case iv corneal hydrops. history 28 year old white male. painful left eye. severe photophobia. hard...
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CASE IV
CORNEAL
HYDROPS
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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.
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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.
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Slit Lamp Examination
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Assessment
• CORNEAL HYDROPS, OS, secondary to advanced keratoconus.
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Symptoms
• Sudden loss of vision.
• Pain.
• Photophobia.
• Red eye.
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Signs
• Decreased visual acuity.
• Opaque, edematous cornea.
• Ciliary injection.
• Anterior chamber reaction.
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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.
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Keratoconus
• Bilateral, asymmetric corneal dystrophy.
• Begins in second to third decade.
• Progresses over 7 to 8 years, then stabilizes.
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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.
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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.
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Appropriate Actions
• Hypertonic sodium chloride ointment or drops.
• Cycloplegia.
• Topical steroid.
• Bandage contact lens.
• Decrease aqueous production.
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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.
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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.
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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.
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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.
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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.
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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.
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Lastly,
• Corneal hydrops does not progress to corneal perforation.
• Emergency penetrating keratoplasty not indicated.