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

CORNEAL HYDROPS, OS, secondary to advanced keratoconus. 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.