Primary Modified Predescemetic Deep Anterior Lamellar Keratoplasty in Acute Corneal Hydrops

Outcomes of deep anterior lamellar keratoplasty in eyes with healed hydrops - A retrospective interventional analysis

AIM

The aim of the study was to analyze the techniques and outcomes of deep anterior lamellar keratoplasty (DALK) done in eyes with healed hydrops.

METHODS

Thirty-one eyes with paracentral scars following acute hydrops underwent DALK and were included in the study. Manual layer-by-layer dissection with stromal air injection was done in all cases, keeping dissection of the site of preexisting perforation to the end.

RESULTS

Out of the 31 eyes, in 28 eyes, DALK could be completed, and in 3 eyes, procedure had to be converted to penetrating keratoplasty. Visual outcomes in all cases were good, with 26 out of 28 eyes (92.8%) achieving a best-corrected visual acuity (BCVA) of 6/12 or better. Preoperative mean BCVA of LogMAR 1.19 ± 0.27 improved to a postoperative mean BCVA of LogMAR 0.23 ± 0.08 (P < 0.00001). Postoperative mean refractive astigmatism at the last follow-up was -2.69 ± 0.82 D with postoperative a spherical equivalent of -2.31 ± 0.7 D. Complications included double anterior chamber in one eye and secondary angle closure in two eyes. Stromal rejection in one eye was managed with steroids and one eye with suture infiltrate needed selective suture removal.

CONCLUSION

Layer-by-layer dissection with limited air injection into the stroma has shown good visual outcomes in patients undergoing DALK following healed hydrops, and DALK can very well be the primary treatment option even in such cases with a paracentral posthydrops scar.

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.

Primary surgical options for acute corneal hydrops: A review

Acute corneal hydrops usually resolves alone or with medical therapy along the first 4-6 weeks. However, depending on the severity of the corneal edema or the size of the Descemet break, self-healing might be difficult. Years ago, those patients had no more options than corneal transplantation, but surgical alternatives are on the rise in this century. These surgeries are becoming more popular with a variety of techniques relegating penetrating keratoplasty to a residual role. These techniques aim to accelerate corneal healing, reduce the edema, improve visual acuity and prevent from severe complications that may appear if corneal hydrops is not treated rapidly. Feasibility and safety are the favorable aspects of these techniques since the complications rates described remain low. In this review, we emphasize the recently published studies that describe both the techniques and their results.