Pseudophakic Bullous Keratopathy case

Pseudophakic bullous keratopathy (PBK) is a post-operative condition that can occur as a complication of cataract extraction surgery and intraocular lens placement.

May be manifest in the immediate post-operative period or symptoms may not present for many years.

1. BY:
NOOR MUNIRAH BINTI AWANG ABU BAKAR
OPTOMETRIST (MOC NO. O-0869)
Pseudophakic Bullous Keratopathy

2. History:
58/C/F came to HSB Hospital on 1
st
April 2016
This is her 8
th
visit to HSB. To review:
Post op x 2/52 LE DSAEK for LE pseudophakic bullous keratopathy
Post op x 1/52 LE rebubbling for partial graft detachment

Complaint of LE painless blurring of vision remains after
surgery.
Ocular History: Next slide
Medical History: Underlying hypertension, on
medication

3. Ocular History:
Ocular History:
BE pseudophakia (ACIOL) done in 2001 at PH Hospital
March 2015: LE pain with redness, photophobia and tearing. Patient went to
clinic.
May 2015: She was referred to HS Hospital for LE epithelial bullae and ben
following up there.
Sept 2015: Referred to HSB for expert opinion since the LE epithelial bullae is
recurring.On hypertonic saline QID LE and ATPF 2H LE.
March 2016 at HSB: LE DSAEK under GA for LE phakic IOL with secondary
bullous keratopathy
March 2016 at HSB: Post LE DASEK x10 days- Op for LE rebubbling for partial
graft detachment

4. Series of Ophthalmology Visit at Hospital Sg Buloh
No
Visit
date
Reason Findings Diagnosis &
Management
1 17/9/2015 Referred from Seremban
Hospital to HSB
Complaint of:
LE pain associated with
tearing even with bandage
contact lens (BCL).
-RE findings were unremarkable
-LE findings:
•VA: 6/36
•RX: -1.75 (6/12)
•Corneal sensation: Reduced
•Cornea: Conj injected, Corneal bullae 3.5mm (V)
x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous
keratopathy
Mx:
•BCL for 2/52
•TCA 2/52 (5/10/2015)
•Prescribe CMC QID LE &
ATPF 2 hourly LE
2 5/10/2015 Complaint of:
LE pain associated with
tearing even with bandage
contact lens (BCL).
-RE findings were unremarkable
-LE findings (same as previous):
•VA: 6/36
•RX: -1.75 (6/12)
•Corneal sensation: Reduced
•Cornea: Conj injected, Corneal bullae 3.5mm (V)
x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous
keratopathy
Mx:
•BCL for 2/52
•Plan for LE DSAEK
•TCA 3/52 (29/10/15) for LE
DSAEK decision
3 29/10/2015For LE DSAEK decision
Complaint of:
LE pain , cannot tolerate
-RE findings were unremarkable
-LE findings (same as previous):
•VA: 6/36
•RX: -1.75 (6/12)
•Corneal sensation: Reduced
•Cornea: Conj injected, Corneal bullae 3.5mm (V)
x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous
keratopathy
Mx:
•Agree to proceed with LE
DSAEK on 16/3/2016.
•TCA 4/12 (1/3/2016) for PC
4 1/3/2016 Pre-clerking for LE
DSAEK
Mx:
•LE DSAEK on 16/3/2016.

