• Users Online: 73
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 253-255

Nocardia keratitis following corneal cross linking for keratoconus

Department of Cornea, Sudarshan Netralaya, Bhopal, Madhya Pradesh, India

Date of Submission28-Jul-2020
Date of Acceptance19-Dec-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Monica Budhwani
Cornea Department, Sudarshan Netralaya, Plot No 61, Old MLA Quarters, Jawahar Chowk, Bhopal - 462 003, Madhya Pradesh
Prateek Gujar
Cornea Department, Sudarshan Netralaya, Plot No 61, Old MLA Quarters, Jawahar Chowk, Bhopal - 462 003, Madhya Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2435_20

Rights and Permissions

We report a case of Nocardia keratitis following corneal cross-linking for progressive keratoconus. A 26-year-old otherwise healthy woman underwent crosslinking for keratoconus in her left eye. She presented with corneal infiltrates with a wreath-like pattern, on the seventh postoperative day. Gram's and acid-fast staining revealed Nocardia. She was managed with topical fortified amikacin 2.5% eye drops. The keratitis resolved to leave dense vascularization which was managed with topical prednisolone 1% eye drops.

Keywords: Corneal Cross linking,Keratoconus, Nocardia Keratitis

How to cite this article:
Gujar P, Budhwani M. Nocardia keratitis following corneal cross linking for keratoconus. Indian J Ophthalmol Case Rep 2021;1:253-5

How to cite this URL:
Gujar P, Budhwani M. Nocardia keratitis following corneal cross linking for keratoconus. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Aug 3];1:253-5. Available from: https://www.ijoreports.in/text.asp?2021/1/2/253/312379

Corneal collagen crosslinking (CXL) is a widely used procedure to halt the progression of corneal ectasias.[1],[2] This is a relatively safe procedure without sight-threatening complications; however, few cases of microbial keratitis following CXL have been reported. Keratitis after CXL has been reported with herpes simplex, acanthamoeba, fungi, and bacteria such as Staphylococcus spp, Streptococcus species, Pseudomonas, and  Escherichia More Details coli.[3],[4],[5],[6],[7]

Ironically, CXL has been used to treat sterile as well as infectious keratitis.[8] Factors that could be attributed to the development of keratitis following CXL include corneal epithelial debridement and use of bandage contact lens (BCL) especially poor BCL handling or tap water usage. Other factors include postoperative use of topical steroids and NSAIDs. Besides, patients on long-term preoperative oral/topical steroids for chronic disorders (chronic vernal keratoconjunctivitis, bronchial asthma, and chronic eczema) are more prone to develop microbial keratitis following CXL.[9] This could be attributed to changes in ocular flora due to chronic steroid use.

We report a case of Nocardia keratitis following collagen crosslinking for progressive keratoconus.

  Case Report Top

A 26-year-old woman underwent collagen cross-linking (CXL) in her left eye (LE) for progressive keratoconus. Preoperatively her best-corrected visual acuity (BCVA) in the LE was 20/60. The CXL was done using standard Dresden protocol and was uneventful. A BCL was placed at the end of the procedure. Postoperatively patient was started on topical moxifloxacin (0.5%) eye drops four times a day, fluorometholone (0.1%) eye drops four times a day, carboxymethylcellulose (CMC 0.5%) eye drops four times a day. The first postoperative week was uneventful. On the seventh postoperative day, the patient presented with pain and redness in her LE. Examination revealed the absence of BCL, about which the patient was unaware. Slit-lamp examination revealed prominent ciliary flush, along with an oval-shaped anterior stromal infiltrate (2.5 * 2 mm), having a wreath-like pattern in the paracentral cornea [Figure 1]. There was a mild anterior chamber reaction. Corneal scraping was performed for Gram's, KOH, and acid-fast stain. Scraping material although scanty was also inoculated onto blood agar. The Gram's stain revealed gram's positive filamentous bacilli. These filamentous bacilli were acid-fast as demonstrated by acid-fast staining with the Kinyoun staining method. The bacterial culture revealed no growth. A presumptive diagnosis of Nocardia keratitis was made. Topical steroid drops were stopped. The patient was started on fortified amikacin (2.5%) eye drops on an hourly basis, moxifloxacin (0.5%) eye drops six times a day, homatropine (2%) eye drops two times a day, and CMC (0.5%) eye drops four times daily. On subsequent visits, the infiltrate showed signs of resolution. Six weeks postoperatively the infiltrate completely resolved leaving dense vascularization [Figure 2]. Topical prednisolone (1%) eye drops four times a day were added to the regimen, under topical antibiotic cover. Topical antibiotics were stopped after 1 month. Topical prednisolone eye drops were tapered in the next 4 months. At the end of 1-year follow-up, a macular grade corneal scar with few ghost vessels could be appreciated [Figure 3]. The BCVA was 20/50 in the LE.
Figure 1: Slit-lamp photograph showing anterior stromal infiltrate with a wreath-like pattern on 7th-day post CXL

