A 23-year-old Chinese man with bilateral keratoconus had preoperative refraction OS of −0.50 diopters (D)/−3.50 × 170 D. Spectacle acuity was logMAR + 0.04, the maximum keratometric (Kmax) measurement was 46.9 D, and the corneal thickness was 563 mm, consistent with Krumeich stage I keratoconus. The cornea was clinically clear, and in the immediate period after CXL, epithelial healing was uneventful and the cornea stayed clear. However, at the 3-month visit, a dense, deep paracentral stromal scar was noted adjacent to the apex of the cone (Figure 1A) at approximately 300 μm depth on anterior segment optical coherence tomography. The refraction was altered to −0.50D/−7.00D × 100, best-spectacle acuity was logMAR + 0.16, and Kmax increased to 51.6 D. At 6 months, the opacity remained unchanged but visual acuity was correctable with a rigid gas permeable lens to logMAR 0.00. Confocal microscopy revealed a regular epithelial mosaic and normal subepithelial nerve plexus morphology. The subepithelial zone revealed changes typical of a post-CXL reaction including increased keratocyte density and reflectivity, stromal hyperreflectivity, and multiple highly reflective spindle-shaped fibroblast processes.5 The deeper stroma revealed atypical and previously unreported changes. In the anterior part of the scar (Figure 1B), keratocyte density was reduced and there were dense hyperreflective bands in a reticular pattern. Keratocyte nuclei assumed attenuated, elongated forms suggestive of fibroblastic transformation. Deeper scans showed dense, homogenous, hyperreflective tissue with no cellular structures seen (Figure 1C). The deep stroma and endothelium posterior to the scar were normal.