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Symptoms ⬇

Decreased vision, pain, tearing, foreign body sensation, photophobia, and redness. History of cataract surgery in the involved eye.

Signs ⬆ ⬇

(See Figure 4.27.1.)

Critical

Corneal edema in an eye in which the native lens has been removed.

Other

Corneal bullae, Descemet folds, subepithelial haze or scarring, corneal neovascularization, with or without preexisting guttae. Cystoid macular edema (CME) may be present.

4-27.1 Pseudophakic bullous keratopathy.

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Etiology ⬆ ⬇

Multifactorial: Corneal endothelial damage, intraocular inflammation, vitreous or subluxed intraocular lens or tube shunt touching (or intermittently touching) the cornea, preexisting endothelial dysfunction, and glaucoma.

Work Up ⬆ ⬇

Workup
  1. Slit lamp examination: Stain the cornea with fluorescein to check for denuded epithelium. Check the position of the intraocular lens if present, determine whether vitreous is touching the corneal endothelium, and evaluate the eye for inflammation. Check for subepithelial haze or scarring. Evaluate the fellow eye for endothelial dystrophy.
  2. Check IOP.
  3. Dilated fundus examination: Look for CME.
  4. Consider a fluorescein angiogram or optical coherence tomography to help detect CME, although evaluation may be limited by corneal opacification.

Treatment ⬆ ⬇

  1. Topical sodium chloride 5% drops q.i.d. and ointment q.h.s., if epithelial edema is present.
  2. Reduce IOP with medications if needed. Avoid epinephrine derivatives and prostaglandin analogs, if possible, because of the risk of CME (see 9.1, PRIMARY OPEN ANGLE GLAUCOMA).
  3. Ruptured epithelial bullae (producing corneal epithelial defects) may be treated with the following:
    • An ophthalmic antibiotic drops or ointment (e.g., erythromycin or bacitracin) and a cycloplegic (e.g., cyclopentolate 1% t.i.d.). The topical antibiotic can be used frequently (e.g., q2h) without patching.
    • Alternatively, sodium chloride 5% drops or ointment q.i.d., a bandage soft contact lens, or, in patients with limited visual potential, anterior stromal micropuncture or excimer laser PTK can be used for recurrent ruptured epithelial bullae (see 4.2, RECURRENT CORNEAL EROSION).
  4. Full-thickness corneal transplant or endothelial keratoplasty (DMEK or DSEK) combined with possible intraocular lens repositioning, replacement, or removal and/or vitrectomy may be indicated when vision fails or when the disease becomes advanced and painful. Anterior stromal micropuncture, excimer laser PTK, conjunctival flap, or amniotic membrane graft surgery may be considered for a painful eye with poor visual potential.
  5. See 11.14, CYSTOID MACULAR EDEMA, for treatment of CME.
NOTE:

Although both CME and corneal disease may contribute to decreased vision, the precise role of each is often difficult to determine preoperatively. CME is less likely with posterior chamber or open-loop anterior chamber intraocular lenses than closed-loop anterior chamber intraocular lenses, which are no longer used.

Follow Up ⬆

If ruptured bullae, every 1 to 3 days until improvement demonstrated, and then every 5 to 7 days until the epithelial defect heals. Otherwise, every 1 to 6 months, depending on symptoms.