5. Series of Ophthalmology Visit at Hospital Sg Buloh
No
Visit
date
Reason Assessment & Findings Diagnosis &
Management
5 16/3/2016 LE DSAEK under GA for LE
phakic IOL with secondary
bullous keratopathy
Few hours after surgey: c/o some LE pain &
nausea
Assessment:
LE conj injected, AC bubble full, Siedel’s negative,
air released leaving 50% air fill
Imp: LE post DSAEK stable
Mx:
•Maxidex 2 hourly,CMC
QID, Paracetamol QID
•Advice pt to lie flat on 1
pillow except when
eating/toilet
6 22/3/2016 •Post op 1 week LE DSAEK for
LE pseudophakic bullous
keratopathy
Complaint of:
LE pain since 4 days ago &
has coughing past few days
Assessment:
•LV: 6/36 (ph: NI)
•LE Anterior: Conj injected, Inferior half
detachment seen between the graft, Corneal
sensation reduced, Lens stable, Siedel’s negative
Imp: LE post DSAEK
Management:
•Admitted for air injection into
AC under LA.
•Cont. Maxidex & CMC
7 25/3/2016 •Op for LE rebubbling for
partial graft detachment
Assessment (2 hours post op):
•90% air fill
•Graft attached
Management:
•Maxidex & CMC LE
•BCL
•Discharge on 26/3/2016 (post
op 1 day)
8 1/4/2016 Today’s visit

6. Pseudophakic bullous keratopathyTaken 1 day before LE DSAEK
Taken 1 day before LE DSAEKCorneal bullae
Corneal bullae

7. Post-op LE DSAEKN
Post-op LE DSAEK
N
Taken 0n 24
th
March, before graft rebubbling
N
Inferior half detachment seen between the graft
•Post-op LE DSAEK
•Taken 0n 24
th
March, before graft rebubbling
•Inferior half detachment seen between the graft

8. Assessment
Assessment
Examination RE LE
VA (aided) 6/9 6/36 (ph:6/36)
RAPD test No RAPD No RAPD
IOP 14 16
Anterior segment •Cornea: Clear
•Conj: White
•AC: D&Q
•ACIOL stable
•BCL in situ
•Subconjunctival hemorrhage inferiorly
•Cornea central epithelial defect measuring 4.4
(V) x 5.2 (H)
•Superior air bubble present 1/4
th
of AC
•Graft attached
•Inferotemporally noted slight inadherent but
stable
•AC well formed
Posterior
segment
•OD pink
•CD 0.3
•Flat retina & macula normal
•OD pink
•CD 0.3
•Flat retina & macula normal

9. NOR MURIAHBMTRHMWMG
KPHES(UMOHCMUR(OBHM. R-MB OBH0MTMCRH8MOA6( U9H)s)HeudHoHpshHead Patient’s left eye:
LE Cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)

10. Management
Imp:
Post LE DSAEK 2 weeks for LE pseudophakic bullous keratopathy:
stable
Post op 1 week LE rebubbling for partial graft detachment: stable
Management:
Reduce Maxidex 4 hourly LE
Continue CMC QID LE
Artificial tears preservative free(ATPF) QID/PRN
BCL LE x 2 weeks
TCA 2/52

11. Management
Rationale of management given:
Maxidex
Contain dexamethasone(corticosteroids) that are used for reducing
inflammation.
Reducing eye inflammation following eye surgery.
Preventing rejection of grafts in the eye
CMC
An antibiotic-To treat bacterial infection
Artificial tears preservative free(ATPF)
For dryness and irritation & to treat epithelial defect
BCL
To shield the cornea and epithelium from the eyelid
Temporary relief of corneal pain and discomfort (Corneal graft and
epithelial defect)

12. Summary of visit:

13. Discussion
Case analysis:
Patient initially had LE pseudophakic bullous keratopathy and undergone
LE DSAEK followed by LE post DSAEK complication: partial graft
detachment.
The VA is still not improved post op during last visit as there was the
presence was cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)
Thus, discussion part will cover on:
Pseudophakic bullous keratopathy (definition, ACIOL-induced,
pathophysiology, management)
Penetrating keratoplasty VS DSAEK
Complication of DSAEK: Graft detachment
Optometric management

14. Discussion
The VA is still not improved post op during last visit as there was the
presence was cornea central epithelial defect measuring 4.4 (V) x 5.2
(H).
In this case, epithelial defect was treated with:
Lubrication. The first step involves support of the ocular surface with aggressive
lubrication using preservative-free artificial tears or lubricating ointment every one to two
hours.
Bandage contact lens (BCL). Soft therapeutic contact lenses serve to protect the
corneal surface from mechanical trauma from the eyelids. (Katzman & Jeng,2014)

