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OBJECTIVE: To report the first case of Rhizopus sp keratitis in a 15-year-old male patient who had undergone a conventional Epi-off CXL procedure for progressive keratoconus.
METHODS: A 15-year-old male studying at school presented with defective vision in both eyes recently. He was diagnosed with progressive keratoconus in the right eye more than left eye. After the conventional CXL procedure, the patient developed corneal ulcer on third postoperative day.
RESULTS: The microbiological diagnosis of both BCL and ulcer revealed Rhizopus sp. The patient responded to topical antifungals, and the ulcer entirely healed with a large central scar.
CONCLUSIONS: Rhizopus keratitis is rare in a healthy individual. Ours is the first case report of Rhizopus keratitis in patient undergone CXL.

The study involves the preparation and characterization of crosslinked-carboxymethyl cellulose (CMC) films using varying amounts of citric acid (CA) within the range 5 %-20 %, w/w, relative to the dry weight of CMC. Through techniques such as Fourier transform infrared spectroscopy, X-ray photoelectron spectroscopy, carbonyl content analysis, and gel fraction measurements, the successful crosslinking between CMC and CA is confirmed. The investigation includes an analysis of chemical structure, physical and optical characteristics, swelling behavior, water vapor transmission rate, moisture content, and surface morphologies. The water resistance of the cross-linked CMC films exhibited a significant improvement when compared to the non-crosslinked CMC film. The findings indicated that films crosslinked with 10 % CA demonstrated favorable properties for application as edible coatings. These transparent films, ideal for packaging, prove effective in preserving the quality and sensory attributes of fresh bananas, including color retention, minimized weight loss, slowed ripening through inhibiting amyloplast degradation, and enhanced firmness during storage.

OBJECTIVE: The aim of this study was to report a case series of central toxic keratopathy (CTK) after collagen cross-linking (CXL) in keratoconus.
METHODS: This is a retrospective case series between January 2020 and September 2021. In this period, CXL was performed for progressive keratoconus in 964 eyes. CXL was performed using the epithelium-off accelerated protocol in all patients with a riboflavin soak time of 20 minutes and a UVA light exposure of 9 mW for 10 minutes using the Avedro KXL (Glaukos Inc, Aliso Viejo, CA) cross-linking system.
RESULTS: Twelve of 964 eyes (1.2%) developed CTK within 1 week of CXL. All patients presented with well-circumscribed, central disciform haze that was broader in the anterior stroma and narrower in the posterior stroma. We noted initial flattening in keratometry up to 3 months post-CXL in these patients, which gradually steepened over 12 months, but did not reach preoperative levels. We also noted exuberant flattening in pachymetry in the first 3 months, which improved over 12 months. There was a statistically significant decrease in pachymetry in patients who developed CTK at 3 and 12 months postoperatively when compared to patients who underwent CXL but did not develop CTK.
CONCLUSIONS: Several reports of CTK postrefractive surgery have been described previously. However, the association of CXL in the development of CTK has not been described previously. Here, we elucidated the clinical features of CTK after CXL and how it differs from corneal scarring or haze that occurs post-CXL.

OBJECTIVE: The aim of this study was to describe the safety and efficacy of the Tel-Aviv Protocol (epithelial photorefractive keratectomy and corneal cross-linking) as a treatment for postrefractive surgery corneal ectasia.
METHODS: This study includes 8 eyes from 7 patients, each diagnosed with postrefractive surgery ectasia years after refractive surgery and treated with the Tel-Aviv Protocol. The procedure included transepithelial PRK using the EX500 excimer laser, a 50-μm laser ablation of the epithelium and anterior stroma, delivered on the visual axis with cyclotorsion correction, treating up to 50% of refractive astigmatism. After the epithelial photorefractive keratectomy, all patients underwent corneal cross-linking.
RESULTS: The mean keratometry (K) and maximal K both decreased [from 43.37 ± 2.23 to 41.84 ± 2.01 ( P = 0.03) and from 44.95 ± 3.08 to 42.78 ± 2.19 ( P = 0.03), respectively]. Astigmatism was significantly reduced (from 3.53 ± 2.36 to 0.88 ± 0.89 diopter; P = 0.02). Uncorrected visual acuity improved significantly in all patients from a mean of 0.56 ± 0.32 to 0.15 ± 0.14 logMAR ( P = 0.01). Best-corrected visual acuity improved from 0.22 ± 0.24 to 0.06 ± 0.06 logMAR ( P = 0.07; 1-tail P = 0.04). All patients maintained visual acuity during the follow-up period, up to 25 months, mean = 329 days. The Tel-Aviv Protocol was found to be safe [mean safety index: 1.63 ± 1.03 (range: 1.00-4)] and effective [mean efficacy index: 1.29 ± 0.66 (range: 0.71-2.1)].
CONCLUSIONS: The Tel-Aviv Protocol, developed initially for keratoconus treatment, is a safe and promising procedure to stop postrefractive surgery ectasia progression while significantly improving vision, thereby avoiding keratoplasty.

