Mechanisms for acute corneal hydrops and perforation

Clinical profile and etiological spectrum of patients presenting with corneal hydrops over a 12-year period

PURPOSE

To describe the demographics, clinical characteristics, and management of corneal hydrops in patients presenting to a multi-tier ophthalmology hospital network in India.

DESIGN

Cross-sectional hospital-based study.

METHODS

Of the total of 3,140,941 new patients presenting between October 2010 and March 2022, patients with a clinical diagnosis of corneal hydrops in at least one eye were included in the study. All the data was collected using an electronic medical record system.

RESULTS

1291 eyes of 1110 patients were diagnosed with corneal hydrops and included in the study and 961 patients (83.69%) had a unilateral affliction. Corneal hydrops was noted to be significantly more common in males (62.43%) and adults (62.7%). The most common age group at presentation was during the second decade of life with 472 (42.52%) patients. They were more commonly from the higher socio-economic status (77.3%) and from the urban geography (44.23%). In the 1291 eyes, 567 (43.92%) eyes had a visual impairment of blindness (> 20/400-20/1200) followed by moderate visual impairment (> 20/70-20/200) in 166 (12.86%) eyes. Overall, the most common etiology was keratoconus in 1,082 (83.81%) eyes followed by primary congenital glaucoma (PCG) in 91 (7.05%) eyes. Surgical intervention to hasten the recovery of hydrops was performed in 7.82% of eyes with ectasia and as a definite management in 7.05% eyes with PCG. Visual rehabilitation was with contact lenses in 29.1% eyes and keratoplasty in 13.94% eyes.

CONCLUSION

Corneal hydrops is predominantly unilateral and is more common in males. Keratoconus was the commonest etiological condition; however, the risk of hydrops was highest in keratoglobus, followed by PMD. Most affected age was the second decade of life and visual impairment was severe in majority (60%). A surgical intervention was performed in a third of the cases.

Scheimpflug-Based Tomographic Risk Factors for the Development of Acute Corneal Hydrops in Keratoconus

PURPOSE

The purpose of this study was to assess the risk factors that predispose patients with keratoconus to develop acute corneal hydrops (ACH), including both clinical and tomographic risk factors. We additionally describe tomographic changes of the cornea over time after ACH.

METHODS

We retrospectively reviewed patients with keratoconus who were followed at our institution from January 2015 to May 2023. Control eyes, defined as eyes with advanced keratoconus (stage IV Amsler-Krumeich classification on initial examination) were compared with eyes that developed ACH. Demographic, clinical, and tomographic factors were investigated. Visual acuity, keratometry, and corneal thickness were assessed at each follow-up visit to monitor progression over time.

RESULTS

Twenty-three eyes of 19 patients developed ACH over the follow-up period. The incidence of known clinical associations including seasonal allergies, eye rubbing, snoring, asthma, and eczema was similar between the hydrops and control groups. There was a higher incidence of Down syndrome in the hydrops group ( P = 0.04). Eyes that developed hydrops had similar best corrected visual acuity on initial examination, but had steeper keratometry ( P = 0.003) and thinner corneas ( P < 0.001) than controls at baseline. After hydrops, progressive corneal flattening and reduced maximum keratometry occurred over time. However, final best corrected visual acuity was worse compared with initial examination before hydrops ( P = 0.03), as well as compared with control eyes ( P < 0.001).

CONCLUSIONS

Risk factors of developing ACH include steep keratometry and thin corneas as well as Down syndrome. Although corneal flattening will occur after resolution of acute corneal edema, visual acuity worsened after ACH.

Development of acute hydrops in eye with infectious keratitis: A case report

Purpose

To determine the characteristics of an eye that developed acute hydrops while being treated for infectious keratitis.

Observation

A 35-year-old man presented with pain and blurred vision in his left eye. He had undergone cataract surgery seven years earlier and was being treated for poorly controlled atopic dermatitis. The decimal best-corrected visual acuity (BCVA) of the left eye was 0.01. Slit-lamp microscopy showed conjunctival injection, corneal opacification, and a corneal ulcer. The patient was diagnosed with infectious keratitis and was treated with topical and systemic antibiotics. During the hospitalization, the patient was noted to rub his eyes frequently and vigorously. Five days after the first visit, the cornea protruded markedly, and the stroma surrounding the ulcerated area was edematous. These findings led to a diagnosis of acute hydrops.Penetrating keratoplasty was performed to prevent corneal perforation. Histopathological study of the excised cornea showed stromal edema, infiltration of leukocytes, and a tear in Descemet's membrane. Unfortunately, the patient developed endophthalmitis the day after the surgery. The anterior chamber was irrigated with antibiotics, and antibiotics were also injected into the vitreous. The endophthalmitis gradually subsided, and two years after the surgery, the patient's decimal BCVA had improved to 0.6.

