , 33 ] along also with cases of sterile peripheral corneal infiltrates [ 34 ]. The incidence of infective keratitis, as indicated from these published cases, would appear to be significantly higher than that reported in a very similar procedure called photorefractive keratectomy (PRK) [ 35 ].…”

Section: Clinical Complications Of CXLmentioning

confidence: 99%

Potential Effects of Corneal Cross-Linking upon the Limbus

Moore

Schiroli

Moore

2016

BioMed Research International

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Corneal cross-linking is nowadays the most used strategy for the treatment of keratoconus and recently it has been exploited for an increasing number of different corneal pathologies, from other ectatic disorders to keratitis. The safety of this technique has been widely assessed, but clinical complications still occur. The potential effects of cross-linking treatment upon the limbus are incompletely understood; it is important therefore to investigate the effect of UV exposure upon the limbal niche, particularly as UV is known to be mutagenic to cellular DNA and the limbus is where ocular surface tumors can develop. The risk of early induction of ocular surface cancer is undoubtedly rare and has to date not been published other than in one case after cross-linking. Nevertheless it is important to further assess, understand, and reduce where possible any potential risk. The aim of this review is to summarize all the reported cases of a pathological consequence for the limbal cells, possibly induced by cross-linking UV exposure, the studies done in vitro or ex vivo, the theoretical bases for the risks due to UV exposure, and which aspects of the clinical treatment may produce higher risk, along with what possible mechanisms could be utilized to protect the limbus and the delicate stem cells present within it.

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Severe microbial keratitis and associated perforation after corneal crosslinking for keratoconus

Cited by 32 publications

References 14 publications

Chlorin e6 mediated photodynamic inactivation for multidrug resistant Pseudomonas aeruginosa keratitis in mice in vivo

Chlorin e6 mediated photodynamic inactivation for multidrug resistant Pseudomonas aeruginosa keratitis in mice in vivo

Methicillin-ResistantStaphylococcus aureusOcular Infection after Corneal Cross-Linking for Keratoconus: Potential Association with Atopic Dermatitis

Potential Effects of Corneal Cross-Linking upon the Limbus

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