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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 61-63

Corneal hydrops following deep anterior lamellar keratoplasty with spontaneous resolution

Department of Cornea and Refractive Surgery, Sankara Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission15-Jun-2021
Date of Acceptance29-Jun-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Vandhana Sundaram
Fellow - Cornea and Refractive Surgery, Sankara Eye Hospital, Sathy Road, Sivanandapuram, Coimbatore - 641 035, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1649_21

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Deep anterior lamellar keratoplasty (DALK) is often the surgery of choice in patients with advanced keratoconus. Corneal hydrops post-DALK is a rare occurrence with only one case reported so far, where the patient eventually underwent a penetrating keratoplasty due to failure of Descemet's membrane reattachment. Here, we present a case of a ten-year-old boy who had corneal hydrops 18 months post uneventful DALK with spontaneous resolution. Late corneal hydrops post DALK with spontaneous resolution is rare and has not been reported so far.

Keywords: Corneal hydrops, eye rubbing, deep anterior lamellar keratoplasty, keratoconus

How to cite this article:
Sundaram V, Reddy JK, Kuttappalayam SS, Dani SS. Corneal hydrops following deep anterior lamellar keratoplasty with spontaneous resolution. Indian J Ophthalmol Case Rep 2022;2:61-3

How to cite this URL:
Sundaram V, Reddy JK, Kuttappalayam SS, Dani SS. Corneal hydrops following deep anterior lamellar keratoplasty with spontaneous resolution. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:61-3. Available from: https://www.ijoreports.in/text.asp?2022/2/1/61/334898

Keratoconus (KC) is a progressive primary corneal ectasia. Therapeutic options for visual rehabilitation include contact lens, intracorneal ring segments, deep anterior lamellar keratoplasty (DALK), and penetrating keratoplasty (PK).[1] Acute corneal hydrops (CH), a complication seen in advanced KC is characterized by a break in the Descemet's membrane (DM) with aqueous intrusion and resultant corneal stromal edema. This occurs secondary to corneal trauma, the most common being vigorous eye rubbing.[2] Although this is seen in 2%–4% of patients with KC, few rare cases of corneal hydrops post keratoplasty have also been reported.[3],[4]

  Case Report Top

A 10-year-old boy diagnosed with both-eye keratoconus was referred to our center for further management. He had previously undergone left eye corneal collagen crosslinking. Best-corrected visual acuity (BCVA) was 6/60 in the right eye and 6/36 in the left eye with scissor reflex in both eyes. On slit-lamp evaluation, both eyes showed Corneal thinning and Vogt's striae with a central full-thickness stromal scar in the right eye and anterior to mid-stromal scarring in the left eye. Fundus evaluation was normal. The patient was advised right eye penetrating keratoplasty and left eye DALK. He underwent DALK in the left eye under general anesthesia.

Manual DALK was done in view of the stromal scarring and thin pachymetry of 300 microns. The graft was partially trephined with a 7-mm-diameter trephine. Manual layer by layer stromal dissection was done, taking care not to perforate the DM. DM stripping of the donor graft was performed, followed by 7.25-mm trephination. The donor cornea was sutured to the recipient cornea with 16 10-0 nylon interrupted sutures. Surgery was performed by an experienced surgeon with more than 15 years of experience in performing DALK surgeries. The surgery was uneventful.

On post-operative day one, slit-lamp examination showed a clear cornea with a well attached anterior lamellar graft. All sutures were intact. The patient was started on tapering doses of Loteprednol and Ofloxacin eye drops. He was on 2 monthly follow-up and underwent complete suture removal by 8 months after surgery. BCVA was 6/12 following suture removal.

Due to the COVID-19 pandemic and lockdown being imposed, the patient could not come for regular follow-up. He presented one and a half years after surgery with a decrease in vision in the left eye of 1-week duration. Left eye vision was hand movements with accurate projection of light rays. The patient gave a history of vigorous eye rubbing following which he noticed a sudden decrease in vision. On slit-lamp examination, there was conjunctival congestion, corneal graft showed microcystic, and stromal edema with a detached Descemet's membrane involving the central and inferior cornea with a relatively clear cornea in the superotemporal periphery. Host cornea was clear. Intraocular pressure (IOP) measured was 24-mm Hg. Fundus was hazy owing to stromal edema. Anterior segment optical coherence tomography (AS-OCT) showed detached DM with stromal edema [Figure 1]. The patient was started on Loteprednol eye drops 4 times a day, Timolol 0.5% eye drops 2 times a day, 1% atropine eye drops once a day, and advised left eye fluid release with air tamponade under general anesthesia. The patient was reviewed 8 days later with improvement in vision to 5/60 and IOP of 18 mm Hg. On examination, there was a reduction of stromal edema with spontaneous reattachment of the Descemet's membrane with fibrosis, more evident in the inferior cornea [Figure 2]. As there was spontaneous reattachment of DM, surgery was deferred and the patient was continued on medical management.
Figure 1: At presentation: Slit lamp photo shows DM detachment. ASOCT shows DM detachment with stromal separation and ingress of fluid

