[Downloadedfreefromhttp://www.meajo.orgonWednesday,May07,2014,IP:112.215.66.

75]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Case Report
Acute Hydrops in the Donor Cornea Graft in
Non-Keratoconus Patients
John B. Cason, Samuel C. Yiu1

Access this article online

ABSTRACT
A 44-year-old Hispanic male and 91-year-old Caucasian male presented to the clinic with acute
vision loss and pain years after penetrating keratoplasty (PKP). Neither patient had a history
of keratoconus. Both patients had a history of eye rubbing and intraocular device present in
the anterior chamber. The first patient had a history of a glaucoma drainage tube and the
second patient had an anterior chamber intraocular lens implanted. Anterior segment ocular
coherence tomography showed deep stromal cystic cavities. Both patients exhibited breaks
in the endothelium by ultrasound biomicroscopy and the histopathologic examination after
repeat PKP. Those findings were most consistent with acute corneal hydrops in the donor graft.

Website:
www.meajo.org
DOI:
10.4103/0974-9233.114808
Quick Response Code:

Key words: Corneal transplant, Descemets membrane, Hydrops

INTRODUCTION

orneal hydrops is a condition of acute stromal edema that

occurs after a rupture in Descemets membrane. This is
not an uncommon sequelae of late keratoconus and is a frequent
indication for penetrating keratoplasty (PKP). Approximately,
3% of keratoconus patients experience one or more episodes
of corneal hydrops.1 Rarely, it can occur in a corneal graft and
is frequently an extension of a break in Descemets membrane
from the host cornea to the donor graft. This has been reported
in two separate case reports.2,3
To the authors knowledge, hydrops in a donor corneal graft
has not been described outside of the context of keratoconus.
We present two patients with no history of keratoconus that
developed acute hydrops in the donor corneal graft.

CASE REPORTS
Case 1

A 44-year-old human immunodeficiency virus positive Hispanic

male with undetectable viral load presented to the clinic with
a 5-week history of decreased vision, 1 year after undergoing

PKP in the left eye. The patient had a history of herpes keratitis
complicated by severe glaucoma in that eye. He had received a
corneal transplant 2 years before for corneal decompensation.
On the day of presentation, his best-corrected vision was 20/20
in the right eye and hand-motion at 6 feet in the left eye. His
manifest refraction in the right eye was 3.00 + 0.50 148. The
intraocular pressure was 15 mm Hg in the right eye. His corneal
graft was very edematous, opaque, and protuberant making it
impossible to measure the intraocular pressure in the left eye.
The glaucoma drainage valve in the superotemporal quadrant
was well-covered. There was no evidence of keratoconus in the
fellow eye. Ocular coherence tomography (OCT) of the anterior
segment showed a deep stromal cystic cavity consistent with
hydrops in the left eye [Figure 1a]. Ultrasound biomicroscopy
(UBM) of the anterior segment revealed a Descemets membrane
detachment and severe corneal edema with stromal cystic cavities
[Figure 1b]. The patient received a repeat PKP of the left eye.
During surgery, the glaucoma drainage tube was noted to be
positioned close to the cornea and was trimmed under the host
cornea rim. Pathology examination revealed a rupture and recoil
of Descemets membrane centrally and a near perforation with
a substantial amount of corneal stromal edema, consistent with
hydrops [Figure 2].

Department of Ophthalmology, Naval Medical Center San Diego, San Diego, California, 1Department of Ophthalmology,
Johns Hopkins University, Wilmer Eye Institute, Baltimore, Maryland, USA
Corresponding Author: Dr. Samuel Yiu, Department of Ophthalmology, The Johns Hopkins University, The Wilmer Eye Institute, 400 N
Broadway/Smith Bldg 6001-R, Baltimore, Maryland 21231, USA. E-mail: syiu2@jhmi.edu

Middle East African Journal of Ophthalmology, Volume 20, Number 3, July - September 2013

265

[Downloadedfreefromhttp://www.meajo.orgonWednesday,May07,2014,IP:112.215.66.75]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Cason and Yiu: Acute hydrops in the donor cornea graft in non-keratoconus patients

