Management of acute corneal hydrops in ectatic corneal disorders

Pediatric keratoconus

Keratoconus is a common pediatric corneal disease, leading to vision impairment and amblyopia. Compared to its adult counterpart, pediatric keratoconus has an advanced presentation, rapid progression, higher incidence of complications such as corneal hydrops, and greater potential impact on the quality of life. It typically manifests during puberty and can evolve rapidly to more severe stages if left untreated. This rapid progression underscores the importance of early diagnosis through regular screening in pediatric populations and vigilant monitoring of pediatric keratoconus suspects. Concomitant ocular allergies, ocular anomalies, systemic diseases (e.g. syndromes), and poor compliance with contact lenses might impede prompt intervention and frequently postpone rehabilitation. Corneal collagen crosslinking is a crucial intervention in the management of pediatric keratoconus because it strengthens the corneal microstructure and halts the disease progression. When conservative measures fail, keratoplasty remains a viable option with generally favorable outcomes, though with unique challenges in post-operative care, including concerns related to sutures, long-term graft survival and need for repeated examinations under anesthesia. A multidisciplinary approach involving ophthalmologists, optometrists, pediatricians, and other healthcare professionals, focusing on early diagnosis and timely intervention, is essential for the comprehensive management of pediatric keratoconus and to mitigate its impact on children's lives.

Microscope-Integrated Optical Coherence Tomography-Guided Rapid Resolution of Acute Hydrops

An 18-year-old boy presented with blurred visual acuity in the left eye for three days associated with mild pain and photophobia. On examination, he had diffuse corneal stromal edema. Anterior segment optical coherence tomography (AS-OCT) revealed stromal edema with a large hypodense fluid pocket in the posterior stroma. A diagnosis of acute hydrops with an intrastromal cleft in the left eye was made, and he was planned for intracameral gas injection. Intraoperatively, microscope-integrated OCT (Mi-OCT)-guided intracameral isoexpansile sulphur hexafluoride(SF6) was injected ensuring an 80% fill of the anterior chamber. Mi-OCT-assisted venting incision with drainage of stromal fluid clefts was done. On the first postoperative day, the fluid pocket and stromal edema resolved completely. At six weeks' follow-up, the central cornea remained clear with the formation of a paracentral scar. Thus, intracameral gas combined with stromal cleft drainage appears to be a highly effective management option for acute hydrops with a single large stromal fluid cleft. Intraoperative OCT (Mi-OCT) can guide real-time drainage of intrastromal fluid clefts, facilitating the closure of focal Descemet's membrane (DM) defects and enabling early visual rehabilitation, as demonstrated in this case as early as one-day postprocedure.

Keratoconus

Keratoconus is a progressive eye disorder primarily affecting individuals in adolescence and early adulthood. The ectatic changes in the cornea cause thinning and cone-like steepening leading to irregular astigmatism and reduced vision. Keratoconus is a complex disorder with a multifaceted aetiology and pathogenesis, including genetic, environmental, biomechanical and cellular factors. Environmental factors, such as eye rubbing, UV light exposure and contact lens wearing, are associated with disease progression. On the cellular level, a complex interplay of hormonal changes, alterations in enzymatic activity that modify extracellular membrane stiffness, and changes in biochemical and biomechanical signalling pathways disrupt collagen cross-linking within the stroma, contributing to structural integrity loss and distortion of normal corneal anatomy. Clinically, keratoconus is diagnosed through clinical examination and corneal imaging. Advanced imaging platforms have improved the detection of keratoconus, facilitating early diagnosis and monitoring of disease progression. Treatment strategies for keratoconus are tailored to disease severity and progression. In early stages, vision correction with glasses or soft contact lenses may suffice. As the condition advances, rigid gas-permeable contact lenses or scleral lenses are prescribed. Corneal cross-linking has emerged as a pivotal treatment aimed at halting the progression of corneal ectasia. In patients with keratoconus with scarring or contact lens intolerance, surgical interventions are performed.

Deep Anterior Lamellar Keratoplasty-Treated Keratoconic Eyes With Descemet Membrane Rupture

PURPOSE

The aim of this study was to evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) and compare it with penetrating keratoplasty (PKP) in keratoconic eyes with Descemet membrane (DM) rupture.