15. Discussion (Bullous keratopathy)
Refers to corneal swelling due to insufficiency of the corneal
endothelial pump resulting formation of subepithelial bullae.
(Heegaard &
Grossniklaus, 2014)
Failure of the corneal endothelium to maintain the normally
dehydrated state of the cornea
(Endothelial cells function as pumps & maintaining corneal clarity).
Failure due to:
Fuchs corneal endothelial dystrophy (Bilateral, Genetic, Progressive)
Corneal endothelial trauma (surgery): Cataract surgery
Cause eye discomfort, decreased vision, glare, photophobia, reduce
contrast

16. Discussion (Pseudophakic bullous keratopathy)
Any type of intraocular surgery, especially cataract surgery, may damage
endothelial cells and accelerate the decline in endothelial cell count.
Pseudophakic bullous keratopathy (PBK) is a post-operative
condition that can occur as a complication of cataract extraction surgery
and intraocular lens placement.
insult to the endothelium and long-term cell damage
May be manifest in the immediate post-operative period or symptoms may
not present for many years.
Some studies have shown that endothelial cell loss may continue to
progress for many years after the operation.

17. Discussion (Pseudophakic bullous keratopathy)
Possible mechanism for endothelial cell loss:869)sAePRA.KTA PMRTAUuA
GRTMWUGKPEO AdoAOIA.KORA PRT
ACIOL was the cause of
pseudophakic BK in this case

18. Discussion (Pseudophakic bullous keratopathy)
Particular attention has also been directed at the relationship between intraocular lens type and
the severity of endothelial cell loss.
Many studies report that anterior chamber intraocular lenses are associated with a greater
degree of endothelial cell loss than posterior chamber intraocular lenses.
ACIOL
“Intermittent touch" (between IOL
and cornea)
Chronic irritation with low-grade
inflammation caused by the IOL
haptics or footplates
Disrupt the normal flow of aqueous
in the anterior chamber
•Affects the nutrient flow
Endothelial
damage
PSK

19. Discussion (Pathophysiology)

20. Discussion (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.Corneal transplantation
•Indicated when vision is decreased significantly by corneal edema or when pain
becomes intractable.
•In this case, LE DSAEK procedure was performed.

21. Discussion (DSAEK)

22. Discussion (Corneal transplant: PK VS DSAEK)
PK DSAEK
In Penetrating keratoplasty (PK) a circular button-
shaped, full-thickness section of tissue is removed
from the diseased or injured cornea using a
trephine or a femtosecond laser
Descemet's stripping automated endothelial
keratoplasty (DSAEK) is the gold standard for the
surgical treatment of corneal endothelial diseases.
Indications:
•Corneal ectasia
•Infectious or non-infectious corneal ulcerations or
perforations
•Combined stromal and epithelial disease (Peters )
•Stromal scarring
Showing excellent results & treatment of choice
over PK
•Fuchs' endothelial dystrophy
•Pseudophakic bullous keratopathy
•endothelial failure after PK
•Iridocorneal endothelial syndrome
The principle of DSAEK:
Full-thickness corneal transplant procedure;
Interrupted and/or running sutures are placed in
radial fashion at equal tension to minimize post-
operative astigmatism
The principle of DSAEK:
Replaces only the diseased endothelium with a
graft consisting of a thin layer of posterior stroma,
Descemet's membrane and endothelium
Gimeno et al., 2010)

23. Discussion (Corneal transplant: Why DSAEK?)
DSAEK PK
Suture-related problems can be
eliminated
Suture-related complications
Minimal change in refractive error Anisometropia
Faster and better visual rehabilitation
& recovery
Long duration of visual rehabilitation
Reduces the risk of sight threatening
complications that may occur with the
PK intraoperatively
Risk of intraoperative expulsive
hemorrhage
Eye becomes much stronger and more
resistant to injury
Long-term risk of corneal allograft
rejection or wound rupture with
minor trauma
Gimeno et al., 2010)

