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This 24 year-old man has had
poor left vision since the age of 14 which could not be
corrected with glasses. A few years ago, he developed a
painful red eye which resolved spontaneously with topical
steroid and antibiotic. The vision is now 6/60.
a. What is the most likely
cause for the attack?
Acute hydrops in keratoconus.
Acute hydrops is caused by the rupture of Descemet’s
membrane. In this condition, there is corneal oedema as a
result of the influx of aqueous. This leads to pain and
further reduction of vision. The condition heals
spontaneously over 4 to 6 weeks time and the pain can be
helped using bandage contact lens and hypertonic saline.
b. What are the associations
with this condition?
Keratoconus may have systemic
or ocular associations.
• Systemic associations include connective tissue disorders
such as Ehlers-Danlos syndrome and Marfan syndrome and
conditions that result in recurrent eye rubbing such as
atopy, Down’s syndrome (which is associated with blepharitis).
• Ocular associations include vernal keratoconjunctivitis,
aniridia, ectopia lentis, Leber congenital amaurosis,
retinitis pigmentosa and persistent eye rubbing.
c. How would you manage the
patient?
Refraction and correction with
glasses is the first line of treatment. However, this
patient has a central corneal scar and therefore unlikely to
improve with glasses. The second line of treatment is rigid
contact lens to correct high irregular astigmatism. In this
patient, the central corneal opacity coupled with high
irregular astigmatism makes the eye unsuitable for rigid
contact lens. Penetrating keratoplasty (or deep lamellar
keratoplasty) is the treatment of choice to improve the
vision. During the operation, it is important to perform a
big graft to remove the cone of the keratoconus. The risk of
rejection is low for keratoconus, however, the visual
rehabilitation will require removal of corneal stitches and
the use of contact lens.
Reference:
Colin J, Velou S. Current surgical options for keratoconus.
J Cataract Refract Surg. 2003 Feb;29(2):379-86.
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