CASE REPORT Sterile corneal infiltrates after simultaneous photorefractive keratectomy and corneal crosslinking Amr Mounir, MD, Mohamed Anbar, MD, Gamal Radwan, MD We report 3 eyes with corneal sterile infiltration after simultaneous photorefractive keratectomy (PRK) and corneal crosslinking (CXL). Case 1 (2 eyes) was a 23-year-old woman who requested refractive surgery for myopic astigmatism in both eyes. Because the thinnest location was less than 500 mm and there was inferior steepening in the left eye, simultaneous PRK and CXL were performed. One day postoperatively, the right eye showed infiltrates at the deepithelialized ablated cornea. Treatment was started with moxifloxacin 0.5% hourly and fluorometholone 0.1% 5 times a day. After 4 days, the epithelium healed with central corneal opacification. In Case 2, the postoperative condition was similar to that in Case 1; however, the treatment was moxifloxacin 0.5% 5 times a day and prednisolone hourly. After 5 days, the infiltrates disappeared and the center of the cornea was clear. Sterile corneal infiltrates are uncommon complications after simultaneous PRK and CXL. Early topical steroid treatment might prevent central corneal scar formation. JCRS Online Case Reports 2017; 5:46–48 Q 2017 ASCRS and ESCRS. A lthough the technology combining corneal cross- linking (CXL) with photorefractive surgeries has many advantages, these types of procedures have not yet been widely performed in clinical practice. This can be explained by a number of undesired side effects of CXL related to the adding effect of corneal exposure to ul- traviolet (UV) radiation. 1–3 It was assumed that combined application of prophylactic CXL and transepithelial photo- refractive keratectomy (PRK) would have a positive effect on refractive outcomes and posterior corneal elevations. 4 Several complications of CXL have been reported. These include haze, 5 infectious and sterile keratitis, 5–8 corneal melting, 9 and diffuse lamellar keratitis. 10 We report 2 cases of sterile corneal infiltrates after combined PRK with accel- erated CXL. CASE REPORTS Case 1 A 23-year-old woman desired refractive surgery for myopic astig- matism error in both eyes. The uncorrected distance visual acuity (UDVA) in the left eye was 6/120 with a refraction of À3.50 À1.75 @ 110 corrected to 6/12. The thinnest location was less than 500 mm in the left eye, which showed inferior steepening. Thus, the decision was made to perform simultaneous PRK and CXL. Under strict sterile conditions using topical anesthesia, transepi- thelial PRK was performed using an excimer laser (Visx Star S4 IR, Abbott Medical Optics, Inc.). Then, mitomycin-C 0.02% was applied to the ablated corneal surface for 20 seconds; this was fol- lowed by a thorough wash with a balanced salt solution. The patient was then treated with riboflavin 0.1% with hydroxypropyl methyl- cellulose (Vibex Rapid, Avedro, Inc.) applied to the corneal surface and spread with an irrigating cannula for 1.5 minutes. After the soaking, the corneal surface was washed thoroughly with a balanced salt solution. An unltraviolet-A (UVA) beam (wavelength, 365 nm) 9.0 mm in diameter was applied to the cornea in a continuous fashion in a uniform circular pattern using the CXL device (Avedro, Inc.). The UVA exposure was performed for 90 seconds at a power of 30 mW/cm 2 (total dose 2.7 J/cm 2 ). At the end of the procedure, topical gatifloxacin 0.50% eyedrops were instilled and a bandage soft contact lens was fitted. Postoper- atively, gatifloxacin 0.50% and fluorometholone 0.1% eyedrops were prescribed 5 times daily. One day postoperatively, slitlamp examination of the right eye showed infiltrates at the deepithelialized ablated cornea extending outside the thickened whitish margin of area of ablation. There was no blepharospasm or ciliary injection. Corneal scraping was performed, and the specimen was sent for Gram and Giemsa staining; the results were negative. Bacterial and viral cultures were performed, and treatment was started while waiting for the results of the culture, which were also negative. Treatment was started in the form of broad-spectrum topical antibiotic moxifloxacin 0.5% hourly with topical steroid therapy in the form of fluorometholone 0.1% eyedrops 5 times daily. The follow-up was done daily for the fear of imminent infection. After 4 days of this treatment, the epithelium started to heal, with dense opacification at the area of ablation (Figure 1). On follow-up, the area of opacification regressed with time, leaving a central rounded scar that necessitated penetrating keratoplasty. Case 2 A 36-year-old woman sought refractive surgery for myopic astigmatism in both eyes. The UDVA was 6/60 with a refraction Submitted: January 1, 2017 | Final revision submitted: March 18, 2017 | Accepted: March 20, 2017 From the Faculty of Medicine, Sohag University, Sohag, Egypt. Corresponding author: Mohamed Anbar, MD, Ophthalmology Department, Sohag University Hospital, Sohag, Egypt. E-mail: manber2006@yahoo.com. Q 2017 ASCRS and ESCRS. Published by Elsevier Inc. 2214-1677/$ - see frontmatter http://dx.doi.org/10.1016/j.jcro.2017.03.003 46