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| CASE REPORT |
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| Year : 2022 | Volume
: 15
| Issue : 2 | Page : 237-239 |
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Management of acute hydrops with pre-Descemet's deep anterior lamellar keratoplasty
Sujatha Mohan, Madhuvanthi Mohan, Sujitha Danasekar, Sashwanthi Mohan
Department of Cornea and Refractive Surgery, Rajan Eye Care Hospital, Chennai, Tamil Nadu, India
| Date of Submission | 31-Oct-2021 |
| Date of Acceptance | 29-Mar-2022 |
| Date of Web Publication | 29-Jun-2022 |
Correspondence Address:
Dr. Sashwanthi Mohan
Rajan Eye Care Hospital, No. 5, Vidyodaya East 2nd Street, T. Nagar, Chennai - 600 017, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_317_21
 Abstract | | |
This case report describes a 23-year-old female patient who had bilateral keratoconus and a history of right eye penetrating keratoplasty who presented with acute hydrops in the left eye which did not respond to conservative management. Pre-Descemet's deep anterior lamellar keratoplasty was performed in the acute stage for management of the impending perforation with good visual outcomes.
Keywords: Acute corneal hydrops, deep anterior lamellar keratoplasty, keratoconus
How to cite this article:
Mohan S, Mohan M, Danasekar S, Mohan S. Management of acute hydrops with pre-Descemet's deep anterior lamellar keratoplasty. Oman J Ophthalmol 2022;15:237-9 |
How to cite this URL:
Mohan S, Mohan M, Danasekar S, Mohan S. Management of acute hydrops with pre-Descemet's deep anterior lamellar keratoplasty. Oman J Ophthalmol [serial online] 2022 [cited 2022 Aug 19];15:237-9. Available from: https://www.ojoonline.org/text.asp?2022/15/2/237/348990 |
| Introduction | |  |
Acute corneal hydrops is characterized by stromal edema due to leakage of aqueous through the tear in the Descemet's membrane (DM). Only 3% of keratoconus patients develop acute corneal hydrops[1],[2] and we report one such case and how it was managed surgically.
| Case Report | | |
A 23-year-old female patient presented with the complaints of pain, photophobia, and defective vision in the left eye for 3 days. She was a known patient of both eyes keratoconus and had undergone penetrating keratoplasty (PK) for advanced keratoconus in the right eye a year ago. The best- corrected visual acuity (BCVA) in the right eye post-PK was 6/6, N6. The left eye visual acuity was 6/9, N6. At this visit, BCVA was 6/18 in the right eye and 6/60 in the left eye. Slit-lamp examination of the right eye showed a clear corneal graft. Slit-lamp examination of the left eye showed localized microcystic epithelial edema and stromal edema with intrastromal fluid clefts covering the visual axis [Figure 1]a and [Figure 1]b. A diagnosis of the left eye acute corneal hydrops was made. The patient was treated conservatively with topical steroids, hypertonic saline, and oral antiglaucoma drug, tablet acetazolamide 250 mg twice a day. Over the next 4 days, no significant improvement was noted, and hence, a stromal puncture was done. Fluid was drained and 0.01 ml of nonexpansile 14% C3F8 was injected into the anterior chamber with a 27G needle under topical anesthesia [Figure 2]. Postoperatively, the patient was symptomatically better. However, after 10 days, the patient developed a recurrence of corneal edema with impending perforation [Figure 3]a. This was also confirmed on anterior segment optical coherence tomography (ASOCT) [Figure 3]b. The patient underwent pre-Descemet's deep anterior lamellar keratoplasty (DALK) in the left eye. Partial-thickness trephination of the host cornea was done using a 9 mm trephine followed by air injection in the area of the uninvolved cornea using a 26G needle with bevel up creating an emphysematous cornea. Manual, layer-by-layer dissection of host stroma was done using the emphysematous cornea as a guide. Dissection was carried out in a centripetal fashion to avoid the area of impending perforation. The area over the DM tear was approached last. Air was injected into the anterior chamber before this step. Manual dissection of deeper layers was done using a no. 15 blade. Deep manual dissection was done to remove as much stroma as possible without collapsing the anterior chamber and retaining a few layers of posterior stroma to avoid collapse of the anterior chamber. The same size donor graft with endothelium removed was sutured with 16 interrupted sutures to the host cornea. Partial air fill in the anterior chamber was done to tamponade the break. The patient was advised to maintain the supine position for 1 day. Postoperatively, that graft was clear and the patient's BCVA improved to 6/9 which she has been maintaining for the past 3 years [Figure 4]a and [Figure 4]b. | Figure 1: (a) Diffuse illumination of the left eye showing a central area of microcystic epithelial edema with surrounding stromal edema covering the pupillary area and visual axis (b) Optical section of the left eye cornea delineating the epithelial and stromal edema with intervening intrastromal fluid clefts
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 | Figure 2: Postoperative slit-lamp photograph of the left eye containing a C3F8 bubble in the anterior chamber
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 | Figure 3: (a) Slit-lamp photograph of the left eye 10 days later showing recurrence of corneal edema and impending perforation (b) anterior segment optical coherence tomography of the left eye confirming the impending perforation
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 | Figure 4: (a) Postoperative day 1 after deep anterior lamellar keratoplasty with air bubble present covering half the anterior chamber in the area of Descemet's tear (b) Postoperative 1 month slit-lamp photograph of the left eye showing a clear graft
