Corneal hydrops

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Rupture of Descemet’s membraneAcute leakage of aqueous into corneal stroma and epithelium

Predisposing factors

Keratoconus, keratoglobus, pellucid marginal degeneration or other primary corneal ectasia
The estimated UK annual incidence of acute corneal hydrops in keratoconus is 1.4 per 1000
Most cases occur in second or third decade with men affected 2-3 times more than women
Eye rubbing may be a risk factor

Symptoms

Sudden reduction in visual acuity
Discomfort
Photophobia
Watering
Contact lens intolerance

Signs

Gross stromal oedema with or without epithelial oedema

  • usually over a clearly demarcated area
    • Descemet’s membrane rupture may be visible
  • periphery usually spared, except in pellucid marginal degeneration

Differential diagnosis

Other causes of corneal oedema including Fuchs dystrophy and infective keratitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Acute hydrops

  • cease contact lens wear
  • avoid bandage contact lens (hypoxia may induce corneal vascularisation)
  • initially, review weekly for appearance of vascularisation or other complication
    • majority of cases resolve over 2-4 months, sometimes with stromal scarring
    • if corneal vascularisation appears, refer urgently to ophthalmologist

After resolution

  • reassess corneal topography (often less steep after hydrops)
  • will probably still need contact lens for optimum acuity; lens fit will need to be reviewed as corneal profile may have changed

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Pharmacological

Topical lubricants for symptomatic relief
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Cycloplegia for symptomatic relief, e.g. gutt. cyclopentolate 1% twice daily
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Systemic analgesia if necessary
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Consider prophylactic topical antibiotic (e.g. gutt. chloramphenicol qds) if epithelial surface acutely disturbed by oedema and if secondary infection seems likely to occur
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
 

Referral

B2: alleviation/palliation: normally no referral
A3: first aid measures and urgent referral (if vascularisation present)

Possible management by ophthalmologist

Treat pain, prophylactic antibiotic if indicated, topical steroid if corneal vessels proliferate, penetrating keratoplasty if scarring reduces acuity following resolution
Possible intracameral gas injection

Evidence base

*GRADE*: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Barsam A, Petrushkin H, Brennan N, Bunce C, Xing W, Foot B, Tuft S. Acute corneal hydrops in keratoconus: a national prospective study of incidence and management. Eye (Lond). 2015;29(4):469-74

Fan Gaskin JC, Patel DV, McGhee CN.Acute corneal hydrops in keratoconus – new perspectives. Am J Ophthalmol. 2014;157(50):921-8

Panda A, Aggarwal A, Madhavi P, Wagh VB, Dada T, Kumar A, Mohan S. Management of acute corneal hydrops secondary to keratoconus with intracameral injection of sulfur hexafluoride (SF6). Cornea 2007;26:1067- 9

Rowson NJ, Dart JK, Buckley RJ. Corneal neovascularisation in acute hydrops. Eye 1992;6:404-6

Sharma N, Maharana PK, Jhanji V, Vajpayee RB. Management of acute corneal hydrops in ectatic corneal disorders. Curr Opin Ophthalmol. 2012;23(4):317-23

Lay summary

This is a rare occurrence seen occasionally in people in whom the cornea (the clear window of the eye) is thinned and distorted, for example in the condition known as keratoconus. Usually for no apparent reason, the back membrane of the cornea splits, allowing fluid from within the eye to flood into the cornea which then loses its clarity. The vision may be badly affected.

The condition usually improves by itself over a period of 2-4 months. If there is any complication in the recovery period, for example if new blood vessels appear in the cornea, patients are quickly referred to the ophthalmologist for specialist treatment.

These patients are usually wearing contact lenses to enhance their vision because glasses do not help very much. The lenses may need to be refitted when the condition improves, because of a change in shape of the eye.

Corneal hydrops
Version 11
Date of search 28.03.17
Date of revision 22.06.17
Date of publication 17.10.17
Date for review 27.03.19
© College of Optometrists 

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