Keratitis Rare After CXL

New protocols may justify a transepithelial approach (“epi-on”), but most clinics still use epi-off CXL as a standard treatment. This study supports that epi-off CXL is a very safe procedure. Photo: Glaukos. Click image to enlarge. While corneal crosslinking (CXL) is generally considered a safe procedure, one potential complication is keratitis. Norwegian researchers who say they have performed almost all CXL treatments performed in their country over the last 15 years investigated the risk of infectious keratitis after CXL in eyes with corneal ectasia in their clinic. They found that the risk was low (0.3%) and visual outcomes were good. The findings were presented recently in Cornea.The authors reviewed medical records of keratitis patients over a six-month period after all CXLs were performed. A total of 1,809 CXLs were performed between 2007 and 2020 and the annual number of CXLs increased from three in 2007 to 219 in 2020. The authors identified 11 (0.6%) cases registered with a keratitis code within six months after CXL, of which the physician considered five (0.3%) to be procedure-related infectious keratitis. Three cases were cultured as Staphylococcus aureus, one was Acanthamoeba and the last was of unknown pathology.They found a presentation of keratitis six days on average after the procedure and in a higher proportion of male patients, which agrees with previous findings. The first postoperative visit was four to six days after the CXL-treatment. This likely influenced the time point for the recognition of keratitis. Despite the routine use of bandage contact lenses and steroids—both of which are possible risk factors—the keratitis risk identified in the present study was low.Both keratoconus status and CXL treatment technique may differ worldwide, the authors noted. “In Northern Europe, antibiotic resistance is low, and one may hypothesize that the standardized use of postoperative antibiotics prevents more keratitis when resistance is low compared with that in other parts of the world,” the authors wrote in their paper. Other risk factors mentioned in previous studies include young age, hygiene and environmental factors.The authors added that a thorough explanation to the patient regarding the postoperative regimen is important. “Our patients had a relatively high median age of 31 years; the youngest patient was 19 years old,” they wrote in their paper, explaining that this high median age is because of the inclusion of two patients with pellucid marginal degeneration (PMD). “It is conspicuous that our keratitis cases contain two patients with PMD considering this rare condition compared with keratoconus. One may speculate if there are factors that lead to higher risk of keratitis in patients with PMD.”“In conclusion, the overall risk of infectious keratitis after CXL procedures identified in our patient population was low, and even in this group, the visual outcomes were good,” the authors concluded. “For comparison, we found that infectious keratitis in our literature search ranged from 0% to 2.6%. However, we found that the infection rates varied across different parts of the world. In the literature search, many studies with small sample sizes reported high infection rates.”Click here for the journal source. Loberg Thorbjorsen B, Velle-Skretteberg MA, Thorsrud A, et al. Infectious keratitis after corneal cross-linking: a retrospective case series. Cornea. May 6, 2025. [Epub ahead of print.]