Insights into the clinical presentation, imaging, and management of infiltrative keratitis following accelerated corneal collagen cross-linking

Purpose: To analyze the risk factors, clinical features, visual outcomes, and in-vivo imaging characteristics in cases of keratoconus developing keratitis following accelerated collagen cross-linking (CXL). Methods: A retrospective observational case series at a tertiary eye center in India evaluating eyes that underwent accelerated CXL from January 2021 to July 2024. Results: Of 723 eyes undergoing CXL, 14 eyes developed infiltrative keratitis (1.93%). The majority belonged to the upper middle socioeconomic class and presented in summer and rainy seasons. The relative risk of developing infiltrates in cases ≤16 years was 2.38, and in cases with history of vernal keratoconjunctivitis, it was 0.7. The median area of epithelial defect was 12 mm 2 , and the average resolution time was 18.4 ± 12.9 days. The most common organism that was isolated was coagulase-negative Staphylococcus. The majority of the cases on anterior segment optical coherence tomography showed involvement anterior to the demarcation line. Scheimpflug imaging showed three keratometric patterns: flattening and thinning, flattening and thinning with transient steepening, and minimal to no change. Conclusion: Infiltrative keratitis following accelerated CXL is a rare clinical entity. Early presentation and timely management including use of topical steroids are associated with good visual outcomes.