Acute Idiopathic Endotheliitis Early After Corneal Cross-linking With Riboflavin and Ultraviolet-A

Purpose: To present a case of acute idiopathic endotheliitis occurred early after corneal collagen cross-linking (CXL) for progressive keratoconus, and to discuss possible risk factors, causes, and other similar complications in the literature. Methods: A 24-year-old woman with bilateral keratoconus underwent a corneal de-epithelization and subsequently CXL in the right eye, which was performed with the application of 0.1% riboflavin with 20% dextran, and exposure to ultraviolet-A light (370 nm, 2.9-3.1 mW/cm(2)) for 30 minutes. A bandage contact lens was placed until complete re-epithelialization. Postoperatively, the patient received 0.5% topical moxifloxacin (3 times a day) and preservative free artificial tears (6 times a day). Results: Postoperatively, the patient presented with significant hyperemia and photophobia on day 3. On biomicroscopy, ring-shaped endothelial infiltrates and localized corneal edema were observed in the inferior paracentral location of the cornea. Idiopathic endotheliitis was diagnosed, the therapeutic contact lens was removed, and 1% prednisolone acetate suspension was started every hour in addition to hypertonic ophthalmic solution every 3 hours. After this intensive corticosteroid treatment, the infiltrates improved and completely resolved after 1 week. Conclusions: We reported a successfully treated acute idiopathic endotheliitis occurring early after routine CXL. This very rare complication is hypothesized to occur as a result of the phototoxic effect of ultraviolet-A transmission on the corneal endothelium, or as an inflammatory response to surgical trauma or solutions used throughout the procedure.