Peripheral Sterile Corneal Ring Infiltrate after Riboflavin-UVA Collagen Crosslinking

in Keratoconus

Ramon C. Ghanem, M.D.1, 2; Vinícius C. Ghanem, M.D.1, 2; Marcony Santhiago, M.D. 2,3; Marcelo V. Netto, M.D. 2,3;

Steven E. Wilson, M.D.3

1. Sadalla Amin Ghanem Eye Hospital, Joinville, Brazil.2. University of São Paulo (USP), São Paulo, Brazil.3. Cleveland Clinic, Cole Eye Institute, Ohio, USA

Financial DisclosuresThe authors do not have a commercial or

proprietary interest in this work.

RC. Ghanem, Poster WCC 2010

PurposeTo report a case series of peripheral ring-

shaped corneal infiltrates that occurred a few days after crosslinking (CXL) for progressive keratectasia secondary to keratoconus.

MethodsA prospective study including 362 eyes with

progressive keratoconus was carried out. After a 9.0 mm epithelial removal, 0.1%

riboflavin with 20% dextran was applied for 30 minutes followed by ultraviolet-A (UVA) irradiation (370 nm, 3 mW/cm2)1.

Therapeutic contact lenses were placed for one week.

RC. Ghanem, Poster WCC 2010

1. Wollensak G, et al. AJO. 2003

ResultsThree eyes (0.8%) developed an unusual type

of peripheral infiltrate. These had a ring-shape and affected the

anterior stroma in the transition between the treated and untreated peripheral cornea a few days after treatment.

RC. Ghanem, Poster WCC 2010

Case 1• 25-year-old male • After 12 days of

CXL

Case 1epithelial ulceration

360 degrees peripheral ring-like infiltrate at the 9.0-mm zone

Case 1• After 3 months

Case 2• 21-year-old male • A week after CXL

Case 3• 24-year-old male • A week after CXL

RC. Ghanem, Poster WCC 2010

Preoperative Data Postoperative Data (3 Months)

Age/Sex/

Eye

Dynamic

Refraction

DCVA

*

Biomicroscopy Max

K**

US

Pachy

Systemic

Workout

Biomicroscopy Dynamic

Refraction

DCVA* Max

K**

US

Pachy

Case 1 25/M/OD +2.0 -6.0 x 50° 20/30 Vogt´s striae 1+,

Fleisher´s ring, no

blepharitis

58.5 487 Negative 360 degrees infiltrate in

the anterior stroma,

faint central haze

+1.50 -6.0 x 50° 20/30 57.7 446

Case 2 21/M/OD -0.25 -4.5 x 180° 20/20 No blepharitis 46.3 433 Negative 180 degrees superficial

infiltrate, no central

haze

N/A N/A N/A N/A

Case 3 24/M/OD -2.25 x 155° 20/25 Two segments of

Ferrara´s ring, no

blepharitis

47.2 441 Negative Discrete inferior

peripheral infiltrate,

central haze 1+

-0.5 -0.5 x 150° 20/30 47.7 436

Cases Sumary

ResultsAll cases had rapid improvement with

steroidal therapy. Due to its shape and location, occurring in

the 9.0 mm edge of the irradiation zone with a limbal clear area, immune reaction seems to be the main explanation.

We hypothesize that the cytotoxic effects of UVA irradiation during CXL may alter the antigenic sites on native proteins in the corneal stroma resulting in a localized autoimmune reaction.

RC. Ghanem, Poster WCC 2010

ConclusionPeripheral sterile corneal infiltrates are not a

rare complication after CXL. Although the exact mechanism is unclear,

identification of this entity and its differentiation from infectious keratitis is essential.

The inflammatory response of the UVA light irradiation during CXL and its role on the immune mechanisms of the cornea demand further investigation.

RC. Ghanem, Poster WCC 2010

Thank you