Click here to view
Figure 2: Slit-lamp photograph showing resolved corneal infiltrate with dense vascularisation at 6 weeks

Click here to view
Figure 3: Slit-lamp photograph showing macular grade corneal scar with ghost vessels at 1 year follow -up

Click here to view

  Discussion Top

CXL with riboflavin-UVA is generally considered a safe surgical procedure for progressive keratoconus. There have been few reports of microbial keratitis following CXL.[3],[4],[5],[6] All these cases presented within one week of CXL. In one particular case report, the authors described the development of Fusarium keratitis 3 weeks after CXL.[7] All the cases were managed with topical antibiotic treatment except one with Acanthamoeba keratitis, which required therapeutic keratoplasty. Our case also presented on the seventh postoperative day.

A study by Shetty et al. showed no incidence of postoperative keratitis in transepithelial or accelerated CXL patients in their series. They attributed this to lesser UV-A exposure or intact epithelium.[8] They also recognized chronic preoperative steroid use as one of the factors for the development of post-CXL keratitis. A study by Maharana et al. showed a high preponderance of mixed infections following accelerated CXL and resistance to fourth-generation fluoroquinolones.[9] Our case does not have a history of preoperative chronic steroid use and was managed by standard Dresden protocol.

Nocardia keratitis is most commonly reported after corneal trauma, with exposure to soil or vegetative matter. Other known risk factors include prior ocular surgery, topical steroids use, and contact lens wear.[10] To the best of our knowledge, this is the first reported case of Nocardia keratitis following CXL. Epithelial debridement during CXL, loss of BCL, and use of topical steroids postoperatively could be the associated risk factors in our case. Early diagnosis and prompt treatment resulted in the resolution of keratitis. A noticeable feature in our case was dense vascularization after the resolution of the infiltrate, which required topical steroid therapy to resolve.

  Conclusion Top

Nocardia keratitis should be on the differential for an otherwise healthy patient who presents with a corneal infiltrate after CXL. Meticulous follow-up until complete epithelial defect healing and BCL removal is recommended. We also recommend for a cautious use of topical steroids until complete epithelial healing and BCL removal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wollensak G. Crosslinking treatment of progressive keratoconus: A new hope. Curr Opin Ophthalmol 2006;17:356-60.  Back to cited text no. 1
Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet-A-induced collagen crosslinking for the treatment of keratoconus. Am J Ophthalmol 2003;135:620-7.  Back to cited text no. 2
Kymionis GD, Portaliou DM, Bouzoukis DI, Suh LH, Pallikaris AI, Markomanolakis M, et al. Herpetic keratitis with iritis after corneal crosslinking with riboflavin and ultraviolet A for keratoconus. J Cataract Refract Surg 2007;33:1982-4.  Back to cited text no. 3
Rama P, DiMatteo F, Matuska S, Paganoni G, Spinelli A. Acanthamoeba keratitis with perforation after corneal cross-linking and bandage contact lens use. J Cataract Refract Surg 2009;35:788-91.  Back to cited text no. 4
Pollhammer M, Cursiefen C. Bacterial keratitis early after corneal crosslinking with riboflavin and ultraviolet-A. J Cataract Refract Surg 2009;35:588-9.  Back to cited text no. 5
Sharma N, Maharana P, Singh G, Titiyal JS. Pseudomonas keratitis after collagen crosslinking for keratoconus: Case report and review of literature. J Cataract Refract Surg 2010;36:517-20.  Back to cited text no. 6
Garcia S, Díaz-Llopis M, Udaondo P, Salom D. Fusarium keratitis 3 weeks after healed corneal cross-linking. J Refract Surg 2010;26:994-5.  Back to cited text no. 7
Shetty R, Kaweri L, Nuijts RM, Nagaraja H, Arora V, Kumar RS. Profile of microbial keratitis after corneal collagen cross-linking. Biomed Res Int 2014;2014:340509. doi: 10.1155/2014/340509.  Back to cited text no. 8
Maharana PK, Sahay P, Sujeeth M, Singhal D, Rathi A, Titiyal JS, et al. Microbial keratitis after accelerated corneal collagen cross-linking in keratoconus. Cornea 2018;37:162-7.  Back to cited text no. 9
Rao SK, Madhavan HN, Sitalakshmi G, Padmanabhan P. Nocardia asteroides keratitis: Report of seven patients and literature review. Indian J Ophthalmol 2000;48:217-21.  Back to cited text no. 10
[PUBMED]  [Full text]  


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded23    
    Comments [Add]    

Recommend this journal