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Figure 2: Slit lamp photo and ASOCT showing attached DM

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After 2 months, BCVA had improved to 6/18 with stromal scarring and inferior fibrosed Descemet's membrane [Figure 3]. Optic disc evaluation showed a CD ratio of 0.4 and a healthy neuro-retinal rim. IOP was 17-mm Hg, controlled with a single antiglaucoma medication.
Figure 3: Slit lamp photo showing inferior corneal scarring and ASOCT showing attached DM

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  Discussion Top

A study conducted in central India estimated a keratoconus prevalence of 2300 per 100,000, of which 44%–55.8% gave a history of eye-rubbing.[5] Eye rubbing has been postulated to cause indentation-induced changes in the corneal curvature and IOP spikes.[6],[7] This causes progression of KC and incites the development of acute corneal hydrops in advanced cases.

Few rare cases of late hydrops in the donor graft post penetrating keratoplasty have been reported. This was attributed to the migration of cells from the pathologic recipient cornea to repopulate the donor graft.[3],[4],[8] Only one case of acute corneal hydrops 52 months post big bubble DALK surgery has been reported so far. As there was persistent detachment of DM and no spontaneous resolution of corneal edema after two months, the patient underwent penetrating keratoplasty. Multiple postulates were put forward to explain the above phenomenon, such as incomplete excision of the cone with further progression of the disease, use of donor graft with undiagnosed keratoconus, and a retained abnormal DM.[9]

Corneal hydrops post keratoplasty differs from that in advanced keratoconus in that it typically starts at the graft host junction most commonly in the inferior cornea. This is attributed to decreased inter-lamellar strength in the inferior cornea in keratoconus.[3],[9]

In our case, the patient presented with corneal hydrops 18 months post uneventful DALK surgery after an episode of vigorous eye rubbing. The retained keratocytes from manual dissection could also be a factor involved in disease recurrence. Topical steroids were started to reduce inflammation and antiglaucoma medication to decrease the hydrodynamic force on the posterior cornea. However, one week later, there was spontaneous reattachment of DM with a decrease in stromal edema. This reinforces the fact that there is faster resolution of edema and wound healing provided the exacerbating factors, such as eye rubbing and increased IOP, are controlled.

  Conclusion Top

Acute hydrops post-DALK is a rare phenomenon, with eye rubbing being the most common inciting factor. Conventionally, these cases require surgical management for DM reattachment; however, in our case, there was good anatomical and visual outcome with conservative management. Our case highlights the importance of preventing eye rubbing and IOP spikes in patients with successful DALK surgeries to prevent disease progression and complications.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Jhanji V, Sharma N, Vajpayee RB. Management of keratoconus: Current scenario. Br J Ophthalmol 2011;95:1044-50.  Back to cited text no. 1
Fan Gaskin JC, Patel DV, McGhee CN. Acute corneal hydrops in keratoconus-new perspectives. Am J Ophthalmol 2014;157:921-8.  Back to cited text no. 2
Ezra DG, Mehta JS, Allan BD. Late corneal hydrops after penetrating keratoplasty for keratoconus. Cornea 2007;26:639-40.  Back to cited text no. 3
Lyon F, Anderson SB, Ellingham RB. Acute hydrops in a corneal graft for keratoconus. Eye 2007;21:1130-1.  Back to cited text no. 4
Jonas JB, Nangia V, Matin A, Kulkarni M, Bhojwani K. Prevalence and associations of keratoconus in rural maharashtra in central India: The central India eye and medical study. Am J Ophthalmol 2009;148:760-5.  Back to cited text no. 5
McMonnies CW. Mechanisms of rubbing-related corneal trauma in kerato-conus. Cornea 2009;28:607-15.  Back to cited text no. 6
Kim JH, Caprioli J. Intraocular pressure fluctuation: Is it important? J Ophthalmic Vis Res 2018;13:170-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
Wickremasinghe SS, Smith GT, Pullum KW, Buckley RJ. Acute hydrops in keratoconus masquerading as acute corneal transplant rejection. Cornea 2006;25:739-41.  Back to cited text no. 8
Javadi MA, Feizi S, Kanavi MR, Faramarzi A, Hashemian J, Mirbabaee F. Acute hydrops after deep anterior lamellar keratoplasty in a patient with keratoconus. Cornea 2011;30:591-4.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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