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AbstractDO.02.02 Corneal perforation after crosslinking (CXL) with riboflavin und UV-A irradiation Kampik D., Schlunck G., Guthoff R., Geerling G.
Augenklinik der Julius-Maximilians-Universität Würzburg Objective: Photochemical collagen crosslinking with riboflavin and UV-A radiation (CXL) is used to strengthen the cornea in keratoconus. We report a case of corneal perforation in advanced keratoconus 7 days after CXL.
Case report: A 34-year-old male patient received CXL treatment for progressive keratokonus. History revealed a unilateral hearing loss since childhood and a primary spontaneous pneumothorax 10 years ago. UCVA was 20/800 on both eyes, BSCVA of OD (to be crosslinked) was 20/100 (OS 20/40). Maximum corneal curvature in the center was 60.4 D, central corneal thickness (CCT) was 428 µm. The cornea showed a subepithelial scar at the keratokonus apex where corneal thickness was 239 µm. Tear film and corneal sensitivity were normal.
After corneal abrasion hypotonic solution (Riboflavin 0,1% in Aqua dest.) was instilled to induce swelling of the stroma. Online pachymetry showed an increase in corneal thickness from 337 µm (post abrasion) to 470 µm. UV-A radiation followed for 30 min under further application of Riboflavin in isotonic solution.
Re-epithelialization was uneventful and without inflammatory corneal infiltration. On postop day 7 a rupture-like ulceration with fistulation from the stomal scar was apparent. Sutures failed to seal the lesion and corneal melting continued. Penetrating keratoplasty followed the other day.
Results: Histology showed rarefied keratocytes in the anterior stroma, some with pycnotic nuclei, but no significant inflammatory response.
According to clinical appearance and histology, an infectious cause for this corneal melting appeares unlikely. Possible pathogenetic mechanisms are atopic diathesis, a dysfunction in collagen metabolism, or a previously ruptured Descemets membrane after possible hydrops.
Conclusions: Even though CXL is a safe method, we should look for hints for connective tissue disease in patient history and the possibility of corneal perforation should be mentioned during preoperative patient counseling.
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