Related Experiment Video
Updated: Feb 23, 2026
Three Different Protocols of Corneal Collagen Crosslinking in Keratoconus: Conventional, Accelerated and Iontophoresis
Published on: November 12, 2015
Bilateral corneal perforation due to MRSA keratitis in a crosslinking patient
Zackery Oakey1, Kevin Thai2, Sumit Garg1
1Gavin Herbert Eye Institute, University of California, Irvine, USA.
Abstract:
Introduction: The cornea may become infected and perforated after epithelium-on collagen crosslinking. Case presentation: A healthy 33-year-old male who underwent corneal collagen crosslinking in both eyes developed a purulent keratitis and bilateral corneal perforations, requiring bilateral penetrating keratoplasties. He was exposed to methicillin resistant staphylococcus aureus (MRSA) by a family member with a tracheostomy and was treated with MRSA-directed antibiotics. After prolonged recovery and treatment of his infection, he had acceptable but limited uncorrected visual acuity, with excellent corrected visual acuity. Conclusion: While epithelium-on crosslinking is commonly thought to be associated with a lower risk of postoperative infection, this case illustrates that even epithelium-on treatment may present the patient with a risk of infection. Patients in higher risk groups who are exposed to infectious disease may be more predisposed.
Insights
Epithelium-on corneal collagen crosslinking can lead to serious infection and perforation, even in healthy patients. This case highlights the risk of methicillin-resistant Staphylococcus aureus (MRSA) keratitis post-procedure.
Area of Science:
- Ophthalmology
- Infectious Diseases
Background:
- Corneal collagen crosslinking (CXL) is a treatment for keratoconus and other corneal ectasias.
- Epithelium-on CXL is generally considered to have a lower risk of postoperative infection compared to epithelium-off CXL.
Observation:
- A healthy 33-year-old male developed purulent keratitis and bilateral corneal perforations after undergoing bilateral epithelium-on CXL.
- The patient was exposed to methicillin-resistant Staphylococcus aureus (MRSA) from a family member with a tracheostomy.
- The keratitis required bilateral penetrating keratoplasties (corneal transplants).
Findings:
- Despite the perceived lower risk, epithelium-on CXL can still lead to severe microbial keratitis.
- MRSA infection was confirmed, and treatment involved MRSA-directed antibiotics.
- The patient experienced significant visual impairment requiring corneal transplantation, though corrected visual acuity was good.
Implications:
- This case underscores that no CXL technique is entirely risk-free regarding infection.
- Patients with potential exposure to infectious agents, especially resistant strains like MRSA, may be at higher risk.
- Ophthalmologists should maintain a high index of suspicion for infection even with epithelium-on CXL, particularly in at-risk individuals.
