A case of infectious crystalline keratopathy after corneal cross-linking

PURPOSE: To present a case of infectious crystalline keratopathy after corneal cross-linking in a child with delayed wound healing, and its successful management with antibiotic and anti-fungal eye drops. OBSERVATIONS: A 14-year-old male presented for a second opinion with a non-staining crystalline keratopathy after corneal crosslinking for progressive keratoconus. He reportedly rubbed his eyes vigorously in the post-operative course and had a slowly healing epithelial defect. He was treated with several antibiotic drops and was put on high dose topical difluprednate drops post-procedure for persistent corneal haze. His infection continued to progress until steroids were stopped and he was treated with topical voriconazole. While cultures were negative, the patient's visual acuity and corneal lesions improved significantly after starting voriconazole therapy and stopping steroid drops, pointing to a diagnosis of infectious crystalline keratopathy. CONCLUSIONS AND IMPORTANCE: This is one of the first case reports to describe a primary infectious crystalline keratopathy after a corneal cross-linking procedure, and the first to describe this phenomenon in a child with delayed corneal re-epithelialization. Though corneal cross-linking is a relatively safe procedure, atypical infections like crystalline keratopathy can occur in these patients in the setting of topical steroid use. Atypical organisms such as fungi should always be on the differential, especially for patients with recalcitrant infection in the setting of immunosuppression.