OBJECTIVE: The purpose of this study was to document, to our knowledge, the first reported case of keratoconus progression accompanied with newly diagnosed pellucid marginal degeneration after corneal cross-linking (CXL).
METHODS: A novel case of further keratoconus progression plus development of pellucid marginal degeneration in the same eye after CXL was documented with supporting evidence from Scheimpflug and optical coherence tomography imaging.
RESULTS: A male patient was diagnosed with progressive keratoconus in the left eye and treated with CXL when aged 25 years. Although strongly cautioned not to rub his eyes, he admitted that he continued eye rubbing in association with atopic disease. At a follow-up examination 3.5 years after CXL, progressive keratoconus was detected and pellucid marginal degeneration was newly diagnosed in the left eye. The eye was retreated with CXL.
CONCLUSIONS: This case illustrates that progressive keratoconus and pellucid marginal degeneration can occur in the same eye after CXL and demonstrates the deleterious effects that can develop with continued eye rubbing.

OBJECTIVE: To present the 7-year experience of a tertiary eye hospital while exploring possible risk factors and incidence of infectious keratitis in patients undergoing standard corneal cross-linking (CXL).
METHODS: This retrospective cohort study included patients with progressive keratoconus undergoing standard CXL in the Farabi Eye Hospital and all other patients who had undergone CXL in other facilities and were diagnosed as having infectious keratitis in the 7-year period of the study.
RESULTS: Among the total of 4,863 eyes that underwent CXL, 6 eyes developed infectious keratitis, yielding an incidence rate of 0.12%. Additionally, 13 eyes from 10 patients with a CXL history in other facilities who developed infectious keratitis were included. The mean age was 23.75 years, and 75% of patients were men and 25% were women. Gram-positive bacteria and Staphylococcus aureus were the most prevalent pathogens. Meibomian gland dysfunction, dry eye disease, or blepharitis were present in 12 patients. Medical treatment did not arrest the disease progress in 5 patients, which eventually required cases to undergo keratoplasty.
CONCLUSIONS: This study supports the need for proper patient selection by using a comprehensive medical history. It also highlights the imperative role of rigorous patient education and follow-up, particularly in the first postoperative week. Finally, the study emphasizes aggressive early therapy for patients with suspicious findings. [J Refract Surg. 2023;39(8):564-572.].

OBJECTIVE: To report a case of Enterobacter cloacae (E. cloacae) keratitis in a patient who underwent corneal crosslinking (CXL) for progressive keratoconus.
METHODS: A 19-year-old female underwent CXL for keratoconus in her left eye. The patient neglected her post-procedure medications and missed the follow-up visit. Subsequently, she presented on day-10 post CXL with redness and pain in the treated eye. Clinical examination revealed a ring-shape infiltrate measuring 7.8 mm in diameter. Culture indicated the presence of E. cloacae. Treatment with gentamicin failed after the emergence of resistance. The patient was successfully treated with amikacin and moxifloxacin over several weeks.
CONCLUSIONS: Judicious antibiotic selection is crucial to limit the emergence of resistance in multidrug-resistant (MDR) pathogens. All patients need to be educated about their role in the management plan.

BACKGROUND: To report a late onset, deep stromal and endothelial corneal scar in a keratoconus patient after corneal collagen cross-linking (CXL).
METHODS: Observational case report. A 29-year-old man with bilateral keratoconus received an accelerated (A-CXL 10*9) epithelium-off CXL procedure in the left eye.6-months postoperatively, a 2.2 × 1.2 mm inferocentral corneal scar was detected, which was located in the posterior stroma ranging from approximately 350 µm until the endothelium, therefore was situated below the demarcation line. A topical corticosteroid treatment did not influence the magnitude or configuration of the scar. Visual acuity was never affected, which includes the examination 12 months postoperatively.
CONCLUSIONS: We report a case of a late onset deep stromal and endothelial corneal scar 6 months after accelerated CXL as postoperative complication without affecting visual acuity.

UNASSIGNED: The question of whether the epithelium should be removed in corneal cross-linking (CXL) in the treatment of keratoconus and other corneal ectatic disorders remains controversial. The motivation for epithelium-on CXL methods, which are not yet FDA approved and vary greatly in methodology, is to reduce the risk of vision-threatening complications related to debridement. However, as discussed in this counterpoint piece, most high-level evidence suggests that removal of the epithelium facilitates greater crosslinking effectiveness as measured by primary clinical outcome metrics such as topographic flattening and stabilization of disease. Furthermore, quality evidence is still lacking for a significant reduction in rates of infectious keratitis or loss of vision that can be attributed to debridement-related complications. In the absence of comparative effectiveness trials or long-term follow-up studies that show otherwise, the FDA-approved epi-off protocol is still the standard-bearer for safe and effective stabilization of corneal ectatic disease.