Sterile corneal infiltrates post collagen cross-linking in pediatric keratoconus associated with vernal keratoconjunctivitis

Parul Jain; Ritu Arora; Jigyasa Sahu; Isha Gupta; Shilpa Ghosh

doi:10.4103/ijo.IJO_1754_21

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Year : 2022 | Volume : 2 | Issue : 3 | Page : 802-803

Sterile corneal infiltrates post collagen cross-linking in pediatric keratoconus associated with vernal keratoconjunctivitis

Parul Jain, Ritu Arora, Jigyasa Sahu, Isha Gupta, Shilpa Ghosh
Department of Ophthalmology, Guru Nanak Eye Centre, MAMC, New Delhi, India

Date of Submission	03-Jul-2021
Date of Acceptance	07-Oct-2021
Date of Web Publication	16-Jul-2022

Correspondence Address:
Dr. Jigyasa Sahu
A-24 Vrindavan Apartments, Sector-6 Plot-1, Dwarka New Delhi - 110 075
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1754_21

Abstract

Keywords: Collagen crosslinking, pediatric keratoconus, sterile infiltrates, VKC

How to cite this article:
Jain P, Arora R, Sahu J, Gupta I, Ghosh S. Sterile corneal infiltrates post collagen cross-linking in pediatric keratoconus associated with vernal keratoconjunctivitis. Indian J Ophthalmol Case Rep 2022;2:802-3

How to cite this URL:
Jain P, Arora R, Sahu J, Gupta I, Ghosh S. Sterile corneal infiltrates post collagen cross-linking in pediatric keratoconus associated with vernal keratoconjunctivitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 19];2:802-3. Available from: https://www.ijoreports.in/text.asp?2022/2/3/802/351127

Spectrum of sterile corneal infiltrates in pediatric keratoconus cases associated with vernal keratoconjunctivitis (VKC) after collagen cross linking (CXL) is heterogeneous. Eight patients in a series of 92 patients (age group 10–15 years) presented nearly 48 hours after the procedure with watering, redness, and blurring of vision. On examination, there was central corneal edema with sterile corneal infiltrates (in the treatment zone) with variable degree of involvement ranging from discrete central involvement (Carl Zeiss slit lamp, [Figure 1]a and [Figure 1]c) to extensive pan-corneal involvement [Figure 1]b and [Figure 1]d. All but one showed resolution of infiltrates with residual scarring after treatment with topical steroids. These patients with sterile infiltrates had associated moderate to severe VKC, which at the time of CXL was medically controlled. Of the eight eyes, one eye had central stromal melt necessitating penetrating corneal graft [Figure 1]d. Topical fortified antibiotics were started for the first 48 hours. Repeated negative smears and cultures from corneal scrapings led to the presumed diagnosis of infiltrates being sterile in nature. Low-dose topical steroid (0.5% loteprednol) drops were added to the treatment regimen from third day. With no further progression of infiltrates, loteprednol was replaced with two hourly 1% prednisolone acetate and topical antibiotics reduced to three times daily. Topical steroids were slowly tapered over 6–8 weeks. Final BCVA ranged from logMAR 1.0 to 0.17. Inclusion criteria for CXL was progressive keratoconus in the children of age group 10–15 years without any corneal scarring and minimum epithelial off thinnest pachymetry of 400 um. All patients were included only after control of VKC on treatment for the last 3 months.

Figure 1: (a) Slit lamp image showing central area of sterile infiltrate (2.5 mm*3 mm) with clear periphery, magnification x12. (b) Slit lamp image showing multiple confluent pin point infiltrates involving central as well as peripheral cornea, magnification x12. (c) Slit lamp image showing central area of healed sterile infiltrate with superficial scarring, magnification x20. (d) Slit image showing large infiltrate involving deep stroma along with necrosis in surrounding area, magnification x20

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Discussion

Sterile corneal infiltrates are not a rare complication after CXL.^[1] Patterns of sterile infiltrates may vary from mild peripheral pin point infiltrates to diffuse central infiltrates and corneal melting. Although the exact mechanism is unclear, identification of this entity and its differentiation from infectious keratitis is essential. Enhanced cell-mediated immune mechanisms and delayed epithelial healing in patients of VKC probably predisposes to development of sterile corneal infiltrates postCXL.^{[2],[3],[4],[5]} CXL in young patients of keratoconus with associated VKC is fraught with the possibility of sterile corneal infiltrates. Hence, it is important to ensure that VKC should be in the quiescent stage before resorting to CXL.

CXL in children with VKC and keratoconus should be performed with extreme caution for the fear of sterile keratitis postCXL. Severe corneal inflammation in the form of sterile infiltrates should be anticipated in such cases and managed accordingly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Çerman E, Özcan DÖ, Toker E. Sterile corneal infiltrates after corneal collagen cross-linking: Evaluation of risk factors. Acta Ophthalmol 2016;95:199-204.
2.	Çakmak S, Sucu ME, Yildirim Y, Kepez Yildiz B, Kirgiz A, Bektaşoğlu DL, et al. Complications of accelerated corneal collagen cross-linking: Review of 2025 eyes. Int Ophthalmol 2020;40:3269-77.
3.	Labiris G, Kaloghianni E, Koukoula S, Zissimopoulos A, Kozobolis VP. Corneal melting after collagen cross-linking for keratoconus: A case report. J Med Case Rep 2011;5:152.
4.	Arora R, Jain P, Gupta D, Goyal JL. Sterile keratitis after corneal collagen crosslinking in a child. Cont Lens Anterior Eye 2012;35:233-5.
5.	Angunawela RI, Arnalich-Montiel F, Allan BD. Peripheral sterile corneal infiltrates and melting after collagen crosslinking for keratoconus. J Cataract Refract Surg 2009;35:606-7.