Bridging gaps in corneal ulcer management: Can photoactivated chromophore for infectious keratitis-corneal collagen cross-linking delay or replace therapeutic keratoplasty?

The retrospective study by Edwar reinforces the role of therapeutic penetrating keratoplasty (PK) as a vital intervention in severe, treatment-resistant infectious keratitis. In advanced cases-often complicated by trauma, delayed presentation, and corneal perforation-PK restores globe integrity and provides limited visual recovery. However, its application is constrained by graft-related complications and donor shortages, particularly in low-resource settings. These limitations highlight the need for earlier, globe-sparing strategies to prevent progression and reduce surgical demand. Photoactivated chromophore for infectious keratitis-corneal collagen cross-linking (PACK-CXL) has emerged as a promising adjunct or alternative. With both antimicrobial and tissue-stabilizing effects, PACK-CXL may control infection and preserve corneal structure in earlier stages. A layered treatment framework that incorporates PACK-CXL as an initial intervention and reserves PK for refractory cases may help improve clinical outcomes. Further studies are needed to define their best use in practice.