Bullous keratopathy


Bullous keratopathy

Description, Causes and Risk Factors:

Edema of the corneal stroma and epithelium; occurs in Fuchs endothelial dystrophy, advanced glaucoma, iridocyclitis, and sometimes after intraocular lens implantation.

Bullous keratopathy

Bullous keratopathy is a condition in which the cornea becomes permanently swollen. This occurs because the inner layer of the cornea, the endothelium, has been damaged and is not pumping fluid properly. The cause of the endothelial damage could be from trauma, glaucoma, or inflammation after eye surgery.

Certain intraocular lens implant designs can damage the cornea. Sometimes it is helpful to replace a lens implant with a newer design when a transplant is being performed to prevent damage to the transplant.

The causes of Bullous keratopathy have changed over the last two decades. Twenty years ago, the most common reason for bullous keratopathy was complications from cataract surgery with or without problems from intraocular lenses. Over the past 20 years, cataract surgery techniques and intraocular lens implants have improved dramatically. Now, corneal problems are less common after cataract surgery. Currently, one of the most common reasons for developing bullous keratopathy, or secondary corneal decompensation, is from problems related to Glaucoma surgery.

With advanced treatment modalities, complete visual rehabilitation may be achieved with an excellent long-term prognosis. However, both the overall ocular condition as well as the duration of the disorder itself may affect the final visual outcome.

Symptoms:

Reduced visual acuity with tearing and sensitivity to light are common. Subepithelial blister formation may induce intense pain.

Signs:

    Epithelial edema with microcysts and formation of subepithelial bullae.

  • Increased stromal thickness due to edema with loss of corneal transparency.

  • Subepithelial and stromal scarring may occur in long-standing cases.

Diagnosis:

The diagnosis is made from the typical appearance of a swollen, cloudy cornea with blisters on the surface. Pachymetry will confirm a thicker cornea.

Histopathology: The changes observed include desquamating epithelial cells from the anterior surface, separation of epithelium from Bowman's layer creating the bullous detachment. There are hydropic changes (tiny bubbles) within the epithelium giving them less apparent staining. Bowman's layer is irregularly thinned probably related to the bullae. The stroma shows areas devoid of keratocyte nuclei and irregular lamellae, features indicative of scarring. The endothelium is markedly attenuated; there are fewer endothelial cells than normal.

Treatment:

In patients with pain due to local corneal decompensation associated with relatively good visual acuity, anterior stromal micropuncture, Excimer laser surface ablation (phototherapeutic keratectomy) or amniotic membrane transplantation may be performed.

Patients with markedly reduced visual acuity are eligible for posterior lamellar keratoplasty, and in particular Descemet's stripping endothelial keratoplasty (DSEK) or Descemet's membrane endothelial keratoplasty (DMEK).

Although widely prescribed, hyperosmotic sodium chloride 5% drops and ointment may only have a limited placebo effect. There may be no proven rationale for intraocular pressure lowering medications. Soft contact lens fitting to control pain may be considered a short-term solution for BK. Penetrating keratoplasty may be considered obsolete.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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