METHODS

In this comparative retrospective case series, 33 keratoconic eyes with a history of hydrops underwent DALK and 27 received PKP. Baseline and postoperative visual acuity, corneal astigmatism, mean keratometry, endothelial cell density, and complication rates were measured.

RESULTS

The median follow-up of patients who underwent DALK was 45 months (range, 4-76 months) and that of patients who underwent PKP was 84 months (range, 4-136 months). Both procedures had comparable postoperative visual acuity, astigmatism, and mean keratometry. Significantly higher endothelial cell densities were observed in DALK than in PKP at 2, 3, and 5 years postsurgery (2043 ± 767 vs. 1165 ± 683 cell/mm 2 , P = 0.007, n = 12 in both groups at 2 years). Intra-DALK, 15 perforations occurred (44.12%) and 1 (2.94%) was converted to PKP. Graft rejection was diagnosed in 1 (3.03%) DALK procedure versus 8 (29.63%) PKP ( P = 0.008), and other long-term complication rates were equivalent. Kaplan-Meier survival analysis also revealed a higher rejection-free survival rate for the DALK group ( P = 0.012). Subgroup analysis within both groups based on the severity of preoperative DM rupture revealed no significant difference in any major 2-year outcomes.

CONCLUSIONS

DALK showed similar beneficial visual outcome and safety but significantly better endothelial protection over PKP in eyes with keratoconus and previous hydrops. Therefore, DALK is recommended in posthydrops cases irrespective of the DM rupture severity.

Scheimpflug-Based Tomographic Risk Factors for the Development of Acute Corneal Hydrops in Keratoconus

PURPOSE

The purpose of this study was to assess the risk factors that predispose patients with keratoconus to develop acute corneal hydrops (ACH), including both clinical and tomographic risk factors. We additionally describe tomographic changes of the cornea over time after ACH.

METHODS

We retrospectively reviewed patients with keratoconus who were followed at our institution from January 2015 to May 2023. Control eyes, defined as eyes with advanced keratoconus (stage IV Amsler-Krumeich classification on initial examination) were compared with eyes that developed ACH. Demographic, clinical, and tomographic factors were investigated. Visual acuity, keratometry, and corneal thickness were assessed at each follow-up visit to monitor progression over time.

RESULTS

Twenty-three eyes of 19 patients developed ACH over the follow-up period. The incidence of known clinical associations including seasonal allergies, eye rubbing, snoring, asthma, and eczema was similar between the hydrops and control groups. There was a higher incidence of Down syndrome in the hydrops group ( P = 0.04). Eyes that developed hydrops had similar best corrected visual acuity on initial examination, but had steeper keratometry ( P = 0.003) and thinner corneas ( P < 0.001) than controls at baseline. After hydrops, progressive corneal flattening and reduced maximum keratometry occurred over time. However, final best corrected visual acuity was worse compared with initial examination before hydrops ( P = 0.03), as well as compared with control eyes ( P < 0.001).

CONCLUSIONS

Risk factors of developing ACH include steep keratometry and thin corneas as well as Down syndrome. Although corneal flattening will occur after resolution of acute corneal edema, visual acuity worsened after ACH.

SMAD4-Dependent Signaling Pathway Involves in the Pathogenesis of TGFBR2-Related CE-like Phenotype

