Spontaneous Resolution of Acute Corneal Hydrops in a Patient with Post-LASIK Ectasia

CASE REPORT

Spontaneous Resolution of Acute Corneal Hydrops in a Patient With Post-LASIK Ectasia

Matthew D. Cooke, MD, and Steven B. Koenig, MD

report the case of a patient with post-LASIK corneal ectasia Purpose: To describe a case of acute corneal hydrops in a patient who was managed successfully with medical therapy. with corneal ectasia after laser in situ keratomileusis (LASIK). Methods: An observational study presenting clinical, slit-lamp, and CASE REPORT optical coherence tomographic findings. A 66-year-old white man was seen in July 2014 because of Results: A 66-year-old man with a history of moderate myopic sudden vision loss, photophobia, tearing, and foreign body sensation astigmatism presented with a sudden loss of vision in his left eye in the left eye for the past week. He had undergone bilateral LASIK 11 years after undergoing LASIK. He underwent a single enhancement in June 2003 by an outside surgeon. His preoperative manifest refraction was 24.25 +1.0 · 035 in the right eye and 24.75 +1.0 · in his left eye and was subsequently diagnosed with ectasia 9 years 127 in the left eye, with a best-corrected visual acuity (BCVA) of later. Slit-lamp examination demonstrated a small tear in the Descemet 20/20 in each eye. Pachymetry showed a central corneal thickness of fl fi fl membrane with a large uid- lled cleft separating the LASIK ap and 611 mm in the right eye and 645 mm in the left eye. Corneal extending to the flap edge. Because no aqueous humor leakage was topography suggested the presence of forme fruste keratoconus in detected, the patient was managed conservatively with eventual the left eye. His slit-lamp examination was unremarkable. LASIK resolution of the fluid-filled cleft and return of 20/30 visual acuity. was performed using a VISX excimer laser (Abbott Medical Optics, Abbott Park, IL). A Moria Carriazo-Barraquer microkeratome Conclusions: Acute corneal hydrops is a rare complication of post- (Moria Inc, Doylestown, PA) was used to create a 160-mm flap in LASIK corneal ectasia. In the absence of flap dehiscence and wound the right eye and a 130-mm flap in the left eye. leak, such patients may be managed with simple observation. Ten months after the initial procedure (April 2004), the uncorrected visual acuity (UCVA) was 20/80 +2 in the left eye, with Key Words: LASIK, ectasia, hydrops a BCVA of 20/20 with a cycloplegic refraction of 21.2 sphere. The m (Cornea 2015;34:835–837) central corneal thickness of the left eye was 561 m. The same outside surgeon performed LASIK enhancement of the left eye in April 2004. The next day, the UCVA was 20/302 in the left eye. He was then lost to follow-up. cute corneal hydrops occurs after a tear in Descemet In March 2012 (almost 9 years after the initial LASIK Amembrane and endothelium and allows the sudden procedure), the patient presented to our clinic complaining of movement of aqueous humor into the corneal stroma.1 The gradually declining vision in the left eye. The BCVA in the right resulting stromal and epithelial edema typically causes eye was 20/302. The UCVA in the left eye was 20/400 (20/502 a dramatic loss of visual acuity as well as photophobia and with pinhole). Automated keratometry and corneal topography foreign body sensation. Hydrops is a rare complication of revealed an asymmetric bow tie pattern with a high degree of keratoconus, keratoglobus, and pellucid marginal degenera- irregular astigmatism in the left eye consistent with post-LASIK 1 ectasia. Pachymetry demonstrated a central corneal thickness of 573 tion. In addition, the recent literature contains isolated case m fi reports of acute corneal hydrops in patients with corneal ectasia m in the left eye. After subsequent tting with a rigid gas- 2–5 permeable contact lens, the visual acuity in the left eye improved to after undergoing laser in situ keratomileusis (LASIK). 20/2522. His last examination in December 2013 revealed a BCVA Although surgical intervention is rarely required in acute of 20/60 in the left eye and mild corneal epithelial edema. The corneal hydrops associated with noniatrogenic ectasia, the patient was treated with topical hypertonic saline and a short course management of hydrops after LASIK is less clear. We herein of topical steroids and then lost to follow-up for about 7 months. The patient returned to our clinic in July 2014 complaining of a 1-week history of sudden severe vision loss in the left eye. His Received for publication January 29, 2015; revision received February 27, UCVA was hand motions in the left eye. Examination revealed 2015; accepted February 28, 2015. Published online ahead of print May a relatively clear LASIK flap with marked underlying stromal edema 13, 2015. confined to the area beneath the flap. A small tear was present in the From the Department of Ophthalmology, Froedtert Hospital and the Medical Descemet membrane inferonasally, and fluid was present in the College of Wisconsin, Milwaukee, WI. interface between the flap and residual stroma nearly to the edge of Supported by a grant from Research to Prevent Blindness and by a private the flap. There was no evidence clinically or on OCT of intrastromal donation from Dr. Myrna Larson. The authors have no conflicts of interest to disclose. cleft formation. There was no evidence of aqueous humor leakage. Reprints: Steven B. Koenig, MD, Department of Ophthalmology, Medical Slit-lamp photographs and anterior segment optical coherence College of Wisconsin, 925 N. 87th St, Milwaukee, WI 53226 (e-mail: tomography images were obtained (Fig. 1). The patient was [email protected]). monitored closely with instructions to lubricate with artificial tears Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. as needed. After 1 month, the central corneal thickness in the left eye

