title: Severe microbial keratitis and associated perforation after corneal crosslinking for keratoconus.
abstract: OBJECTIVE
  To report two cases of microbial keratitis with subsequent corneal perforation immediately following corneal collagen crosslinking (CXL).
  
  
  METHODS
  Retrospective case note review.
  
  
  RESULTS
  First case was a 19 year old female presented with staphylococcal corneal abscess 3 days post CXL procedure. Corneal perforation occurred during hospital admission and was successfully treated with corneal gluing. Microbial keratitis eventually resolved, with both topical and systemic antibiotics therapy, resulting in a vascularized corneal scar. Second case was an 18 year old male whom developed Methicillin Resistant Staphylococcus aureus (MRSA) corneal abscess 5 days after CXL procedure for progressive keratoconus. Corneal perforation occurred 48 h after presentation and patient underwent uneventful corneal gluing. Although infective keratitis was successfully treated with topical therapy, patient had visual outcome of count fingers due to scarring.
  
  
  CONCLUSIONS
  CXL has been widely used in the treatment of corneal ectatic conditions and complications, such as infective keratitis, are uncommon post procedure. We present two cases of severe microbial keratitis with subsequent corneal perforation within 7 days of CXL. The exact mechanism for the accelerated keratolysis process is unclear. Nonetheless, patients should be well-informed of such potentially devastating complication.
authors.affiliation: Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom.
authors.forename: M
authors.initials: M
authors.lastname: Rana
authors.affiliation: Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom; National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore.
authors.forename: A
authors.initials: A
authors.lastname: Lau
authors.affiliation: Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom.
authors.forename: A
authors.initials: A
authors.lastname: Aralikatti
authors.affiliation: Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom. Electronic address: sunilshah@doctors.org.uk.
authors.forename: S
authors.initials: S
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000328:Adult; D057112:Corneal Perforation / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy*; D015818:Eye Infections, Bacterial / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D005260:Female; D006801:Humans; D007634:Keratitis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy*; D007640:Keratoconus / Q000150:complications / Q000188:drug therapy*; D008297:Male; D017319:Photosensitizing Agents / Q000627:therapeutic use; D012256:Riboflavin / Q000627:therapeutic use; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D016896:Treatment Outcome; D014467:Ultraviolet Therapy / Q000009:adverse effects*
chemical_list: D017319:Photosensitizing Agents; D012256:Riboflavin
keywords: Corneal collagen cross linking; Keratoconus; MRSA; Microbial keratitis; Staphylococcus