Figure 1: (a) High-definition anterior segment optical coherence tomographic image

of corneal hydrops. There is marked fluid within the corneal stroma (b) Ultrasound
biomicroscopy of acute corneal hydrops. Note the apparent break in Descemets
membrane

frequent eye rubbing. On examination, he had light perception

with projection in the right eye and 20/25 best-corrected
vision in the left eye. The manifest refraction in the left eye was
1.50 + 1.50 141. Intraocular pressure was not measurable
in the right eye and was 14 mm Hg in the left eye. A very large
pedunculated cyst was seen within the corneal graft in the
right eye [Figure 3]. There was no evidence of keratoconus
in the fellow eye. OCT of the anterior segment revealed
a deep stromal cystic cavity consistent with the hydrops.
UBM of the anterior segment showed the presence of an
anterior chamber intraocular lens and a large cystic cavity
with a suspected break in the superior region of Descemets
membrane. The patient subsequently received a PKP of the
right eye. The anterior chamber intraocular lens was an openloop Kelman-style and was left in place. The corneal graft
was oversized by 0.5 mm. Pathology examination revealed
marked central corneal edema consistent with the hydrops.
Descemets membrane was absent except for fragments on
both sides of the button.

DISCUSSION

Figure 2: Pathology slide showing a focal break in Descemets membrane and large
amounts of stromal edema

Corneal edema after corneal transplant can also be secondary

to corneal graft failure from endothelial dysfunction or corneal
transplant rejection. In those occasions, the edema is not quite so
dramatic. The large fluid clefts in this case series demonstrated
by anterior segment OCT and UBM show focal collections of
fluid rather than a diffuse distribution consistent with corneal
edema secondary to rejection or endothelial failure. Those cases
highlight the importance of clinical suspicion and thorough
diagnostic evaluation to rule out these other causes since the
treatment would be markedly different.
We could not find other reports of patients without a history of
keratoconus who developed hydrops in the donor corneal graft.
An anterior chamber intraocular lens and a glaucoma drainage
tube were the suspected culprits in the two patients who were
surgically treated.

Figure 3: Acute corneal hydrops within a corneal donor graft

Case 2

A 91-year-old Caucasian male with a history of PKP in the right

eye was referred to the clinic for descemetocele evaluation.
He had a corneal transplant of the right eye originally for
pseudophakic bullous keratopathy. The patient reported
266

Hydrops within a corneal donor graft is a rare complication after

corneal transplant for patients with a history of keratoconus. In
prior reports, it was believed to occur in patients who developed
a tear in Descemets membrane within the host corneal rim.
This break would then extend into the donor cornea and allow
the cornea to imbibe the fluid.

The common feature in these patients was eye rubbing,

which might be implicated in the unexpected dislocation of
intraocular devices and damage of the Descemets membrane.
If this important structure is violated, hydrops could ensue.
Corneal transplant patients should be advised not to rub
their eyes.

Middle East African Journal of Ophthalmology, Volume 20, Number 3, July - September 2013

[Downloadedfreefromhttp://www.meajo.orgonWednesday,May07,2014,IP:112.215.66.75]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Cason and Yiu: Acute hydrops in the donor cornea graft in non-keratoconus patients

REFERENCES
1.
2.

Tuft SJ, Gregory WM, Buckley RJ. Acute corneal hydrops in

keratoconus. Ophthalmology 1994;101:1738-44.
Wickremasinghe SS, Smith GT, Pullum KW, Buckley RJ.
Acute hydrops in keratoconus masquerading as acute corneal
transplant rejection. Cornea 2006;25:739-41.

3.

Ezra DG, Mehta JS, Allan BD. Late corneal hydrops after
penetrating keratoplasty for keratoconus. Cornea 2007;26:639-40.

Cite this article as: Cason JB, Yiu SC. Acute Hydrops in the Donor Cornea
Graft in Non-Keratoconus Patients. Middle East Afr J Ophthalmol 2013;20:265-7.
S ource of S upport: Thi s w ork w as supported i n part by an
unrestricted grant from Research to Prevent Blindness, New York, NY,
Conflict of Interest: None declared.

Middle East African Journal of Ophthalmology, Volume 20, Number 3, July - September 2013

267