To clarify the clinical and imaging characteristics of Candida keratitis using in vivo confocal microscopy (IVCM) for improved early diagnosis and management.A retrospective study of 40 patients with Candida keratitis at Beijing Tongren Hospital from January 2015 to December 2023 was conducted. Data included demographics, risk factors, clinical assessments, lab tests, and IVCM images. Ex vivo confocal microscopy and methylene blue staining of Candida colonies were also analyzed to complement the findings.Key risk factors identified were topical steroid use, intraocular surgery history, and systemic diseases. Common clinical signs included multifocal infiltration, cream-colored infiltration, and blurred boundary lesions. IVCM on 37 eyes (92.5%) consistently showed round, highly reflective Candida spores, and short rod-shaped spores in some cases. Spores exhibited two patterns: caviar-like clusters (51.4%) and sand-like dispersion (89.2%). Multifocal infiltration was significantly associated with a greater prevalence of clustered spores (75.0% vs. 33.3%; P < 0.05). Candida pseudo-hyphae appeared as beaded (91.7%) or lotus root-shaped (41.7%), highly reflective structures. These IVCM findings closely matched colony ex vivo confocal microscopy and light microscopy observations. After treatment, 45% of patients required surgery owing to minimal improvement in best-corrected visual acuity. Poor outcomes were linked to cream-colored infiltration, blurred lesions boundaries, hypopyon, high inflammatory cell density, and deep Candida infiltration (P < 0.05). Clustered spores suggested better outcomes, but lacked statistical significance (P > 0.05).IVCM effectively identifies characteristic spores and pseudo-hyphae in Candida keratitis, facilitating early detection and timely management, particularly in cases with multifocal infiltration and blurred boundary lesions.IVCM works well for the early diagnosis of Candida keratitis, especially in cases of deep corneal stromal infiltration or corneal interface infection after corneal transplantation.