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Acute Corneal Edema Decades After Penetrating Keratoplasty for Keratoconus in Scleral Contact Lens Wearers
TAKE-HOME MESSAGE
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The authors present 3 cases of penetrating keratoplasty graft failure after more than 3 decades associated with scleral contact lens wear. Potential mechanisms for this include corneal hydrops with a split in Descemet's membrane within the wound interface or just outside the wound in the host within the areas of recurrent ectasia. Detection and management of these cases are discussed.
- The proximity of scleral contact lens fitting to the keratoplasty graft failure in 2 cases suggests a potential association between these events.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To report three cases of acute corneal edema occurring decades after penetrating keratoplasty (PK) for keratoconus in eyes wearing scleral contact lenses (ScCLs) with previously clear corneal grafts.
METHODS
Retrospective chart review of three ScCL wearers presenting for sudden onset pain and blurred vision. Data extracted included clinical presentation, year and reason for PK, ocular medications and comorbidities, contact lens wearing history, results of any ancillary testing available including corneal topography, anterior segment optical coherence tomography (OCT), and specular microscopy surrounding the event, treatment and outcomes of intervention. The number of PK eyes fit with ScCLs in the author's practice was determined to estimate the prevalence of this event.
RESULTS
The three patients each had a longstanding PK for keratoconus performed between 33-35 years prior to presentation and recurrent ectasia. Each patient presented with an acute, painful eye and reduced vision either 3 days, 4 months or 9 years after refitting into ScCLs. Each eye had well demarcated focal microcystic epithelial and stromal edema within the graft and crossing the wound margin onto the host cornea. Although a definitive break or detachment of Descemet's membrane was not visualized, the presentations suggest these were episodes of acute hydrops.
CONCLUSIONS
Longstanding PKs with recurrent ectasia and acute focal edema suggestive of corneal hydrops is demonstrated in this case series of ScCL wearers. Although similar events have occurred as part of the natural history of post-PK corneas for keratoconus, the proximity of ScCL refitting to two of the events suggests some association.
Additional Info
Disclosure statements are available on the authors' profiles:
Acute Corneal Edema Decades After Penetrating Keratoplasty for Keratoconus in Eyes Wearing Scleral Contact Lenses
Cont Lens Anterior Eye 2020 Nov 04;[EPub Ahead of Print], SE Murillo, A Shariff, JH Lass, LB Szczotka-FlynnFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Scleral lenses have a key role in providing vision to patients with high irregular astigmatism, particularly where it is advantageous to delay or avoid surgery. Progressive corneal ectasia after grafting for keratoconus can result in such high astigmatism, particularly if there is graft-host junction dehiscence. Despite scleral lenses being increasingly used for such cases there are scarce outcome data on what happens to the graft after long-term scleral contact lens wear.
Murillo et al report 3 cases of acute focal corneal edema in patients who had had corneal grafts for keratoconus over 30 years earlier. The 3 patients were identified from 66 patients from their practice fitted with scleral lenses (4.5%). All 3 patients had progressive corneal ectasia following grafting for keratoconus managed with scleral lenses. Sudden onset corneal edema occurred in the same quadrant of the cornea that showed progressive steepening and in 2 cases with recent scleral lens fitting. In their specialty corneal contact lens practice over 28 years the authors had not seen hydrops-like (acute corneal edema) episodes in eyes with similarly advanced grafts that wore CL types aside from scleral CLs nor seen episodes in patients who had grafts for indications other than keratoconus.
Hydrops was thought to be the cause of their patients’ corneal edema. The break in Descemet’s membrane was proposed to be within or just outside the wound interface and have occurred due to extreme ectasia and induced negative pressures, and/or blunt trauma from insertion and removal of the scleral lens. The episodes may have also occurred as scleral lenses typically delay the need for regrafting such that the grafts may have been compromised over time.
The take-home messages for clinicians are that they should warn their patients of the risk of hydrops when there is progressive ectasia and take care to avoid mechanical stress in scleral lens fitting especially in an “older” graft.