Surgery: SF6 Gas Injection for Acute Hydrops

Dr. Dasa V. Gangadhar: ’m Dasa Gangadhar from Grene Vision Group in Wichita, Kansas. I would like to present a case highlighting the use of intracameral SF6 gas for non-resolving hydrops. This is a case of a 26-year-old male with known keratoconus, who presents with acute loss of vision and pain in the right eye. Acute hydrops was diagnosed. We treated him conservatively with hyperosmotics, cycloplegics, and steroids. Even after eight weeks, the hydrops continued unabated.

As we know, hydrops results from a break in Descemet’s membrane, which then allows aqueous to rush into the corneal stroma. If the break is sufficiently large, it may not be possible to mend itself without intervention. In such cases, placing intracameral SF6 gas allows for a tamponade of the break, giving the body a chance to mend.

Here we have dilated the patient with cyclogyl. Using topical anesthesia, a small paracentesis tract is made. We then place an isoexpansile mixture of 20% SF6 gas to fill the anterior chamber to 60% fill. The procedure is very straightforward and we are simply adjusting the size of the gas bubble. We request that the patient maintain a supine positioning for 48 hours, with hourly 10 minute breaks. As in DMEK and DSEK, we want to avoid pupillary block. Dilation, with appropriate gas bubble size, should decrease the risk for acute glaucoma. This patient began to respond within one week of therapy.

Let me present one more case of a 12-year-old Hispanic female with a two year history of bilateral visual decline of unknown cause. She was being fit with contact lenses. She was otherwise healthy, except for now a superimposed acute vision loss in her right eye.

We diagnosed her with keratoconus and acute hydrops. Conservative treatment with hyperosmotics, cycloplegics, topical steroids, and time did not work. A transplant should be avoided in the acute setting when the cornea is so edematous. Here we show a slit lamp view of the hydrops as well as external views. Over the course of a month, the hydrops continued to deteriorate. The cornea behaved as if it were an overfilled water balloon with real concern for perforation.

This young lady could not even close her eye completely due to the severity of the extasia and edema. Four weeks into the hydrops episode, the patient was taken into the operating room, and due to her young age general anesthesia was induced. An intracameral 20% SF6 gas bubble was injected, filling 60% of the anterior chamber.

Within one week, the patient began to respond with resolving edema. And by six weeks, the edema had resolved into a scar. As the scar and keratoconus were visually significant, a corneal transplant was performed restoring her vision. Although this is a very dramatic case of hydrops, it beautifully highlights how SF6 gas can be successfully utilized in these recalcitrant cases.

Thank you for your attention. Again, I’m Dasa Gangadhar, coming from the cornea service in Wichita, Kansas.