Complications of corneal crosslinking: What can go wrong?

Corneal cross-linking (CXL) is a widely used treatment that is effective in halting the progression of corneal ectasias. Although its therapeutic efficacy is well established, various short- and long-term complications following CXL have been reported. We evaluate the potential complications of the CXL procedure and summarize their management. The most common post-CXL complications include corneal haze, sterile corneal infiltrates, microbial infection, endothelial dysfunction, limbal damage, Herpes simplex reactivation, and treatment failure. These complications may arise from alterations in the microscopic structure and properties of the cornea, as well as from the surgical procedure itself. A preoperative thin (<400 microns) and steep (maximum K reading >58.00 D) cornea, accompanying ocular surface problems (e.g., blepharitis, dry eye), advanced age, and a history of atopy are key factors that increase the risk of complications after CXL. While most of these complications can be reversed with short-term topical treatments, serious surgical intervention may occasionally be required. Therefore, the treatment approach for each complication should be individualized and disease-specific. Appropriate patient selection, addressing preexisting ocular surface conditions, adherence to the safety protocols of the procedure, a comprehensive postoperative treatment regimen, and early recognition of complications are crucial for minimizing risks after CXL.