Year : 1967 | Volume
: 15 | Issue : 5 | Page : 197--199
Bilateral keratoconus with ocular hypertension and the natural cure of one eye
Department of Ophthalmology, King George's Medical College, Lucknow, India
K K Bisaria
Department of Ophthalmology, King George�SQ�s Medical College, Lucknow
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Bisaria K K. Bilateral keratoconus with ocular hypertension and the natural cure of one eye.Indian J Ophthalmol 1967;15:197-199
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Bisaria K K. Bilateral keratoconus with ocular hypertension and the natural cure of one eye. Indian J Ophthalmol [serial online] 1967 [cited 2023 Nov 30 ];15:197-199
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Keratoconus usually begins at about puberty but is considered by most authors to be of congenital ori�gin, and by others as a result of some general disturbance either from endo�crinal dyscrasias or avitaminosis. It affects mostly females and runs a chronic course. At times acute ectasia develops due to rupture of Descemet's membrane leading to imbibition of aqueous with swelling and opacifica�tion of the cornea. This phase persists until the endothelium covers the gap. The central portion of the cornea is mainly affected which thins out con�siderably. Both in Bowman's mem�brane and Descemet's membrane rents are formed which get filled with un�usual type of connective tissue con�taining elastic fibres.
The earliest sign as described by THOMAS (1955) is the finding of marked astigmatism. This condition however should be well differentiated from keratotorus where there is regular increase in corneal curvature over a limited area.
As regards treatment, both conser�vative and surgical procedures have been tried. The former consists of the use of local application of cortisone ophthalmic ointment, pressure band�age and contact lenses which help in prevention of further progress of the condition. The surgical treatment com�prises of penetrating keratoplasty, Sato's operation and other measures such as cautery performation (HUDELO, 1956), diathermocoagula�tion of the ectatic area (DELL' AQUILA, 1961).
This communication describes a single case of keratoconus due to its interesting features.
History. K., a 25-year-old woman, was first seen on September 20, 1963 complaining of gradual diminution of vision in both the eyes for the last 6 years and headache 3 years. She had been changing her glasses frequently in the past. Her general health was ex�cellent.
Ocular examination.-(On September 20, 1963) visual acuity was doubtful perception of light in the right eye and finger counting at 3 meters in the left eye. There was bilateral divergent squint, more marked in the right eye which was a little proptosed and both cornea; showed central leucoma. The leucoma of the left eye was more dense. Both eyes presented a well marked conical appearance of the cornea which was clearly visible on lateral inspection [Figure 1]. There was staphyloma in the superior three-quar�ter portion of the sclera around the right limbus and part of it at 11 o'clock meridian was quite prominent with the uveal tissue visible behind. An exag�gerated Munson's sign was present [Figure 2]. The pseudomunson's sign was also demonstrable in both the eyes.
The anterior chambers were deep and the pupils reacted sluggishly to light. The fundus details could not be seen. Tension was 40 mm Hg. in the right eye and 30 mm Hg. in the left eye. Slit lamp examination of both eyes revealed the presence of linear scars and thinning of cornea at the apex. Ruptures in both the Descemet's and Bowman's membranes were observed, more extensive in the left eye.
Treatment. -The patient was kept on pilocarpine eye drops and hydrocorti�sone eye ointment. She was given acetazolamide (Diamox) (250 mgh) 1 tablet thrice daily.
Ocular Examination.-(On September 24, 1963) There was no appreciable relief to the patient. Tension in the right eye was 38 mm Hg. and 28 mm Hg. in the left eye. She was advised enucleation of the right eye and a fil�tering operation for the left eye, to which she did not agree and left the hospital.
Ocular Examination. -(After two months). She came this time with marked pain, lacrimation and photo�phobia in the left eye for the last four�teen days. Right eye did not show any change. Left eye showed marked cir�cumcorneal congestion with a perforat�ed corneal ulcer in the centre of the corneal opacity. The cornea was flat and there was no sign of the estasia. Anterior chamber was non-existent and a part of iris was seen through the ulcer. It was a corneal fistula [Figure 3].
Conjunctival flapping was perform�ed on the same day. After dressing the eye with hydrocortisone eye oint�ment, pressure pad and bandage were applied. The healing of the ulcer was uneventful although all the dressings were done with hydrocortisone. An�terior chamber was well formed on the third day. A strict watch was kept on for any relapse. A follow up of four months did not reveal any change except the persistence of a very minute descemetocele in the centre of the heal�ed ulcer.
AMSLER (1961) from the study of 1,114 affected eyes observed that ma�jority of cases (86%) were bilateral. SORSBY (1964) too pointed out, the rarity of unilateral affections. This condition has been described to be in association with large number of ano�malies like retinitis pigmentosa, retinal aplasia, Marfan's syndrome, mongol�ism, and other congenital or dystrophic ocular affections (SORSBY 1964), Vernal catarrh (BIETTI AND FER�RABOSCHI, 1958; 1959). RIDLEY (1956) from his series of 92 cases re�corded the presence of interstitial kera�titis with cataract and nebule in two cases, squint one case, iridectomy one case, myopic fundus degeneration one case, lenticonus 10 cases, keratoconus posticus 6 cases, while 15.2% of his cases presented a history of allergy which included hay fever, asthma, and allergic dermatitis. None of the workers mentioned about the asso�ciation of glaucoma with this malady.
The reported case here showed bi�lateral affection. It is unusual because of its association with raised tension in both the eyes and a finding of scleral staphyloma around a big sector of the limbus in one eye. The condi�tion had advanced to an extent that it could be diagnosed on naked eye exa�mination. There was in addition slight proptosis and divergent squint in the right eye which was almost blind owing to gross damage produced as a result of long standing glaucoma. It would be dangerous to retain such an eye, since most of them show malign�ant growth at puberty (AMSLER, 1961). The case was further unusual in that, without undergoing any ope�ration in a useful eye, it got marked relief by self perforation of the thinned ectatic cornea which could not stand the raised tension. It strengthens basi�cally the treatment of HUDELO (1956) who observed marked improvement of severe keratoconus by artificial per�foration with galvano-cautery just be�low the centre of the cornea followed by carrying with a conjunctival flap.
A case of keratoconus in a 25 year old woman is reported because of two interesting features glaucoma and self�-perforation.
|1||AMSLER, M.. (1961) Bull. Soc. Beige Ophthal. 129, 331-354.|
|2||BIETTI, G. B. and FERRABOSCHI, C., (1958) Bull. Soc. franc. Ophthal. 71, 185-201.|
|3||BIETTI, G. B. and FERRABOSCHI. C., (1959) Boll. Oculist. 38, 85-101.|
|4||DELL 'AQUILA, A., (1961) Rassital. Ottal. 30, 455-468.|
|5||HUDELO, A.. (1956) Ann. Oculist (Paris), 189, 491-495.|
|6||RIDLEY, F., (1956) Brit. J. Ophthal. 40, 295-304.|
|7||SORSBY. A., (1964) Modern Ophthal�mology, Vol. 3, p. 225, Butterworth, London.|
|8||THOMAS, C. I., (1955), The Cornea, Charles C. Thomas, Springfield, Illinois. p. 233.|