| Author | Affiliation |
|---|---|
| Justin Anderson, MD | |
| Ryan Grinnell, BS | |
| Kristina Domanski, MD | |
| Jamie Baydoun, MD |
ABSTRACT
Case Presentation
A 32-year-old male with a history of left eye keratoconus presented to the emergency department with left eye pain and blurry vision for two days. Out of concern for corneal hydrops, ophthalmology was consulted, and the diagnosis was confirmed. Per ophthalmology recommendations, the patient was started on hypertonic saline and prednisolone eye drops and referred to a corneal specialist.
Discussion
Corneal hydrops is characterized by stromal edema caused by leakage of aqueous humor due to rupture of Descemet membrane. This case describes a patient with a keratoconus deformity who developed corneal hydrops.
CASE PRESENTATION
A 32-year-old male with a history of left eye keratoconus secondary to remote trauma presented to the emergency department (ED) with left eye pain and blurry vision for two days. Visual acuity was 20/40 in the right eye and 20/200 in the left eye, and 20/25 bilaterally with baseline corrective lenses. Examination showed central left eye corneal opacification overlying the pupil and keratoconus deformity (Image 1). Fluorescein exam revealed no uptake over the pupil (Image 2). Ocular ultrasound showed a deformed cornea (Image 3).
DISCUSSION
Corneal hydrops is characterized by stromal edema caused by leakage of aqueous humor due to rupture of Descemet membrane.1 It is a rare complication of keratoconus, likely due to a combination of corneal thinning and ectasia and trivial trauma to the eye.2 Risk factors include atopy, Down syndrome, keratoconus, and eye rubbing, which may incur the highest risk. Acute corneal hydrops can cause vision-debilitating scarring of the cornea.3 The ED workup of suspected corneal hydrops should rule out infectious causes of corneal edema such as keratitis and uveitis, as well as include a fluorescein exam to rule out corneal ulcer. Treatment is usually conservative, and most cases resolve within two to four months.
Given our patient’s history of keratoconus, with new onset opacification of the cornea and without fluorescein uptake, the presentation was concerning for corneal hydrops. An ocular ultrasound was performed, which revealed the keratonoconus deformity, but it was otherwise unremarkable, with normal optic nerve sheath, lens, iris, and without abnormal retinal contour. Ophthalmology was consulted, and the diagnosis was confirmed. The patient was started on 5% sodium chloride eye drops and prednisolone eye drops per ophthalmology recommendations to decrease edema, and he was referred for urgent outpatient follow-up with a corneal specialist.
Initial outpatient management of corneal hydrops centers around decreasing the edema and includes options such as antibiotics to prevent secondary infection, hypertonic saline drops to cause an osmotic gradient to reduce edema, cycloplegics for pain control, and topical nonsteroidal anti-inflammatory drugs/steroids to decrease inflammation and pain.1 Surgery is sometimes indicated and can improve visual acuity and delay corneal transplantation.4 When ophthalmology is not on call, medical management is as discussed, and transfer to a facility with ophthalmology should be considered, as the patient will require urgent outpatient follow-up with ophthalmology as surgical intervention may be required.4
CPC-EM Capsule
What do we already know about this clinical entity?
Corneal hydrops is a rare entity that can cause severe corneal damage and permanent blindness without intervention.
What is the major impact of the image(s)?
Clinically it is similar in appearance to corneal abrasions or ulcerations, but it has no fluorescein uptake on staining.
How might this improve emergency medicine practice?
Corneal hydrops must be identified early and managed appropriately to avoid risk of significant morbidity.
Footnotes
Section Editor: Jacqueline Le, MD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
The authors attest that their institution does not Institutional Review Board approval for publication of this case report. Documentation on file. Patient consent has been obtained and filed for the publication of this case report.
Address for Correspondence: Justin Anderson, MD, University of Nevada, Las Vegas, Kirk Kerkorian School of Medicine, 6661 Silverstream Ave Apt 2019, Las Vegas, NV 89107. Email: justin.anderson@unlv.edu. 8:386 – 387
Submission history: Revision received July 27, 2024; Submitted September 14, 2024; Accepted September 17, 2024
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
REFERENCES
1. Maharana PK, Sharma N, Vajpayee RB. Acute corneal hydrops in keratoconus. Indian J Ophthalmol. 2013;61(8):461-464.
2. Barsam A, Petrushkin H, Brennan N, et al. Acute corneal hydrops in keratoconus: a national prospective study of incidence and management. Eye (Lond). 2015;29(4):469-474.
3. Santodomingo-Rubido J, Carracedo G, Suzaki A, et al. Keratoconus: an updated review. Cont Lens Anterior Eye. 2022;45(3):101559.
4. Fan Gaskin JC, Patel DV, McGhee CN. Acute corneal hydrops in keratoconus – new perspectives. Am J Ophthalmol. 2014;157(5):921-928.
