CASE IV

CORNEAL

HYDROPS

History

• 28 year old white male.

• Painful left eye.

• Severe photophobia.

• Hard to keep open.

• Duration of 1 month.

• Taking 1 gtt homatropine 5% bid, and darvocet po for past three weeks.

Exam Findings

• VA- LP, OU.

• Gross observation reveals whitish haze, OS.

• Mild protrusion of lower eyelid.

• Mild bulbar hyperemia, OS.

• 4+ central corneal haze with 4+ edema.

• Anterior chamber clear.

Slit Lamp Examination

Assessment

• CORNEAL HYDROPS, OS, secondary to advanced keratoconus.

Symptoms

• Sudden loss of vision.

• Pain.

• Photophobia.

• Red eye.

Signs

• Decreased visual acuity.

• Opaque, edematous cornea.

• Ciliary injection.

• Anterior chamber reaction.

Pathophysiology

• Sudden tearing of Descemet’s layer.

• Flooding from the anterior chamber into the corneal stroma.

• Loss of corneal transparency.

• Secondary to progressive corneal thinning from advanced keratoconus.

Keratoconus

• Bilateral, asymmetric corneal dystrophy.

• Begins in second to third decade.

• Progresses over 7 to 8 years, then stabilizes.

Keratoconic Causes

• 10-15% have family history.• Association with vernal keratoconjunctivitis,

retinitis pigmentosa, connective tissue disorders, mitral valve prolapse, atopic dermatitis, and Down syndrome.

• Few elderly patients have been noted with keratoconus.

• Studies have not proven a link with fatal disease.

Management Plan

• Begin Pred Forte 1%, 1 gtt qid, OS.

• Begin NaCl 5%, 1 gtt qid, OS.

• Continue with homatopine 5%, 1 gtt bid.

• Discontinue davocet.

• Patient scheduled to return in two weeks for follow-up care.

Appropriate Actions

• Hypertonic sodium chloride ointment or drops.

• Cycloplegia.

• Topical steroid.

• Bandage contact lens.

• Decrease aqueous production.

Explanation of Treatment

• Hypertonic solution, 8 to 10 weeks, to draw out corneal edema in an attempt to restore corneal integrity.

• Topical steroid, 1-2 weeks, may help to reduce corneal scarring.

• Cycloplegia, bandage CL for pain management.• *Treatment is supportive as corneal should clear

in 8-10 weeks, naturally.

Plan for Follow-Up

• Assess patient comfort.

• Slit lamp examination.

• If worse or no better, consider consult with corneal specialist.

• Follow-up schedule:– 1 week, 1 month, 2 month.

Prognosis…Let the Cornea Heal!

• Descemet’s membrane will heal over the course of several weeks.

• Corneal endothelium will pump fluid out of stroma into the anterior chamber.

• Corneal transparency will be restored.• Contraction within the stromal may result in a

flattening of the corneal cone.• Patients may end up with a small residual scar.

Furthermore…

• Patients may end up with a small residual scar.

• If scar results in permanent decreased visual acuity, surgery would be in order.

• Patient may resume RGP lenses with minimal effect on vision.

Surgical Indications

• A corneal patch graft may be indicated if there is wound leakage.

• Penetrating keratoplasty if the cornea does not clear sufficiently after several months, for better visual acuity.

Corneal Perforation

• Rare, but reported.

• Usually require penetrating keratoplasty.

• Cornea 24(4):503-504, May 2005. Intracameral sulfur hexafluoride and tissue adhesive prevents keratoplasty in perforating corneal hydrops.

Lastly,

• Corneal hydrops does not progress to corneal perforation.

• Emergency penetrating keratoplasty not indicated.