Severe Eye Infection and Corneal Hydrops Strike Three Young Patients After Cross-Linking

Three young patients with keratoconus and atopic dermatitis developed infectious keratitis together with acute corneal hydrops–like changes within days of undergoing corneal cross-linking, according to a case series published in BMC Ophthalmology. The report, released online on 26 October 2026, describes a strikingly similar clinical course in all three eyes, a combination of complications that the authors say has not been well characterized in the post-cross-linking setting.

Before surgery, the mean steepest keratometry value (Kmax) was 76.4 diopters (±19.4) and the mean thinnest corneal thickness was 404.7 micrometers (±53.9), figures that indicate advanced disease and markedly thin corneas.

On the first day after the procedure, all eyes appeared unremarkable. The picture changed abruptly on postoperative days three to four, when each patient developed severe eye pain, corneal infiltration and epithelial defects. The treating team promptly started intensive topical antibiotics, but within one to two days of the keratitis onset every eye showed a sudden-onset acute corneal hydrops–like manifestation, a complication in which fluid enters the corneal stroma after a break in Descemet membrane.

Anterior segment optical coherence tomography confirmed the diagnosis in all three eyes, revealing breaks in Descemet membrane with intrastromal clefts. This imaging evidence is notable because acute corneal hydrops typically arises from a break in Descemet membrane in advanced keratoconus, and the authors note that it is rarely observed after cross-linking. Its appearance here alongside infection, rather than as an isolated event, is the central observation of the series.

Treatment with intensive topical antibiotics ultimately achieved resolution of both the keratitis and the hydrops-like changes in all eyes, after a mean of 31.3 days (±3.5). The infections and fluid accumulation cleared, but the episodes left stromal scarring in every cornea, a reminder that even successful resolution of these complications can carry lasting structural consequences for tissue already compromised by advanced keratoconus.

At final follow-up, which averaged 17.0 months (±11.7), the mean Kmax had fallen to 50.3 diopters (±2.3) and the mean thinnest corneal thickness measured 428.3 micrometers (±83.5). Best spectacle-corrected decimal visual acuity ranged from 0.06 to 0.2 across the three patients, levels of vision that reflect substantial residual impairment consistent with the corneal scarring.

The authors propose a possible mechanism for the unusual pairing of complications. They hypothesize that corneal thinning from ulceration, compounded by biomechanical fragility in advanced keratoconus and possible eye rubbing associated with atopic dermatitis, may predispose these corneas to Descemet membrane breaks.

The report is a case series of three patients, so it cannot establish how often these concurrent complications occur after cross-linking or confirm the proposed mechanism. Infectious keratitis remains, as the authors describe it, a rare but serious complication following corneal cross-linking for keratoconus, and acute corneal hydrops in the post-cross-linking setting has not been well characterized. The authors conclude that meticulous perioperative management is warranted in high-risk keratoconus patients with atopic dermatitis.

Subject of Research: Infectious keratitis and concurrent acute corneal hydrops after corneal cross-linking in keratoconus patients with atopic dermatitis

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

Article References: Den, S., Kato, N., Toda, I., Higashi, Y., Kasai, K., & Nakano, T. (2026). Infectious keratitis with concurrent acute corneal hydrops following corneal cross-linking in atopic dermatitis patients: a case series. BMC Ophthalmology. https://doi.org/10.1186/s12886-026-05475-4

Image Credits: AI Generated

DOI: 10.1186/s12886-026-05475-4

Keywords: corneal cross-linking, infectious keratitis, acute corneal hydrops, keratoconus, atopic dermatitis, Descemet membrane, AS-OCT, BMC Ophthalmology, case series, corneal thinning, topical antibiotics, stromal scarring