(1) Background: Our previous data indicated that disturbance of the Transforming Growth Factor beta (TGFB) signaling pathway via its Type-2 Receptor (TGFBR2) can cause a Corneal Ectasia (CE)-like phenotype. The purpose of this study is to elucidate whether the SMAD4-dependent signaling pathway is involved in the TGFBR2-related CE-like pathogenesis. (2) Methods: Smad4 was designed to be conditionally knocked out from keratocytes. Novel triple transgenic mice, KerartTA; Tet-O-Cre; Smad4flox/flox (Smad4kera-cko), were administered with doxycycline (Dox). Optical Coherence Tomography (OCT) was performed to examine Central Corneal Thickness (CCT), Corneal Radius, Anterior Chamber and CE-like phenotype and compared to the littermate Control group (Smad4Ctrl). (3) Results: The OCT revealed normal cornea in the Smad4Ctrl and a CE-like phenotype in the Smad4kera-cko cornea, in which the overall CCT in Smad4kera-cko was thinner than that of Smad4Ctrl at P42 (n = 6, p < 0.0001) and showed no significant difference when compared to that in Tgfbr2kera-cko. Furthermore, the measurements of the Anterior Chamber and Corneal Radius indicated a substantial ectatic cornea in the Smad4kera-cko compared to Smad4Ctrl. The H&E staining of Smad4kera-cko mimics the finding in the Tgfbr2kera-cko. The positive immunostaining of cornea-specific marker K12 indicating the cell fate of cornea epithelium remained unchanged in Smad4kera-cko and the Proliferating Cell Nuclear Antigen (PCNA) immunostaining further indicated an enhanced proliferation in the Smad4kera-cko. Both immunostainings recapitulated the finding in Tgfbr2kera-cko. The Masson's Trichrome staining revealed decreased collagen formation in the corneal stroma from both Smad4kera-cko and Tgfbr2kera-cko. The collagen type 1 (Col1a1) immunostaining further confirmed the reduction in collagen type 1 formation in Smad4kera-cko. (4) Conclusions: The aforementioned phenotypes in the Smad4kera-cko strain indicated that the SMAD4-dependent signaling pathway is involved in the pathogenesis of the CE-like phenotype observed in Tgfbr2kera-cko.

Management of acute corneal hydrops - Current perspectives

Acute corneal hydrops (ACH) is a rare but sight-threatening complication of corneal ectasias. We aim to review the current literature on etiopathogenesis, histology, role of ancillary investigations, management, and outcomes of ACH by classifying the various management strategies based on their site of action and the underlying mechanism. A review of the literature was conducted by searching the following databases: PubMed (United States National Library of Medicine), Embase (Reed Elsevier Properties SA), Web of Science (Thomson Reuters), and Scopus (Elsevier BV) till April 2023. The literature search used various combinations of the following keywords: acute corneal hydrops, keratoconus, ectasia, management, keratoplasty. Nine hundred eighty-three articles were identified based on the above searches. Case reports which did not add any new modality of treatment to the existing literature, articles unrelated to management, those with no full text available, and foreign-language articles with no translation available were excluded. Eventually, 75 relevant articles that pertained to the management of ACH were shortlisted and reviewed. Recent studies have described newer surgical interventions like full-thickness or pre-Descemetic sutures, thermokeratoplasty, and plasma injection that aim to close the posterior stromal break. Posterior lamellar keratoplasties act by replacing the posterior torn Descemet's membrane (DM), and early deep anterior lamellar keratoplasty (DALK) has been attempted to combine the correction of the anatomical defect and visual rehabilitation in a single surgery. These surgical interventions may help by reducing the scarring and increasing the number of patients who can be visually rehabilitated with contact lenses rather than keratoplasty.

Full-Thickness Compressive Corneal Sutures with Removal of Anterior Chamber Air Bubble in the Management of Acute Corneal Hydrops

Acute hydrops is a rare complication of corneal ectatic disease, which occurs secondary to Descemet membrane break. Spontaneous resolution of this condition is associated with longstanding ocular discomfort and corneal scar. Intracameral gas/air injection with or without corneal suturing, anterior segment ocular coherence tomography (ASOCT)-guided drainage of intrastromal fluid, and penetrating keratoplasty are some of the described surgical interventions to manage this condition. The purpose of our study was to assess the effect of full-thickness corneal suturing as a solo treatment in the management of acute hydrops. A total of five patients with acute hydrops received full-thickness corneal sutures perpendicular to their Descemet break. A complete resolution of symptoms and corneal oedema was observed between 8 to 14 days post-operation with no complications. This technique is simple, safe, and effective in the management of acute hydrops and saves patients from a corneal transplant in an inflamed eye.

Different compression sutures combined with intracameral air injection for acute corneal hydrops

AIM

To evaluate the efficacy and safety of full-thickness sutures combined with intracameral air injection (FTS-AI) versus pre-Descemet's membrane sutures combined with intracameral air injection (PDS-AI) in the management of acute corneal hydrops in keratoconus.

METHODS

The research included 8 patients (8 eyes) suffering from acute corneal hydrops caused by keratoconus. Four patients were randomly assigned to FTS-AI. And the other four were randomly assigned to PDS-AI. Corneal oedema, visual acuity, corneal thickness were assessed during follow-up.

