Acute Corneal Hydrops in Keratoconus Coinciding With COVID-19 Infection : The Asia-Pacific Journal of Ophthalmology

Secondary Logo

Journal Logo

Scientific Correspondence

Acute Corneal Hydrops in Keratoconus Coinciding With COVID-19 Infection

Koh, Shizuka MD, PhD*†; Soma, Takeshi MD, PhD; Jhanji, Vishal MD; Nishida, Kohji MD, PhD

Author Information
Asia-Pacific Journal of Ophthalmology ():10.1097/APO.0000000000000566, September 21, 2022. | DOI: 10.1097/APO.0000000000000566

To the Editor:

Acute corneal hydrops (AH), characterized by corneal stromal edema after a Descemet membrane rupture that allows aqueous humor entry, is observed in cases of keratoconus. Patients typically present with rapidly deteriorating visual acuity, photophobia, and pain. A timely diagnosis and management are essential to ruling out other vision-threatening pathologies such as corneal edema, infectious keratitis, uveitis, Fuchs endothelial dystrophy, postoperative edema, and acute transplant rejection. Here we describe a case of AH in a patient with keratoconus coinciding with coronavirus disease 2019 (COVID-19) infection and emphasize the importance of patient education in the context-restricted face-to-face consultations.

A 20-year-old healthy man was evaluated regularly every 3 months for keratoconus using visual acuity and refraction assessments and anterior segment optical coherence tomography imaging. He wore corneal rigid gas-permeable contact lenses in both eyes. He also had a mild ocular allergy but no atopy or habit of eye-rubbing. There was no family history of keratoconus. A year earlier, he had an episode of AH in his left eye. While his left eye stabilized after pressure patching, the keratoconus progressed in his right eye. Examination findings at his last visit before the COVID-19 diagnosis included: corrected distance visual acuity with a gas-permeable contact lens of 20/30 (right) and 20/16 (left), anterior keratometry of 66.4 D (right) and 43.5 D (left), the thinnest corneal thickness of 264 mm (right) and 468 mm (left), and posterior “best-fit sphere” 9-mm radius values of 4.88 (right) and 6.46 mm (left). Approximately 2 months after the last follow-up, he developed flu-like symptoms (sore throat and fever) and was diagnosed the next day with COVID-19 on polymerase chain reaction. Two days after symptom onset, he noticed sudden deterioration of vision in his right eye and called our hospital. The cornea specialist in the ophthalmology department made a tentative phone diagnosis of AH based on his ocular history and instructed him to apply a pressure patch with ophthalmic ointment. He was examined at our hospital after 10 days of quarantine. The corrected distance visual acuity of the right eye was 20/2000, while a slitlamp examination revealed corneal protrusion and marked corneal epithelial as well as stromal edema in the right eye. Fluorescein corneal observation showed no epithelial abnormality, and a definitive AH diagnosis was made. Optical coherence tomography imaging revealed a break in Descemet membrane with overlying corneal edema (Supplemental Digital Content Fig. 1, No abnormality was noted in the left eye. He had received the second COVID-19 vaccine dose 1 month before the viral infection and reported experiencing no vaccine-related complications. On examination a month later, the AH in the right eye had remarkably improved.

Various ophthalmic management and care delivery experiences have been reported during the COVID-19 pandemic. Perspectives in corneal crosslinking were reported relating to keratoconus in particular.1,2 To the best of our knowledge, our case is the first of AH with concomitant keratoconus and COVID-19 infection, although it was not possible to demonstrate a clear association among them. A previous history of AH in either eye is a predisposing risk factor for AH.3 This case underscores the importance of informing patients of their disease status and the need to undergo regular examinations. However, patients with COVID-19 may not be able to receive a timely ophthalmic examination. This patient was distressed until the postquarantine ophthalmic examination was performed; however, his previous experience with AH including successful pressure patching was helpful for the clinician and patient, who was better able to understand the extent of his condition and follow the provided instructions. In the absence of a clinical history of keratoconus, effectively managing AH before a face-to-face examination could be performed would have been challenging.

Here are summary points of consideration when educating a patient with an acute event during a pandemic setting:

  • Recognize the patient’s distress due to being in isolation during the acute event.
  • Provide clear information about the disease and instructions for its independent management during quarantine. Strict hand hygiene should be thoroughly practiced while applying the pressure patch and patients should keep unwashed hands away from their face at times.
  • Remote management may require conservative management methods. This requires careful consideration, particularly in acute ophthalmic cases.

Although keratoconus was previously considered a noninflammatory ectatic corneal disease, recent evidence shows a relationship between its pathogenesis and chronic inflammatory events.4,5 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is known to cause a proinflammatory state.6 There are several reports of corneal graft rejection in patients infected with COVID-19.6–8 Large population-based case-control studies are needed to investigate the possible association between AH in keratoconus and the SARS-CoV-2 cytokine response.

Shizuka Koh, MD, PhD*†

Takeshi Soma, MD, PhD†

Vishal Jhanji, MD‡

Kohji Nishida, MD, PhD†


1. Legrottaglie EF, Balia L, Camesasca FI, et al. Management of an ophthalmology department during COVID-19 pandemic in Milan, Italy. Eur J Ophthalmol. 2021;31:2259–2267.
2. Shah H, Pagano L, Vakharia A, et al. Impact of COVID-19 on keratoconus patients waiting for corneal cross linking. Eur J Ophthalmol. 2021;31:3490–3493.
3. Barsam A, Brennan N, Petrushkin H, et al. Case-control study of risk factors for acute corneal hydrops in keratoconus. Br J Ophthalmol. 2017;101:499–502.
4. Lema I, Durán JA. Inflammatory molecules in the tears of patients with keratoconus. Ophthalmology. 2005;112:654–659.
5. D’Souza S, Nair AP, Sahu GR, et al. Keratoconus patients exhibit a distinct ocular surface immune cell and inflammatory profile. Sci Rep. 2021;11:20891.
6. Jin SX, Juthani VV. Acute corneal endothelial graft rejection with coinciding COVID-19 infection. Cornea. 2021;40:123–124.
7. Singh G, Mathur U. Acute graft rejection in a COVID-19 patient: co-incidence or causal association? Indian J Ophthalmol. 2021;69:985–986.
8. Moriyama AS, Campos MSQ. Presumed DMEK graft rejection associated with COVID-19 infection. Cornea. 2022;41:e1.

Supplemental Digital Content

Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.