**7. Investigations**

Though acute hydrops is mostly diagnosed clinically, anterior segment OCT (ASOCT) can be performed to assess the severity and pattern of the resolution (**Figure 2**), [42]. ASOCT manifests as hypo reflective areas in the presence of fluid, hyper-reflective areas in the presence of fibrous tissues. In the early phase of corneal edema, epithelial micro cysts with pseudocysts formation in the intrastromal area are

**5**

*Acute Hydrops and Its Management*

*DOI: http://dx.doi.org/10.5772/intechopen.94592*

are presumed to be inflammatory cells [48].

**8. Complications**

corneal endothelial cells [49].

extremely poor prognosis [51].

**9. Differential diagnosis**

corneal scar [51].

witnessed as hyporeflective areas [43]. Pseudocysts develop due to fluid accumulation in the intrastromal spaces separating the stromal lamellae because of the sudden egress of the fluid. The word "pseudocyst" was coined because the cyst wall formation does not involve epithelium. These pseudocysts are initially small in size and multiple in number but eventually they fuse to become a large cyst [44]. Sometimes, the fluid reaches the anterior stroma leading to bullous swelling of the corneal surface, referred as "epitheliocoele" in literature [45]. High-resolution ASOCT can demonstrate a breach in the continuity of the DM and stromal access to the aqueous humor [46]. ASOCT can also demonstrate a slow healing process of polygonal defects in the DM that is caused by its rupture. Healing of DM takes place slowly than that of the corneal epithelium. Hence, decrease in the size of DM defect can be witnessed after a week, and in the due course, the corneal edema which is seen as hypo-reflective/ dark areas gets reduced eventually allowing the visibility of hyper-reflective shadows

Confocal microscopy is a new modality in the investigation process; though it is more useful for academic purpose, it gives an insight into the pathology of the disease [47]. Confocal microscope acts like an in vivo electron microscope; hence, the technique is termed as in vivo confocal microscopy (IVCM). It analyses the anterior and middle parts of the cornea. Bullae are seen in the superficial and wing layers of the corneal epithelium. Stromal area shows hyper-reflective band-shaped structures in the anterior stroma, and microfilms are seen in the mid and anterior stroma. Hyper-reflective cells are seen in the anterior stroma and epithelium, which

Acute hydrops commonly resolves spontaneously over a period of 4–8 weeks; however, it can be delayed because of large DM deficit or poor functionality of the

The risk of corneal perforation in cases of extreme penetration of fluid into the anterior stromal space is also present, which results in the formation of the epithelial bullae [50]. Any trivial trauma or ocular rubbing causes the rupture of the bullae, which may lead to shallowing of an anterior chamber and the formation of an anterior synechiae. Upon healing, it forms a dense vascularized corneal scar with

Corneal vascularization can be accentuated with a delay in the process of corneal edema reduction. Long-term cornea edema is associated with a risk of the release of vascular endothelial growth factors that induces corneal vasculogenesis from the peripheral corneal vessels, eventually leading to the formation of a vascularized

Bullous rupture of the corneal surface exposes raw stroma to the tear film and ocular commensals. Poor hygienic practices may lead to infectious keratitis [52]. Mostly bacterial keratitis has been reported; however, fungal keratitis has also been reported in the tropical countries. In developing countries such as India, the use of over-the-counter topical corticosteroids without clinical consultation is rampant

Penetrating ocular trauma may mimic acute hydrops; however, it has a recent

that has led to the development of debilitating infectious keratitis [53].

background history of trauma and entry wound [54].

in the sub epithelial area marks the healing of acute hydrops [46].

**Figure 2.** *ASOCT showing corneal edema, clefts and cysts (courtesy-Dr.Sridevi Gunda).*

#### *Acute Hydrops and Its Management DOI: http://dx.doi.org/10.5772/intechopen.94592*

*Eyesight and Imaging - Advances and New Perspectives*

**7. Investigations**

Grade 1: Involves 3-mm diameter of cornea. Grade 2: Between 3- and 5-mm diameter of cornea. Grade 3: More than 5 m-diameter of cornea.

Though acute hydrops is mostly diagnosed clinically, anterior segment OCT (ASOCT) can be performed to assess the severity and pattern of the resolution (**Figure 2**), [42]. ASOCT manifests as hypo reflective areas in the presence of fluid, hyper-reflective areas in the presence of fibrous tissues. In the early phase of corneal edema, epithelial micro cysts with pseudocysts formation in the intrastromal area are

**4**

**Figure 2.**

*ASOCT showing corneal edema, clefts and cysts (courtesy-Dr.Sridevi Gunda).*

witnessed as hyporeflective areas [43]. Pseudocysts develop due to fluid accumulation in the intrastromal spaces separating the stromal lamellae because of the sudden egress of the fluid. The word "pseudocyst" was coined because the cyst wall formation does not involve epithelium. These pseudocysts are initially small in size and multiple in number but eventually they fuse to become a large cyst [44]. Sometimes, the fluid reaches the anterior stroma leading to bullous swelling of the corneal surface, referred as "epitheliocoele" in literature [45]. High-resolution ASOCT can demonstrate a breach in the continuity of the DM and stromal access to the aqueous humor [46]. ASOCT can also demonstrate a slow healing process of polygonal defects in the DM that is caused by its rupture. Healing of DM takes place slowly than that of the corneal epithelium. Hence, decrease in the size of DM defect can be witnessed after a week, and in the due course, the corneal edema which is seen as hypo-reflective/ dark areas gets reduced eventually allowing the visibility of hyper-reflective shadows in the sub epithelial area marks the healing of acute hydrops [46].

Confocal microscopy is a new modality in the investigation process; though it is more useful for academic purpose, it gives an insight into the pathology of the disease [47]. Confocal microscope acts like an in vivo electron microscope; hence, the technique is termed as in vivo confocal microscopy (IVCM). It analyses the anterior and middle parts of the cornea. Bullae are seen in the superficial and wing layers of the corneal epithelium. Stromal area shows hyper-reflective band-shaped structures in the anterior stroma, and microfilms are seen in the mid and anterior stroma. Hyper-reflective cells are seen in the anterior stroma and epithelium, which are presumed to be inflammatory cells [48].