RESULTS

The demographics, preoperative duration of symptoms and severity of corneal hydrops between the two groups were not significantly different. The mean corneal oedema resolution time after FTS-AI and PDS-AI were 11±1.15 and 15±1.41d, respectively (P=0.005). The maximum corneal thickness of the scarred region decreased in both groups at one week postoperatively (P<0.05). No obvious difference was found in the mean maximal corneal thickness between the two groups postoperatively. The BCVA improved significantly after FTS-AI and PDS-AI at three months postoperatively. No obvious difference was found in the BCVA after FTS-AI and PDS-AI at three months postoperatively.

CONCLUSION

FTS-AI and PDS-AI are safe and effective therapies to accelerate the resolution of corneal oedema in acute corneal hydrops secondary to keratoconus. Despite faster resolution of corneal oedema in the FTS-AI group, we recommend PDS-AI to avoid potential endothelium cell damage.

Treatment strategies for the management of acute hydrops

Acute corneal hydrops is a condition characterized by marked stromal edema attributable to leakage of aqueous humor through a rupture in Descemet's membrane. In addition to the clinical examination, imaging options include ultrasound biomicroscopy, anterior segment optical coherence tomography and in vivo confocal microscopy. While it is a self-limiting condition, the duration of acute hydrops is an important factor linked to complications such as neovascularization. Therapeutic options may relieve symptoms and/or reduce healing time; these include conservative, medical and/or surgical therapies. Several new medical and surgical management options have been reported in the past few years and will be discussed in this article.

Visual and Anatomic Results After Sole Full-Thickness Sutures for Acute Corneal Hydrops

PURPOSE

To determine whether sole full-thickness corneal sutures are a feasible treatment for acute corneal hydrops, and if so, report the anatomic and visual results of this technique.

METHODS

A retrospective case series was carried out in 17 patients, all of whom received sole full-thickness sutures as a treatment for corneal hydrops.

RESULTS

The included patients reported symptom commencement a median of 15 days before the surgical intervention. The patients' median preoperative corneal pachymetry was 1235 μm, whereas 1 month after the surgery, the median corneal thickness was 830 μm, and after 3 months, it was 502 μm (P < 0001). Preoperative best corrected visual acuity (BCVA) was 1.40 LogMAR and a final postsurgical BCVA of 1.00 LogMAR after 3 months of the follow-up (P < 0001). Deep neovascularization was present in 3 patients (17.6%); none of the patients developed cataract formations or pupillary blocks.

CONCLUSIONS

Given the improvement of the corneal pachymetry and the BCVA, sole full-thickness sutures seem to be a feasible surgical option to treat severe acute corneal hydrops.

Management of acute corneal hydrops with intracameral gas injection

Purpose

To report two cases of severe acute corneal hydrops that were resolved by intracameral gas injection alone.

Observations

Case 1 is a 27-year-old woman with bilateral severe keratoconus who developed sequential acute corneal hydrops in the right eye followed by the left eye that were each successfully treated using intracameral 20% sulfur hexafluoride gas injection. Case 2 is a 62-year-old man that developed a large fluid cleft beneath a pre-existing LASIK flap, which resolved with intracameral 20% sulfur hexafluoride gas injection without the need for corneal transplantation.

Conclusions and importance

In acute corneal hydrops, intracameral gas injection to tamponade Descemet's membrane tears with decompression of stromal fluid can be an effective intervention to delay or avoid keratoplasty in individuals whose corneal hydrops does not improve with conventional medical management.

Compression sutures combined with intracameral air injection versus thermokeratoplasty for acute corneal hydrops: a prospective-randomised trial

AIMS

To compare the efficacy of compression sutures combined with intracameral air injection (CSAI) and thermokeratoplasty (TKP) for the management of acute corneal hydrops in keratoconus.

METHODS

In this multi-centre randomised clinical trial, 20 patients with keratoconus (20 eyes) with acute corneal hydrops were enrolled and randomised to receive either CSAI or TKP and followed-up for a period of 6 months.