Conclusion and importance

Vigorous eye rubbing in cases of infectious keratitis can induce acute hydrops, and timely surgical intervention is recommended.

Management of acute corneal hydrops - Current perspectives

Acute corneal hydrops (ACH) is a rare but sight-threatening complication of corneal ectasias. We aim to review the current literature on etiopathogenesis, histology, role of ancillary investigations, management, and outcomes of ACH by classifying the various management strategies based on their site of action and the underlying mechanism. A review of the literature was conducted by searching the following databases: PubMed (United States National Library of Medicine), Embase (Reed Elsevier Properties SA), Web of Science (Thomson Reuters), and Scopus (Elsevier BV) till April 2023. The literature search used various combinations of the following keywords: acute corneal hydrops, keratoconus, ectasia, management, keratoplasty. Nine hundred eighty-three articles were identified based on the above searches. Case reports which did not add any new modality of treatment to the existing literature, articles unrelated to management, those with no full text available, and foreign-language articles with no translation available were excluded. Eventually, 75 relevant articles that pertained to the management of ACH were shortlisted and reviewed. Recent studies have described newer surgical interventions like full-thickness or pre-Descemetic sutures, thermokeratoplasty, and plasma injection that aim to close the posterior stromal break. Posterior lamellar keratoplasties act by replacing the posterior torn Descemet's membrane (DM), and early deep anterior lamellar keratoplasty (DALK) has been attempted to combine the correction of the anatomical defect and visual rehabilitation in a single surgery. These surgical interventions may help by reducing the scarring and increasing the number of patients who can be visually rehabilitated with contact lenses rather than keratoplasty.

[From ocular itching to eye rubbing: a review of the literature]

Ocular itching and eye rubbing are frequent complaints in an ophthalmology practice. Numerous studies address the consequences of eye rubbing, such as keratoconus. However, there are few studies concerning the pathophysiology of itching, its transmission pathways, or its interactions with eye rubbing. Through this literature review, we will address the various clinical, physiological and therapeutic aspects of this pair of symptoms with a variety of ocular consequences. We will then describe the state of the art in itching and scratching in dermatology, in order to draw a parallel between these two vicious cycles. A better understanding of the pathophysiology of ocular itching and eye rubbing, as well as new studies based on dermatological data, might allow more appropriate clinical management of our patients and their symptoms.

Pathogenesis and complications of chronic eye rubbing in ocular allergy

PURPOSE OF REVIEW

To review the updated literature regarding eye rubbing complications and its association with ocular allergy disorders.

RECENT FINDINGS

Atopy and ocular allergy disorders, mainly vernal keratoconjunctivitis (VKC), are strongly associated with rubbing-related complications, most probably via itching and watery eye sensations that trigger the habit of chronic eye rubbing. Vigorous and prolonged rubbing may lead to establishment of corneal remodeling and ectatic disorders, such as keratoconus. Keratoconus development in rubbed eyes can be caused by mechanical mechanisms of corneal thinning and its loss of rigidity, by elevated temperature of the epithelium during rubbing, by increased intraocular pressure (IOP) because of distending forces, and by inflammatory molecules that may serve as a causal mediator between eye rubbing and keratoconus. Other eye rubbing complications include acute hydrops and perforation, IOP spikes, iris prolapse and iridoschisis rupture of lens capsule and IOL dislocation, and even posterior segment disorders, such as glaucomatous optic neuropathy, retinal detachment and extrusion of implanted silicone oil in the eye.

SUMMARY

Chronic eye rubbing in allergic eye diseases can lead to progression of keratoconus, and to other rare anterior and posterior segment complications. Strategies eliminating eye rubbing and its consequences are vital, mainly among at-risk populations, such as young children and individuals with allergic ocular disorders or corneal transplants.

Case Report: Acute Hydrops with Descemet Membrane Schisis in Corneal Ectasia after Radial Keratotomy

SIGNIFICANCE

As patients with previous radial keratotomy (RK) are still occasionally encountered, recognition of the anatomy of post-RK corneas and management of their complications remain relevant. High-definition anterior segment optical coherence tomography (AS-OCT) is a very useful tool to assess these postsurgical corneas.

PURPOSE

To describe a case of acute corneal hydrops with Descemet membrane schisis after RK with observation by AS-OCT.

