5.5 Hydrops, Corneal

Date of last review:

29/4/2026

Date of next review:

29/4/2028

Date of publication:

6/7/2026

Differential Diagnosis ⁽¹⁾

Fuchs endothelial dystrophy
Infective keratitis

Possible management by optometrist

Advice

Acute Hydrops ⁽¹⁾

Stop contact lens wear immediately
Do not use bandage contact lenses, as hypoxia may promote corneal neovascularisation
Review weekly to monitor for complications, especially vascularisation
Most cases resolve over 2–4 months, typically leaving some stromal scarring
Urgent referral is required if corneal vascularisation develops

After Resolution ⁽¹⁾

Reassess corneal topography (often less steep after hydrops)
Patients will likely still require contact lenses for optimal vision; refitting is often required due to corneal profile changes

Treatment

Ocular lubrication (unmedicated or medicated ointment) ⁽¹⁾. Refer to local formularies for suitable options ⁽⁶⁾
Hyperosmotic agents (e.g. 5% sodium chloride) may help reduce oedema ⁽¹⁾
Cycloplegia for pain relief ⁽¹⁾
Recommend simple over the counter pain relief with advice from pharmacist if needed ^(1,7) 
Prophylactic topical antibiotics (e.g. chloramphenicol) if the epithelium is compromised and secondary infection risk is high ⁽¹⁾
Topical corticosteroids (e.g. dexamethasone 0.1% tapered over weeks) may be considered ⁽¹⁾

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Chloramphenicol 1% eye ointment ^(1,5)(POM, off-label): Apply at night (if eye drops used during the day), alternatively apply 3–4 times daily, if ointment used alone. The course of treatment should be 5 days (even if symptoms improve)^(2,3)
Chloramphenicol 0.5% eye drops ^(1,5)(POM, off-label): One drop every 2 hours for 48 hours. After this period, treatment should be every 4 hours during waking hours. Eye drops may be supplemented by 1% ointment at night ⁽⁷⁾. The course of treatment should be 5 days (even if symptoms improve)^(2,3)
Sodium chloride 5% eye ointment (P/CE): Apply before bedtime ⁽¹⁾
Cyclopentolate 1% eye drops ^(1,5)(POM : One drop up to 3 times daily, consider reducing (or stopping) as condition improves ^(6,7) (consult local guidance as they may vary on timescales)
Dexamethasone 0.1% eye drops ^(1,5)(POM): One drop 4-6 times daily until inflammation is controlled, then reduce frequency, where required ⁽⁷⁾
Prednisolone Sodium Phosphate 0.5% eye drops ⁽⁷⁾(POM): One drop 4-6 times daily until inflammation is controlled, then reduce frequency, where required ⁽⁷⁾

Monitor inflammatory response to steroid and measure IOP regularly during treatment and on completion ⁽⁷⁾

NB. Chloramphenicol 0.5% eye drops and 1% eye ointment are available via the NHS Pharmacy First service for the treatment of infected eye conditions only and not for prophylactic use in this condition. Where prophylactic antibiotic treatment is clinically indicated, chloramphenicol must be supplied on prescription by an independent prescribing (IP) optometrist, or requested from the patient’s GP where the optometrist is not IP‑qualified ⁽⁷⁾

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate ⁽⁷⁾
No referral usually required when symptoms are mild and only palliation is needed ⁽¹⁾
Urgent referral is indicated when corneal vascularisation appears ⁽¹⁾

Possible management in secondary care or local/community pathways where available

See Further management options ⁽⁷⁾
Pain control and prophylactic antibiotics where appropriate ⁽¹⁾
Topical steroids when corneal vascularisation is present ⁽¹⁾
Penetrating keratoplasty (PK) if post‑resolution scarring significantly reduces vision ⁽¹⁾
Intracameral gas injection (with or without compression sutures) to promote re‑apposition of Descemet’s membrane ⁽¹⁾
Endothelial keratoplasty (e.g. DMEK, DSAEK) to replace the damaged endothelial–Descemet complex ⁽¹⁾
Deep anterior lamellar keratoplasty (DALK) or PK depending on tissue involvement ⁽¹⁾.

College of Optometrists Clinical Management Guideline⁽¹⁾ 

Corneal hydrops - College of Optometrists*

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation, and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways.

Users should note that Guidelines which have not yet been updated should be considered with caution. Where the Eyecare Guidelines contain links to other sites and/or resources provided by third parties, these links are provided for information only.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines are made available on the basis of excluding all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Eyecare Guidelines.

CEG disclaimer for updated guidelines:

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

While the Common Services Agency (“PSD Scotland”) makes reasonable efforts to ensure that the information on the Eyecare Guidelines area of the Website is correct, the Website is provided ‘as is’ and PSD Scotland does not warrant the accuracy and completeness of the material on the Website. PSD Scotland may make changes to the Website at any time without notice. Some of the material on the Website may be out of date, and PSD Scotland makes no commitment to update such material. Users should note that some Eyecare Guidelines on the Website have not been updated for several years and should be considered with caution.

Where the Eyecare Guidelines section of the Website contains links to other sites and or resources provided by third parties, these links are provided for information only. PSD Scotland has no control over, and no liability in respect of, the content of these sites and resources.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines area of the Website is made available by PSD Scotland on the basis that PSD Scotland excludes all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Website. 