RESULTS

There were no significant differences in patient demographics, severity of corneal hydrops and preoperative duration of symptoms between the two groups. In both groups, corneal oedema resolved within 2 weeks. The maximum thickness of the corneal scars following CSAI and TKP was not significantly different. Best spectacle-corrected visual acuity was superior in the CSAI group at 6-month follow-up (CSAI vs TKP, 0.52 (0.37, 0.85) vs 0.96 (0.70, 1.34) LogMAR, p=0.042). CSAI resulted in greater corneal endothelial cell density (CSAI vs TKP, 2677.8±326.7 vs 1955.3±298.1 cells/mm², p<0.001) and flatter corneal curvature (CSAI vs TKP: mean keratometry value, 52.13±4.92 vs 63.51±5.83D, p<0.001; maximum keratometry value, 65.21±7.42 vs 77.13±12.01D, p=0.016) at the 6-month follow-up.

CONCLUSION

Although both CSAI and TKP resulted in resolution of acute corneal hydrops in keratoconus, CSAI was associated with superior clinical outcomes in this study.

CHINESE CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-IOR-17013764.

Unilateral acute hydrops in a child with bilateral microcornea and iridofundal coloboma

A 15-year-old female child with history of bilateral poor vision since childhood presented with sudden onset pain, photophobia, and diminution of vision OD for 10 days. Visual acuity was hand motion OD and 1/60 OS. Slit lamp examination revealed microcornea OU with multiple intrastromal fluid clefts OD and an irregular cornea and iridofundal coloboma OS. A clinical diagnosis of acute corneal hydrops OD was made, and the child was subjected to intraoperative optical coherence tomography guided intrastromal fluid drainage with air tamponade. The corneal edema resolved completely within 2 weeks resuming visual acuity to 3/60 allowing laser delimitation of fundal coloboma OD.

Using intracameral vital dye as a guide for venting incision in acute corneal hydrops

PURPOSE

To introduce a new surgical technique for the localization of corneal bulla to drain a massive corneal hydrops.

METHODS

Four consecutive cases with acute large protruded hydrops were selected. A limbal paracentesis was made via 15° blade. Afterward, trypan blue with a concentration of 0.1% was injected into the anterior chamber. Upon pooling trypan blue in the bulla, the surgeon immediately marked the primary site of stromal staining before further spreading of the dye. Anterior chamber irrigation was then carried out using balanced salt solution, and the excess of trypan blue was washed out. Subsequently, the surgeon made a beveled venting incision to decompress bulla via 15° blade resulting in a stream of dye egressed from the venting incision. At the end of the surgery, 20% diluted SF₆ was injected into the anterior chamber.

RESULTS

Postoperatively, Descemet's membrane was attached up to the second postoperative day. The corneal edema was resolved up to 3 weeks. Contact lens-corrected visual acuity was improved in all cases.

CONCLUSION

Venting incision under the guide of injected trypan blue into the anterior chamber combined with intracameral SF₆ injection could be effectively used for a large acute hydrops. This technique could prevent other interventions like passing full-thickness corneal suturing and subsequent complications.

Unusual Case of Acute Corneal Hydrops in Mooren's Ulcer Treated with Intracameral Injection of Perfluoropropane

A 15-year-old boy was diagnosed with Mooren's ulcer in the right eye at our cornea clinic. On treatment, he developed acute corneal hydrops, and the vision in the right eye dropped to perception of light. The patient was treated with intracameral injection of perfluoropropane (C3F8) gas which resulted in complete resolution of corneal edema. Contact lens fitting yielded a good visual outcome with a best-corrected visual acuity of 20/80. To the best of our knowledge, this is the only case reporting the occurrence of acute corneal hydrops in a child with Mooren's ulcer.

Acute corneal edema without epithelium compromise. A case report and literature review

El edema de córnea es una entidad que se produce por un gran número de causas y tiene diversas formas de presentación y diferentes grados de afección. En este artículo se reporta el caso de un hombre con edema de córnea agudo sin compromiso epitelial, en el que el cuadro clínico, el examen oftalmológico y los estudios de extensión no lograron establecer su etiología. Además, se hace una revisión de la literatura disponible respecto a todas las posibles causas de edema de córnea agudo, agrupándolas en aquellas que ocasionan el edema por lesión o inflamación epitelial o estromal, por disfunción endotelial o por un aumento en la presión intraocular.