CASE REPORT

A 43-year-old woman presented with a 9-day history of sudden vision loss, foreign body sensation, and photophobia in her left eye. She had undergone bilateral RK 25 years ago at her local hospital. Slit-lamp examination revealed marked corneal edema and stromal clefts in the central cornea along with radial surgical scars in her left eye. Pentacam imaging showed the typical pattern of a post-RK cornea with ectasia in her right eye. Multiple dilacerations of collagen lamellae and fluid-filled intrastromal cysts together with epithelial edema were observed in her left eye using AS-OCT. A Descemet membrane detachment with schisis was also shown by AS-OCT. After 5 months of medication with topical 0.1% fluorometholone eye drops four times daily together with 3% ofloxacin eye ointment once daily, the corneal edema, Descemet membrane detachment, and Descemet membrane schisis had completely resolved resulting in pan-stromal scarring.

CONCLUSIONS

This report describes acute corneal hydrops with Descemet membrane schisis after RK imaged using high-definition AS-OCT. The acute hydrops was possibly caused by corneal ectasia or underlying keratoconus, which was aggravated by RK. High-definition AS-OCT is a useful tool to demonstrate the details of different corneal layers and to observe the resolving process of acute hydrops. Topical medications consisting of antibiotic, lubrication, and corticosteroid can be used to treat the acute event effectively.

Eye rubbing type and prevalence including contact lens 'removal-relief' rubbing

BACKGROUND

Eye rubbing is commonly associated with keratoconus and may contribute to disease onset and progression. Verbal counselling to avoid rubbing may not be successful and adverse consequences of rubbing, which occurs on contact lens removal may be more serious. This study examines the prevalence of 'removal-relief' rubbing and its potential consequences.

METHODS

Rubbing histories were recorded for contact lens wearing normal and keratoconic patients as well as for normal non-contact lens wearers. Analogue scaled responses were used to identify and compare abnormal rubbing habits.

RESULTS

Contact lens wearing patients (both with and without keratoconus) reported significantly more rubbing before contact lens insertion (p < 0.05) compared to non-contact lens wearers. Eye rubbing after contact lens removal ('removal-relief' rubbing) was found to be significantly more prevalent among contact lens-wearing keratoconic patients compared to contact lens-wearing non-keratoconic patients (p < 0.001 in both cases).

CONCLUSIONS

Rubbing-related trauma occurring before contact lens insertion may predispose the cornea to wound healing activities and greater levels of adverse response to contact lens wear. Such adverse responses could predispose the cornea to greater trauma, which occurs in response to rubbing on removal of contact lenses. Strong counselling to avoid eye rubbing is often not an adequate form of management for a significant number of patients with keratoconus. Evidence of relapses indicates the need for better methods of counselling and for them to be repeated regularly. Apart from keratoconus, any other keratectasia, corneal disease or wound healing (including post-surgical) may increase susceptibility to corneal rubbing trauma. Such cases also appear to warrant counselling on avoidance of rubbing.

An examination of the relation between intraocular pressure, fundal stretching and myopic pathology

Pathological myopia is one of the leading causes of visual impairment worldwide. Myopic development and progression is biomechanical and dominated by axial elongation. This clinical perspective examines some of the stretch-related fundal changes, which are associated with axial elongation and myopic pathology. The biomechanics of stretching of the fundus appears to depend on genetically and/or visual experience-based scleral changes, which reduce its thickness and elastic modulus so that it becomes more susceptible to the distending forces of intraocular pressure. These changes include reduced collagen synthesis, altered collagen fibres, tissue loss, altered proteoglycans and increased matrix metalloproteinase activity. Such changes are associated with reduced scleral rigidity and related increased potential to stretch in response to intraocular pressure. As axial elongation progresses, the sclera appears likely to continue to reduce in thickness and in its capacity to resist intraocular pressure, especially when pressure becomes elevated. Tessellation, lacquer cracks, myopic crescents, staphylomata, chorioretinal atrophy and retinal detachment are examined within a model for stretching of the fundus. Age, refractive error and axial length, for example, are associated with increased pathological progression. Myopic pathological progression can become dominated by vascular changes and include a greater risk of loss of acuity and blindness. Measures to control myopic pathology, which successfully slow or prevent stretching of the fundus, appear to be key factors in reducing or even avoiding permanent visual loss associated with this condition. For example, limiting axial elongation and related myopic fundus pathology by inhibiting changes which reduce the elastic modulus of scleral tissue is a desirable outcome from interventions to control myopia. Similarly, reducing exposure to the distending stress of elevated intraocular pressure appears to be a desirable form of intervention to control myopia, especially if myopic pathology can be reduced or prevented.