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Conservative management of CH includes topical hypertonic saline solution, cycloplegics, topical corticosteroids, topical antibiotics, and a bandage soft contact lens if needed for comfort.
This long duration of corneal edema not only prolongs the patient's discomfort but also can have lasting sequelae such as infectious keratitis, corneal neovascularization, stromal scarring, corneal perforation, and the need for corneal transplantation.
In this article, we describe the successful use of the topical Rho kinase inhibitor ripasudil hydrochloride hydrate (Glanatec Ophthalmic Solution 0.4%, Kowa Co Ltd, Nagoya, Japan) for noninvasive treatment of CH with rapid resolution of corneal edema in 21 days.
A 32-year-old male presented with a 2-week history of decreased vision in the central and inferior visual field of the left eye with irritation and foreign-body sensation. He had already been prescribed topical fluorometholone, sodium chloride 5% hypertonic ophthalmic ointment, and topical chloramphenicol by another provider, with no improvement. His distance corrected visual acuity with glasses was 6/6 OD and 6/60 OS. Anterior segment examination demonstrated a large central corneal edema of the left eye with central pachymetry above 2000 µm. He was diagnosed with CH and started on topical ripasudil 0.4% twice a day in the left eye in addition to topical chloramphenicol.
At the 3-week follow-up, his symptoms had improved significantly, but his distance corrected visual acuity of the left eye remained poor at 3/60. His corneal edema had resolved completely at this point but was replaced by visually significant stromal scarring. His corneal tomography and anterior segment optical coherence tomography images at presentation and 3-week follow-up are shown in Figure 1.
Fig. 1(A) Corneal tomography of the left eye depicting axial curvature, corneal thickness, and front and back elevation before and 3 weeks after ripasudil treatment. (B) Anterior segment optical coherence tomography of the left eye before and 3 weeks after ripasudil treatment.
Because of the poor visual acuity, a manual predescemetic deep anterior lamellar keratoplasty was offered at an early stage, 3 weeks after resolution of his CH. At 14 months after his transplant, his graft was clear (Fig. 2), and his visual acuity with glasses was 6/9 in the affected eye.
Fig. 2Anterior segment photograph of the left eye following manual predescemetic deep anterior lamellar keratoplasty.
In this article, we report the successful use of ripasudil in rapid resolution of CH in keratoconus. To accelerate the resolution of CH, various surgical interventions have been used. Intracameral injection of air or gas (sulfur hexafluoride [SF6] or perflouropropane [C3F8]) has been used to tamponade the tear and prevent further leakage of fluid into the stroma.
Microscope-integrated optical coherence tomography-guided drainage of acute corneal hydrops in keratoconus combined with suturing and gas-aided reattachment of Descemet membrane.
However, multiple injections often were needed, and potential complications of intraocular pressure spikes, cataract formation, pupillary block, and intrastromal gas migration have been reported.
Additionally, corneal compression sutures have been employed to approximate the edges of Descemet membrane, especially for large defects with cleft formation.
Microscope-integrated optical coherence tomography-guided drainage of acute corneal hydrops in keratoconus combined with suturing and gas-aided reattachment of Descemet membrane.
Microscope-integrated optical coherence tomography-guided drainage of acute corneal hydrops in keratoconus combined with suturing and gas-aided reattachment of Descemet membrane.
The rapid resolution of edema in this case was unexpected. Although it provided rapidly improved comfort and re-formation of the epithelial barrier, it was not accompanied by improved visual acuity. A scleral lens may have been an option in this case, but a manual predescemetic deep anterior lamellar keratoplasty was chosen as a more definitive method of resolution. The clear view created allowed good visualization of planes and provided confidence that deeper layers were intact during surgery.
Rho kinase inhibitors have been reported previously to promote endothelial cell delamination and migration, accelerating endothelial wound healing.
There is growing evidence supporting their utility in multiple corneal pathologies. Our centre has reported positive experience with the use of Rho kinase inhibitors as an adjuvant to Descemet stripping only or descemetorhexis without endothelial keratoplasty.
Similarly, netarsudil has been reported to assist with the treatment of corneal endothelial disease in iridocorneal endothelial syndrome and penetrating keratoplasty graft failure.
This is the first published report of the use of a Rho kinase inhibitor for the management of CH and offers a well-tolerated, noninvasive alternative to the surgical techniques used. The mechanism of healing is consistent with our understanding of Rho kinase inhibitors as promoters of cell migration across endothelial defects, such as those occurring in CH.
We acknowledge the lack of a control to confirm this finding as significant. In CH, it may be impossible to design such a study. Nevertheless, we present the fastest published resolution of CH with medical therapy and feel this to be of significance even in isolation.
Footnotes and Disclosure
Greg Moloney was a previous consultant of Kowa India Private Limited, manufacturers of Ripasudil; the other authors have no conflicts of interest to disclose. Use of ripasudil for corneal hydrops is an off-label use of the medication.
References
Sharma N
Maharana PK
Jhanji V
Vajpayee RB.
Management of acute corneal hydrops in ectatic corneal disorders.
Microscope-integrated optical coherence tomography-guided drainage of acute corneal hydrops in keratoconus combined with suturing and gas-aided reattachment of Descemet membrane.
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