Pre-Operative Oct-Guided Corneal Compression Sutures With Sf₆ Gas And Inferior Peripheral Iridectomy For Acute Corneal Hydrops In Keratoconus

To describe a simple, cost-effective technique using pre-operative anterior segment OCT (AS-OCT) to guide accurate corneal compression suture placement in the surgical management of acute corneal hydrops secondary to keratoconus, eliminating the need for intraoperative OCT.

Tertiary corneal service, Norfolk and Norwich University Hospital NHS Foundation Trust, United Kingdom.

Two patients with acute hydrops due to keratoconus underwent surgical management with full-thickness corneal compression sutures, intracameral 20% sulphur hexafluoride (SF₆) gas injection, and inferior peripheral iridectomy. Pre-operative AS-OCT was used to localise the Descemet’s membrane (DM) rupture, stromal clefts, and determine optimal suture depth and trajectory. The intended suture entry sites corresponding to the pre-Descemet’s layer were marked on the corneal surface with a sterile surgical marker prior to surgery, enabling controlled needle passage at the desired stromal plane without real-time imaging.

Pre-operative marking enabled precise placement of compression sutures across the DM tear in both cases, resulting in DM reattachment and reduction of stromal oedema. In one patient, hydrops occurred on 27 September 2024 and surgery was performed the same day; at 13-month follow-up, best-corrected visual acuity was 6/12, improving to 6/9 with a contact lens. The second patient had counting fingers vision at 3 months post-operatively and was awaiting contact lens fitting. The inferior peripheral iridectomy prevented pupillary block, and SF₆ gas provided sustained tamponade. No intraoperative complications occurred, intraoperative OCT was not required, and both patients successfully avoided corneal transplantation.

Pre-operative OCT-guided surface marking is an effective, accessible, and low-cost method for optimising compression suture placement in acute corneal hydrops surgery. This technique enables accurate targeting of the pre-Descemet’s plane without expensive intraoperative imaging and may facilitate Descemet’s membrane reattachment while avoiding corneal grafting.