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FIGURE 1. Slit-lamp photograph of the left eye upon presentation with corneal hydrops demonstrating marked corneal edema extending nearly to the edge of the flap. A small tear was present in the Descemet membrane, which is indicated by an arrow (A). These findings were confirmed by anterior seg- FIGURE 2. Slit-lamp photograph 2 months after presentation ment optical coherence tomography, as shown in (B), with an with corneal hydrops demonstrating resolution of corneal asterisk marking the fluid in the interface and a cross marking edema (A). Anterior segment optical coherence tomography the LASIK flap. confirmed resolution of edema and of fluid in the interface between the flap and residual stroma (B). The arrows indicate was 789 mm, with significant improvement in the corneal edema. the interface between the flap and residual stroma. After 2 months, the edema had resolved (Fig. 2), with a BCVA with spectacle correction of 20/25 in the left eye. After 3 months, the BCVA was 20/30, with a central corneal thickness of 483 mm. perforation may accompany acute hydrops; risk factors may include eye rubbing, pregnancy, topical corticosteroid use, and elevated intraocular pressure.5,9 Corneal ectasia is a rare complication of LASIK and may DISCUSSION occur years after uncomplicated refractive surgery.10 Although Acute corneal hydrops results from the sudden move- the pathogenesis is not well understood, purported risk factors ment of aqueous humor into the corneal stroma after a tear in may include abnormal preoperative topographic findings (such the Descemet membrane and endothelium. Formation of as forme fruste keratoconus), low corneal pachymetry, a thin intrastromal clefts may also be an important factor in hydrops residual posterior stromal bed, high myopia, and young age.11 development.6 Although rare, hydrops is most commonly Presumably, in these patients, the residual cornea is bio- seen in association with advanced keratoconus (2.6%–2.8%) mechanically weakened and unable to maintain a stable curva- although it may occur with a greater frequency in rarer ectatic ture postoperatively. Progressive thinning and protrusion may disorders, such as pellucid marginal degeneration (6%–11%) cause myopic astigmatic progression and, in rare cases, tears in and keratoglobus (11%).1,7,8 Hydrops is usually considered the Descemet membrane. The literature contains 4 case reports a self-limited disease because endothelial cell migration of acute corneal hydrops after undergoing LASIK.2–5 In each adjacent to the tear in the Descemet membrane typically case, there were recognized risk factors for ectasia including results in corneal deturgescence, scarring, and flattening over young age or forme fruste keratoconus.2–5 In all cases, the a 2- to 4-month period.7 On very rare occasions, corneal rupture in the Descemet membrane created a fluid-filled

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