Infectious keratitis with concurrent acute corneal hydrops following corneal cross-linking in atopic dermatitis patients: a case series

Infectious keratitis is a rare but serious complication following corneal cross-linking (CXL) for keratoconus. Acute corneal hydrops (ACH), which typically results from a break of Descemet membrane (DM) in advanced keratoconus, is rarely observed after CXL. Therefore, the occurrence of ACH in the post-CXL setting has not been well characterized. Here, we report three cases of infectious keratitis with concurrent ACH-like manifestations that developed shortly after CXL in patients with atopic dermatitis (AD). All patients exhibited remarkably similar clinical courses. Three patients (mean age 22.3 ± 7.5 years) with progressive keratoconus and AD underwent epi-off accelerated CXL. Preoperatively, the mean steepest keratometry (Kmax) was 76.4 ± 19.4 D and thinnest corneal thickness (TCT) was 404.7 ± 53.9 μm. All eyes showed unremarkable findings on postoperative day one but developed severe eye pain and corneal infiltration with epithelial defects on days 3–4. Despite prompt initiation of topical antibiotics, all developed sudden-onset ACH-like manifestations within 1–2 days after keratitis onset. Anterior segment optical coherence tomography (AS-OCT) confirmed DM breaks with intrastromal clefts in all eyes. Intensive topical antibiotics achieved resolution of keratitis and ACH within a mean of 31.3 ± 3.5 days, leaving stromal scarring. At final follow-up (mean 17.0 ± 11.7 months), mean Kmax was 50.3 ± 2.3 D, mean TCT was 428.3±83.5 μm, and best spectacle decimal visual acuity ranged from 0.06 to 0.2. This case series demonstrates that infectious keratitis and ACH-like changes may occur concurrently after CXL in patients with AD. We hypothesize that corneal thinning from ulceration, compounded by biomechanical fragility in advanced keratoconus and possible eye rubbing from AD, may predispose to Descemet membrane break. Meticulous perioperative management is warranted in high-risk keratoconus patients with AD.