Acute corneal hydrops during pregnancy with spontaneous resolution after corneal cross-linking for keratoconus: a case report

BACKGROUND

Keratoconus may progress to acute corneal hydrops even after cross-linking. In some cases, keratoconus progresses during pregnancy. In this report, we present a case of a patient with increased anterior stromal resistance after cross-linking that would favor nonprogression of keratoconus during pregnancy.

CASE PRESENTATION

We report that cross-linking is likely to have had a protective effect in a white pregnant patient with acute corneal hydrops who showed rapid improvement, as documented by corneal topography. Improvement occurred within 8 days, whereas up to 250 days are reported in the literature. No keratoconus progression occurred in the 20-month follow-up period.

CONCLUSIONS

Cross-linking failed to prevent the occurrence of acute corneal hydrops after rupture of Descemet's membrane but most likely helped to accelerate the resolution of the condition. Corneal hardening resulting from cross-linking may have also contributed to stabilizing keratoconus during pregnancy.

Spontaneous Corneal Hydrops in a Patient with a Corneal Ulcer

PURPOSE

We report the case of a 77-year-old man with no history of keratoconus or other ectatic disorders who presented with corneal hydrops in the setting of a corneal ulcer. The risk factors, pathogenesis and treatment options of corneal hydrops are discussed.

METHOD

This is an observational case report study.

RESULTS

A 77-year-old man presented with a 1-day history of severe pain, redness, mucous discharge and photophobia in the right eye. A slit-lamp examination of the right eye showed an area of focal corneal edema and protrusion. Within the area of edema and protrusion, there was an infiltrate with an overlying epithelial defect consistent with an infectious corneal ulcer. The Seidel test showed no leakage, so a clinical diagnosis of corneal hydrops associated with nonperforated corneal ulcer was made. With appropriate antibiotic treatment, the corneal ulcer and hydrops both resolved over a 1-month period.

CONCLUSION

Corneal hydrops can occur in the setting of corneal infections.

Corneal Hydrops in Keratoconus

Purpose

The purpose of this review is to outline the etiology, clinical features, and management of acute corneal hydrops (CH) in cases of keratoconus (KC).

Recent findings

The advent of newer investigative modalities like ultra biomicroscopy, anterior segment optical coherence tomography and confocal microscopy has contributed toward the diagnosis, treatment planning and following the course of therapy in cases of acute hydrops.

Summary

Corneal hydrops is an acute complication of keratoconus which in most instances resolves spontaneously. However, prolonged corneal edema can lead to complications, such as corneal neovascularization which can jeopardise a future corneal graft. Hence, timely intervention is required in most cases to prevent such complications as well as for early visual rehabilitation. Intracameral gas injection is the most commonly performed surgical procedure for hydrops. Modifications in surgical technique can help to tackle difficult situations.

How to cite this article

Maharana PK, Nagpal R, Sharma N. Corneal Hydrops in Keratoconus. Int J Kerat Ect Cor Dis 2015;4(2):52-55.

[Management of corneal hydrops using air and micro-punctures]

CASE REPORT

A 22-year- old woman with an acute hydrops and Descemet membrane detachment was managed by intracameral air injection combined with multiple corneal stromal venting incisions for the drainage of intrastromal fluid. No intraoperative complications were encountered, and the intrastromal fluid was resolved over 2 weeks.

DISCUSSION

Acute corneal hydrops is a significant complication of keratoconus. If not treated, resolution usually occurs over a period of 2-4 months. The persistent oedema can cause complications, such as corneal neovascularisation, infection and corneal perforation.

Acute corneal hydrops in keratoconus

Acute corneal hydrops is a condition characterized by stromal edema due to leakage of aqueous through a tear in descemet membrane. The patient presents with sudden onset decrease in vision, photophobia, and pain. Corneal thinning and ectasias combined with trivial trauma to the eye mostly by eye rubbing is considered as the underlying cause. With conservative approach self-resolution takes around 2 to 3 months. Surgical intervention is required in cases of non-resolution of corneal edema to avoid complications and for early visual rehabilitation. Intracameral injection of air or gas such as perflouropropane is the most common surgical procedure done. Recent investigative modality such as anterior segment optical coherence tomography is an extremely useful tool for diagnosis, surgical planning, and postoperative follow up. Resolution of hydrops may improve the contact lens tolerance and visual acuity but most cases require keratoplasty for visual rehabilitation.