Corinne Blum

Special Testing to Accurately Diagnose Corneal Hydrops Abstract Text:

Abstract

Corneal hydrops is a spontaneous complication seen in keratoconus. There are many differentials for a keratoconic patient presenting with an acute, painful red eye. Special testing including AS- OCT can assist in making the correct diagnosis.

I. Case History

 41-year-old black female  Presents with right eye pain, redness, burning, tearing and photophobia which began that morning  Keratoconus OU  No other medical conditions or medications  Rigid gas permeable contact lens wearer for 10 years

II. Pertinent findings

 Clinical Findings

OD DVA s 20/400

OS DVA s 20/200

OD PH 20: 80

OS PH 20: 50+1

Pupils/EOMs normal

 Physical Findings:

Biomicroscopy

- OD conjunctiva: grade 2+ injection

- OS conjunctiva: grade 1+ injection

- OD Cornea: apical thinning, striae, central area of NaFl pooling 3.5mmH x 2mmV, central raised area, surrounding ring of negative staining/edema - OS Cornea: apical thinning, 1-2 mm round inferior central scar with overlying confluent punctate staining

- Anterior Chamber: deep and quiet OU

Anterior Segment OCT (Visante)

OD: Thin cornea adjacent to hyperfluorescent thickened cornea

(-) epithelial defect, cystic spaces, break in descemet’s membrane, endothelial involvement

III. Differential diagnosis

 Corneal abrasion overlying subepithelial fibrosis  Corneal hydrops  Recurrent epithelial erosion  Infectious corneal ulcer  Salzmann’s nodular degeneration  Phlyctenulosis

IV. Diagnosis and discussion

 When a patient with keratoconus presents with an acute red eye with edema and photophobia, the presentation can be ambiguous, especially when the patient is a contact lens wearer. Special testing including anterior segment OCT can be helpful in making the appropriate diagnosis.  This patient presented with significant pain, corneal edema, uneven epithelial surface, and a large area of NaFl staining/pooling. Based on her initial presentation, it was difficult to determine if the patient had a severe corneal abrasion with the uneven appearance of the cornea due to subepithelial fibrosis, or if she was having an episode of acute corneal hydrops. The anterior segment OCT images that we obtained solidified the diagnosis of a corneal abrasion versus corneal hydrops. This distinction is important due to differences in management and follow-up.

V. Treatment, management

 Moxeza QID OD, D/C CL wear until cornea has healed. Patient responded well to treatment and on follow-up the next day was feeling much better  Literature Review:

Sharma N, Mannan R, Jhanji V, Agarwal T, Pruthi A, Titiyal JS, Vajpayee RB. Ultrasound biomicroscopy-guided assessment of acute corneal hydrops. Ophthalmology 2011; 118:2166- 2171.

Gaskin JCF, Patel DV, Mcghee CNJ. Acute corneal hydrops in keratoconus-new perspectives. Am J Ophthalmol 2014;157:921-928.

Sandali O, Sanharawi ME, Temstet C, Hamiche T, Galan A, Ghouali W, Goemaere I, Basli E, Borderie V, Laroche L. Fourier-domain optical coherence tomography imaging in keratoconus. Ophthalmology 2013;120:2403-2412.

VI. Conclusion

 Hydrops is a relatively rare complication of keratoconus (occurring in less than 5% of keratoconic patients) and special testing can help the primary care optometrist choose the correct differential diagnosis.  Anterior Segment OCT can be used to differentiate acute corneal hydrops from other anterior segment pathologies in keratoconic patients.