24. Discussion (DSAEK)
Procedure
•Inserts a full air bubble through a side port to push
the donor disc up against the host posterior stroma
•Once the graft is adherent, the air bubble is left in
place for 10 minutes
Prior to leaving the operating room, bubble will
be removed 20 to 25 percentVOREAUu A 6PWKSAEISWBTHIGS A ST PMRTA.KTAWUIUCA.ORRMTAORAKT(WAOIA
G(P TAeO.KAPIAPOCASMSS(TAOIR.TPWAUuARM.MCTR
Risk of graft detachment because the donor tissue is held in
place with an air bubble instead of sutures

25. Discussion (Complication)
The DSEK offers an effective and efficient alternative
to traditional PKP.
Complications of DSAEK (Suh et al. 2008):
In this caseN
NOR MUIAHBMTIWTGMIK PEMSITHM KORMTIPMTGWSW(T
IARROMTARTPMBGTASTUBK MTCAIPTKSTKA(THOHHBMTASRIMKGTW.T
ROIO(MR
N
-OMTIW0TBK 8TW.TIA6PI9T.OBBTKA(THOHHBMTW(T(OHHAS6TM)M
N
sK)TPKUUMSTUWRITWUTeTGK)9TuTGK)R9TW(TMdMSTeTCMM8
N
NWBOIAWS0T oMHOHHBAS6TW(T(MUWRAIAWSAS6TIPMT6(K.I
•Susceptible to detachment because the donor
tissue is held in place with an air bubble instead of
sutures
•Due to: lack of tight, full air bubble or rubbing eye
•May happen post op 1 day, 2 days, or even 1 week
•Solution: Rebubbling or repositioning the graft

26. Discussion (Optometric management)
Bullous keratopathy
Early detection, vision can be preserved, with complete history taking
to rule out the etiology
Detect any graft dislocation or failure and refer to ophthalmologist.
A comprehensive eye exam by an optometrist using
•Slit lamp, specular microscope or confocal microscope: To
examine the cornea to look for subtle changes in the appearance of cells in
the endothelium that are characteristic of the disease.
•Pachymetry : To detect increased corneal thickness that might indicate
corneal swelling from the disease.
•Visual acuity testing : Reveal decreased vision due to corneal swelling.
Management with Bandage Contact lens:
Bandage contact lenses to reduce discomfort

27. Discussion (Optometric management)
Consult on do’s and dont’s post-DSAEK procedure:
Explain to patient the eye will be red, sore and watery for a week
or two.
Vision can be quite hazy whilst the cornea is still oedematous, but
should clear as the graft starts to function.
Keep the eyes looking vertically upwards to help hold the graft in
place whilst it sticks.
Avoid rubbing the in the first few weeks to prevent dislocating the
graft.
Steroid drops are used to settle the inflammation and reduce the
risk of rejection
In some patients there may be a problem with a rise of IOP (glaucoma) associated with the
steroid eye drop treatment, and this may require additional medical or surgical treatment.

28. References
Gimeno FL, Lang, M, Mehta JS, Tan DT. Descemet's Stripping Automated Endothelial
Keratoplasty: Past, Present and Future. Expert Rev Ophthalmol. 2010;5(3):303-311.
Suh LH, Yoo SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O'Brien TP.
Complications of Descemet's stripping with automated endothelial keratoplasty: survey of
118 eyes at One Institute. Ophthalmology. 2008 Sep;115(9):1517-24. doi:
10.1016/j.ophtha.2008.01.024. Epub 2008 Apr 18.
Katzman LR, Jeng BH. Management strategies for persistent epithelial defects of the
cornea. doi:10.1016/j.sjopt.2014.06.011

29. THANK YOU