Bullous keratopathy

bullous keratopathy

1. Bullous keratopathy

2. Bullous keratopathy Refers to corneal swelling due to insufficiency of the corneal endothelial pump resulting in formation of subepithelial bullae ( Heegaard & Grossniklaus , 2014 ) and microcysts . It follows persistent corneal edema due to endothelial dysfunction Endothelial dysfunction may bue to trauma , inflammation or dystrophies.

3. Bullous keratopathy occurs secondary to following conditions : 1 . ENDOTHELIAL CHANGES- increased permeability or decreased transport function or both in this cellular layer can lead to subsequent corneal changes in case of traumatic conditions such as * Pseudophakic/ aphakic bullous keratopathy as in cataract extraction *with IOL implantation *With ACIOL *following glaucoma surgeries

4. In pseudo/ aphakic bullous keratopathy rapid cell degeneration and death occurs which is then repaired by sliding and rearrangement of neighbouring cells. Resulting endothelium is characterised by decreased cell number and enlarged and irregularly shaped cells showing polymegathism and pleomorphism . -When cell density falls below 220-400 cells/mm 2. their pump function begins to fail and stroma begins to swell

5. 2.dystrophic conditions i ] FUCH’S DYSTROPHY -abnormal production of collagenous material by the affected endothelial cell causes marked thickening of DM . - characteristic wart like ‘GUTTAE’ which progress to give beaten metal appearance. -epithelial edema develops when stromal thickness increases by 30% -persistent epithelial edema causes formation of microcysts and bullae II] CHED - rare condition associated with scanty or absent endothelium and thickened DM

6. 3. RAISED IOP CONDITION- as in chronic glaucoma 4. INFLAMMATIONS - as in herpetic ocular disease - in herpes simplex ocular disease where focal bullous keratopathy may develop -pathogenesis may be due to active infection or immune response or both - disciform edema of cornea develops which later becomes diffuse. 5.IMMUNOGENIC RESPONSE- in case of graft rejection

7. 6.EPITHELIAL EDEMA- - Results from endothelial dysfunction or elevated IOP or combination or both -fluid begins to accumulate in space between basal epithelial layer. later in the process these fluid filled spaces enlarge to form fine blister, visible as microcystic edema. -finally layer bullae develop characteristic of bullous keratopathy

8. Clinical features 1. decreased vision-initially painless decreased vision upon walking. Vision may improve as day progresses as evaporation promotes corneal deturgence 2.glare and halo 3.pain- when epithelial and subepithelial bullae develop and rupture resulting in severe pain as underlying nerve endings are exposed.

9. 4. erosive symptom present as-discomfort, foreign sensation, photophobia and watering. 5. when scarring occurs-cornea is opaque and compact pain is decreased Vision reduced to hand motion Corneal sensation is decreased or absent Peripheral corneal vasculization may occur

10. EVALUATION TECHNIQUE 1 . SLIT- LAMP EXAMINATION  Corneal bullae  Position of IOL  Vitreous touches endothelium  IOP  Fundus examination: Look for CME ( FFA or OCT ) 2 . CORNEAL PACHYMETRY (ultrasonic or optic):  measures corneal thickess .[normal:500-550 microns]  If 650 microns suggest a higher risk for edema after intra-ocular surgery  If 700 microns suggest corneal decompensation

11. 3. SPECULAR MICROSCOPY  demonstrates reduced endothelial cell density and abnormal morphology Its helpful in detecting  `warts or guttae ` in fuchs dystrophy  polymegathism and pleomorphism . 4. CLINICAL CONFOCAL MICROSCOPY - used to study cell layers of cornea even in edema and scarring.thus helpful in diagnosis of bullous keratopathy

12. MANAGEMENT 1 . HYPERTONIC AGENTS , such as sodium chloride 2% and 5% solution and ointment. • Creates a hypertonic tear film, thereby drawing water out of the cornea 2. BANDAGE CONTACT LENS • Useful as an adjunct to medical treatment for the temporary relief of corneal pain and discomfort. • To shield the cornea and epithelium from the eyelid . 3 . REDUCE IOP 4. RUPTURED EPITHELIAL BULLAE :  Antibiotic ointment  Cycloplegic  BSCL  Recurrent ruptured bullae: anterior stromal micropuncture or PTK

13. 4. CORNEAL TRANSPLANTATION • Indicated when vision is decreased significantly by corneal edema or when pain becomes intractable. • Full-thickness corneal transplant or endothelial keratoplasty ( DSEK ) 5. CONJUNCTIVAL FLAP OR AMNIOTIC MEMBRANE GRAFT Dr. Priyanka choudhary