Case Study

A 72-year-old pseudophakic patient presented with progressive blurred vision, ocular discomfort, and recurrent episodes of foreign body sensation several months after uncomplicated cataract surgery.

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Pseudophakic Bullous Keratopathy

Visual acuity was markedly reduced, and symptoms were worse in the morning. Slit-lamp examination revealed corneal edema with multiple epithelial bullae and Descemet membrane folds.

Specular microscopy demonstrated significantly reduced endothelial cell density. Anterior segment OCT confirmed stromal thickening without evidence of intraocular inflammation or raised intraocular pressure.

Based on the clinical findings and surgical history, a diagnosis of pseudophakic bullous keratopathy was established.

Disease Entity

Pseudophakic bullous keratopathy (PBK) is a form of irreversible corneal edema that occurs due to endothelial cell failure following cataract surgery with intraocular lens implantation.

It represents one of the most common indications for endothelial keratoplasty worldwide.

The condition arises when endothelial cell loss exceeds the cornea’s compensatory capacity, leading to chronic stromal and epithelial edema.

Pathophysiology

The corneal endothelium maintains corneal transparency through active fluid transport from the stroma into the anterior chamber.

Cataract surgery can damage endothelial cells through mechanical trauma, ultrasound energy, irrigation fluids, or postoperative inflammation.


When endothelial cell density falls below a critical threshold, endothelial pump function fails. As a result, stromal hydration increases, collagen lamellae separate, and corneal thickness rises.

Chronic edema causes epithelial bullae formation, which may rupture and result in significant pain.

Etiology and Risk Factors

Several factors increase the risk of developing pseudophakic bullous keratopathy:

  • Pre-existing low endothelial cell count

  • Fuchs endothelial corneal dystrophy

  • Complicated cataract surgery

  • Prolonged phacoemulsification time

  • Excessive ultrasound energy

  • Intraoperative endothelial trauma

  • Intraocular lens malposition or endothelial touch

Older age and repeated intraocular surgeries further raise the risk.

Clinical Features

Patients with PBK typically present with both visual and symptomatic complaints.

Symptoms

  • Progressive blurred vision

  • Glare and halos

  • Ocular pain from ruptured bullae

  • Foreign body sensation

  • Photophobia

  • Excessive tearing

Signs

  • Diffuse corneal edema

  • Epithelial and subepithelial bullae

  • Descemet membrane folds

  • Stromal haze

  • Reduced corneal transparency

Symptoms often fluctuate, with worse vision upon awakening.

Pseudophakic Bullous Keratopathy

Examination Findings

  • Visual acuity: Reduced, often severely

  • Slit-lamp exam: Corneal edema with bullae

  • Specular microscopy: Low endothelial cell density

  • Pachymetry: Increased central corneal thickness

  • Anterior segment OCT: Stromal and epithelial edema

Differential Diagnosis

Several conditions may mimic pseudophakic bullous keratopathy:

  • Fuchs endothelial corneal dystrophy

  • Aphakic bullous keratopathy

  • Chronic uveitis-related corneal edema

  • Herpetic endotheliitis

  • Corneal decompensation from glaucoma

A careful surgical history is essential for diagnosis.

Diagnosis

PBK is primarily a clinical diagnosis based on patient history, slit-lamp findings, and evidence of endothelial dysfunction. Ancillary testing helps confirm severity and guide management, but is not always required.

Management

Management depends on disease severity and symptom burden.

Medical Management

Conservative therapy aims to relieve symptoms but does not reverse endothelial failure.

  • Hypertonic saline drops and ointment

  • Lubricating eye drops

  • Bandage contact lenses for pain control

  • Topical antibiotics if epithelial defects are present

These measures offer temporary relief only.

Surgical Management

Definitive treatment requires corneal transplantation.

  • Descemet stripping endothelial keratoplasty (DSEK)

  • Descemet membrane endothelial keratoplasty (DMEK)

  • Penetrating keratoplasty (in advanced cases)

Endothelial keratoplasty has largely replaced full-thickness grafts due to faster recovery and better visual outcomes.

Prognosis

Visual prognosis depends on timely intervention. Early endothelial keratoplasty can restore good visual acuity. Delayed treatment may result in irreversible stromal scarring and suboptimal outcomes. Pain relief is usually achieved after successful surgery.

Prevention

Preventive strategies focus on minimizing endothelial damage during cataract surgery:

  • Preoperative endothelial assessment

  • Gentle surgical technique

  • Reduced phacoemulsification energy

  • Adequate viscoelastic use

  • Early recognition of endothelial compromise

HOW TO TAKE SLIT-LAMP EXAM IMAGES WITH A SMARTPHONE?

Smartphone slit-lamp photography is the new advancement in the field of science and technology in which photographs of the desired slit-lamp finding can be taken with smartphones by using the slit-lamp adapters.

Slit-lamp Smartphone photography

References

  1. Bourne WM. Biology of the corneal endothelium in health and disease. Eye.

  2. Price MO, Price FW. Endothelial keratoplasty—A review. Clinical & Experimental Ophthalmology.

  3. Melles GRJ, Ong TS, Ververs B, van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea.

  4. Lass JH, Benetz BA, Gal RL. Corneal endothelial cell loss after cataract surgery. Ophthalmology.

  5. Patel SV. Corneal edema and endothelial dysfunction after intraocular surgery. American Journal of Ophthalmology.

  6. Eye Bank Association of America. Indications for corneal transplantation. EBAA Statistical Report.

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