Purpose To highlight the roles of intraoperative optical coherence tomography (iOCT) in managing acute corneal hydrops (ACH) and outcomes of iOCT-guided pneumodescemetopexy and corneal compression sutures.

Methods This was a retrospective, consecutive, interventional case series of patients with keratoconus who presented with significant ACH and underwent iOCT-guided pneumodescemetopexy (18% sulfur hexafluoride gas) and compression sutures at Birmingham and Midland Eye Centre, UK, between Aug 2023 and May 2025.

Results Five patients were included; mean age was 32.3±6.6 years old and 3 (60%) were male. The mean follow-up duration was 16.3±5.6 months. At presentation, the mean corrected-distance-visual-acuity (CDVA) was 1.90±0.67 logMAR, central corneal thickness (CCT) was 1187.6±372.6μm, maximal corneal thickness was 1624.0±383.5μm and maximal height and diameter of pre-Descemet layer/Descemet membrane (PDL/DM) detachment was 1014.6±366.4μm and 4456.0±839.4μm, respectively. The surgery successfully achieved complete PDL/DM attachment in all cases, with a mean time from surgery to ACH resolution of 17.8±8.0 days. iOCT successfully visualized the area of PDL/DM break/detachment, revealed the involvement of PDL (evidenced by a persistent taut type 1 DM detachment after gas tamponade), and guided the placement of compression sutures. Compared to preoperative, there was a significant improvement in the mean CDVA (0.52±0.32 logMAR; p=0.014) at last follow-up. One patient required a repeat procedure to fully attach the PDL/DM.

Conclusions This study demonstrated favorable outcomes of iOCT-guided pneumodescemetopexy and corneal compression sutures. iOCT revealed the involvement of PDL in ACH and provided plausible explanations why pneumodescemetopexy alone may not be able to resolve significant ACH rapidly in certain cases.

The authors have declared no competing interest.

DSJT acknowledges support from the Medical Research Council (MRC) Clinician Scientist Fellowship (UKRI2441) and the Birmingham Health Partners (BHP) Clinician Scientist Fellowship.

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This study was approved as a clinical audit by the local Clinical Effectiveness Team at Sandwell and West Birmingham NHS Trust, Birmingham, UK (Reference: #3118). Informed consent was obtained from all included patients for the treatment and publication. All data have been de-identified prior to use in this study.

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