Molly Smith Abstract: A 28 year-old white male with keratoconus OU presents with cloudy vision OS for 1 day. His diagnosis is acute hydrops and treatment includes Pred Forte and Vigamox QID with 2 day follow up. I. Case History A 28 year old white male presented to the clinic complaining of gradual onset cloudy/blurred vision OS for one day. He was asymptomatic for pain or photophobia. This patient’s ocular history included keratoconus OD<OS since 2006 with mild contact lens related dry eye. His personal medical history was positive for chronic migraines with aura, anxiety, kidney stones and chronic allergies. This patient’s medications included Zoloft, Lamictal, Excedrin migraine, and buspirone. II. Pertinent findings The patient’s uncorrected entrance visual acuities were 20/200 OD, which improved to 20/100 with pinhole, and 20/800 OS, which improved to 20/250 with pinhole. This pinhole visual acuity OS was reduced compared to his previous comprehensive exam two weeks prior, where his pinhole visual acuity was 20/150 OS. Slit lamp exam OD revealed trace conjunctival injection with mild linear scars in the central cornea. Upon examination OS, the central cornea appeared cloudy and hazy with significant edema. There were areas of cystic change around 1 and 7 o’clock approximately 1-2 mm in size along with smaller, more diffuse areas of microcystic changes throughout the central cornea. View of the anterior chamber was difficult to attain due to haze, but looking through the superior cornea with patient in down gaze revealed no cells or flare. The conjunctiva appeared mildly injected. III. Differential diagnosis The primary diagnosis for this patient was acute hydrops OS as a complication from keratoconus. Other differential diagnoses included microbial keratitis, herpetic stromal keratitis, and corneal scarring from keratoconus. IV. Diagnosis and discussion Corneal hydrops occurs in approximately 2.6-2.8% of patients with keratoconus and is more likely to occur in patients with steeper keratometry values, poorer Snellen visual acuity, and earlier age of diagnosis. The condition occurs as a complication from corneal ectasias, causing a development of corneal edema resulting from disruption in Descemet’s membrane. An influx of aqueous humor into the cornea causes diffuse stromal edema and focal bullae in the stroma, which may move anteriorly and rupture. Patients with corneal hydrops generally present with photophobia, pain, and a decrease in visual acuity. Resolution typically occurs after approximately 2-4 months without intervention, but topical medication can be applied to quicken recovery time, thereby decreasing risk for complications such as bacterial keratitis, neovascularization, or corneal perforation. V. Treatment, management Initial treatment of this condition included Pred Forte QID, Vigamox QID OS only. Follow up was scheduled for 2 days later to re-evaluate the condition. At the two day follow up appointment, Muro 128 2% solution was added QID OS only in addition to the Pred Forte and Vigamox, which were continued at QID dosing. Follow up, nine days after initial presentation, the patient presented with a large inferior bullous with significant overlying negative staining. The bullous started resolving without rupture 14 days after initial presentation and has continued to resolve while maintaining the above drop regimen. The patient’s visual acuity with pinhole has improved to 20/100 OS. OD remains unaffected. Ehlers, Justis P., and Chirag P. Shah. "Cornea." The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008. 92-93. Print. Fan Gaskin, Jennifer C., Dipika V. Patel, and Charles N.J. McGhee. "Acute Corneal Hydrops in Keratoconus-New Perspectives." American Journal of Ophthalmology 157.5 (2014): 921-28. Http://www.ncbi.nlm.nih.gov/pubmed/24491416. Web. 21 Aug. 2014. Romero-Jimenez, Miguel, Jacinto Santodomingo-Rubido, and James S. Wolffsohn. "Keratoconus: A Review." Contact Lens & Anterior Eye 33.4 (2010): 157-66. Http://www.sciencedirect.com/science/article/pii/S1367048410000561. Web. 21 Aug. 2014. VI. Conclusion Patients presenting with acute corneal hydrops need frequent follow up to monitor for bullae rupture, in which case a bandage contact lens is appropriate for patient comfort and to protect the cornea. While the patient is wearing the bandage soft contact lens, the Muro 128 solution needs to be discontinued to maintain the integrity of the lens itself. The Muro 128 solution is typically dosed BID in the affected eye until the edema resolves, which can be anywhere from one to four months depending on the severity of the condition. .