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| Discussion | | |
Acute corneal hydrops develops secondary to a break in DM which results in the percolation of aqueous from the anterior chamber into the corneal stroma leading to focal corneal edema and the formation of fluid clefts.[3]
Diagnosis is based on history and slit-lamp examination. Investigations such as ASOCT and ultrasound biomicroscopy can help to determine the extent and size of edema and DM tear. It has been postulated that the resolution of hydrops requires two steps. First, the detached DM must reattach to the posterior stroma which depends on the depth of detachment. Second, the endothelium must migrate from the reattached DM to cover the gaps between broken ends which depends on the size of the break.[4]
Conservative treatment provides symptomatic relief till spontaneous resolution occurs. This includes topical lubricants, prophylactic topical antibiotics, topical hypertonic saline, antiglaucoma medications, steroids, and cycloplegics.[1],[2],[5]
The surgical approach includes stromal puncture, intracameral air/gas injection into the anterior chamber such as 20% sulfur hexafluoride (SF6) and 14% perfluoropropane (C3F8). These agents give a tamponade effect preventing aqueous from entering into the stroma and also help in bringing back the torn ends of the ruptured DM to their normal position.[6],[7]
Other methods include cyanoacrylate glue with bandage contact lenses for smaller perforations[1],[8] and compressive sutures with gas injection in cases with a wide separation of DM.[4],[9] PK is indicated in cases of persistent edema, large DM tear, large intrastromal cyst, and corneal neovascularization.[2],[3],[10] DALK is a challenging procedure to perform following acute corneal hydrops due to difficulty in separating DM from posterior stroma because of scarring after the acute episode. However, the advantage is that the host DM and endothelium are retained, and hence, the risk of rejection is lesser than with PK.
The modified technique of DALK we followed called primary pre-Descemet's DALK has been previously described by Jacob et al.[11] The modifications include using a 26-gauge needle with a bevel up instead of down, directed away from the break, and injection of only a small amount of air slowly and at multiple sites, to avoid buildup of pressure from the air. The air helps in creating tissue emphysema which is used as a guide for depth of dissection. A centripetal dissection helps avoid the area of the Descemet's break which is approached last. Deeper dissection is done by Melles technique if required.[12] To prevent the anterior chamber from collapsing, the minimal stroma is retained above the Descemet's tear. The donor graft without Descemet's and endothelium is sutured to the host bed and the air is injected into the anterior chamber to tamponade the break at the end of surgery.[11]
Surgery with this technique in the acute stage has many advantages. It prevents healing by stromal scarring and provides early anatomical correction and rapid visual rehabilitation.[12] DALK has the advantage over PK as the host DM and endothelium are retained and thus risks such as rejection and graft failure are avoided. In our case, we obtained a successful anatomical and visual outcome by following this technique.
| Conclusion | | |
Acute corneal hydrops especially in cases of impending perforation can be managed with this modified technique of pre-Descemet's DALK with good visual outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Tuft SJ, Gregory WM, Buckley RJ. Acute corneal hydrops in keratoconus. Ophthalmology 1994;101:1738-44.  |
| 2. | Grewal S, Laibson PR, Cohen EJ, Rapuano CJ. Acute hydrops in the corneal ectasias: Associated factors and outcomes. Trans Am Ophthalmol Soc 1999;97:187-98. |
| 3. | Sharma N, Mannan R, Jhanji V, Agarwal T, Pruthi A, Titiyal JS, et al. Ultrasound biomicroscopy-guided assessment of acute corneal hydrops. Ophthalmology 2011;118:2166-71. |
| 4. | Basu S, Vaddavalli PK, Vemuganti GK, Ali MH, Murthy SI. Anterior segment optical coherence tomography features of acute corneal hydrops. Cornea 2012;31:479-85. |
| 5. | Maharana PK, Nagpal R, Sharma N. Corneal hydrops in keratoconus. Int J Keratoconus Ectatic Corneal Dis 2015;4:52-5. |
| 6. | Sharma N, Maharana PK, Jhanji V, Vajpayee RB. Management of acute corneal hydrops in ectatic corneal disorders. Curr Opin Ophthalmol 2012;23:317-23. |
| 7. | Miyata K, Tsuji H, Tanabe T, Mimura Y, Amano S, Oshika T. Intracameral air injection for acute hydrops in keratoconus. Am J Ophthalmol 2002;133:750-2. |
| 8. | Aldave AJ, Mabon M, Hollander DA, McLeod SD, Spencer WH, Abbott RL. Spontaneous corneal hydrops and perforation in keratoconus and pellucid marginal degeneration. Cornea 2003;22:169-74. |
| 9. | Rajaraman R, Singh S, Raghavan A, Karkhanis A. Efficacy and safety of intracameral perfluoropropane (C3F8) tamponade and compression sutures for the management of acute corneal hydrops. Cornea 2009;28:317-20. |
| 10. | Sharma N, Mannan R, Titiyal JS. Nonresolution of acute hydrops because of intrastromal migration of perfluoropropane gas. Cornea 2010;29:944-6. |
| 11. | Jacob S, Narasimhan S, Agarwal A, Sambath J, Umamaheshwari G, Saijimol AI. Primary modified predescemetic deep anterior lamellar keratoplasty in acute corneal hydrops. Cornea 2018;37:1328-33. |
| 12. | Melles GR, Rietveld FJ, Beekhuis WH, Binder PS. A technique to visualize corneal incision and lamellar dissection depth during surgery. Cornea 1999;18:80-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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