Bullous keratopathy refers to corneal swelling caused by a dysfunctional endothelial pump, resulting in the formation of fluid-filled blisters on the cornea. It develops due to endothelial dysfunction from trauma, inflammation, or dystrophies. The endothelial cells fail to function properly, allowing fluid to accumulate in the stroma and epithelium of the cornea. This causes vision impairment, eye irritation, and the potential formation of painful corneal blisters. Treatment involves the use of hypertonic agents, bandage contact lenses, and sometimes corneal transplantation to address more severe cases.

1. Bullous Keratopathy

2. Bullous Keratopathy
Refers ro 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 be due to trauma ,
inflammation or dystrophies

3. Endotheli
 Endothelial layer fail to Function
 Stromal swelling
 VA reduced, Tearing, Hazy Vision, Photophobia
 Subepitheilial Fluid filled Bullae
 Bullae Rupture can cause pain and FB sensation
 Bullous keratopathy

4. Bullous Keratopathy Occur Secondary to
following conditions
 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 / apakic Bullous Keratopathy as in Cataract extraction
 With IOL inplantation
 With AC IOL

5. In Pseudo./Aphakic Bullous keratopathy
 Rapid cell degeneration and death occurs which is then repaired by sliding and
rearrangement of neighbouring cells
 Resulting endotheliaum is charaterised by decresed cell number and enlarged and
irregularly shaped cells showing polymegathism and polymorphism
 When cell density falls below 220-400 cells/mm2 their pump function begins to fail
and stroma begins to swell.

6.  Direct trauma during surgery
 Prolonged irrigation
 Toxic medication
 Inflammation
 Increased IOP
 IOL types ACIOL
 Pseudophakic Bullous keratopathy

7. Dystrophic conditions
 Fuch’s Dystrophy - Abnrmal production of collagenous materialby the affected
endothelial cells cause marked thickening of the DM.
 Charateristic wart like guttae which progress to give beaten metal appearance.
 Epithelial edema develops ehen stromal thickness increases by 30%
 Persistent epithelial edema causes formation of microcysts and Bullae.
 CHED
 Rare condition associated with scanty or absent endotheliaum and thickened M

8.  Raised IOP Condition as in chronic Glaucoma
 Inflammation – 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
 Immunogenic Response – In case of graft Rejection

9.  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 process
these fluid filled spaces enlarge to form fine blisters, visible as microcystic edema
 Finally layer Bullae develop Characteristic of Bullous keratopathy

10. Clinical Features
 Decreased vision – Initially painless decreased vision upon waking .Vision may
Improve as day progress as evaporation promotes corneal deturgescence.
 Glare and halo
 Pain - when epithelial and Subepithelial Bullae develop and rupture resulting in
severe pain as underlying nerve endings are exposed.

11.  Erosive symptom present as discomfort foreign sensation photophobia and
watering
 When scarring occur – cornea is opaque and compact
 Pain is decreased
 Vision Reduced to hand motion
 Corneal sensation is decreased or absent
 Peripheral corneal Vasculization may occur.

12. Evaluation Technique
 Slit Lamp examination
 Corneal bullae
 Position of IOL
 Vitreous touces endothelim
 IOP
 Fundus examination – look for CME( FFA or OCT)
 Corneal pachymetry( Ultrasonic or Optic)
 Measures Corneal thickness( normal 500 -550 microns)
 If 650 microns suggest higher risk for edema after intra-ocular surgery
 If 700 microns suggest corneal decompensation

13.  Specular microscopy
 Demonstrates reduced endothelial cell density and abnormal morphology
 It helps in detecting
 Warts or guttae in fuchs Dystrophy
 Polymegathism and pleomorphism
 Clinical Confocal Mmicroscopy
 Used to study cell layers of cornea even in edema and scarring. Thus helpful in
diagnosis of bullous Keratopathy

14. Management
 Hypertonic agents- Such as sodium Chloride 25 and 5% solution and ointment
 Creates a hypertonic tear film, thereby drawing water out of cornea
 Bandage contact lens
 Useful as an adjunct to medical treartment for the temporary relief of corneal pain and discomfort.
 To shield the cornea and epithelium from the eyelid
 Reduce IOP
 Ruptured epithelial bullae
 Antibiotic Ointment
 Cycloplegic
 BSCL
 Recurrent Ruptured Bullae; Anterior Stromal micropuncture or PTK

15.  Corneal transplantation
 Indicated when visionis decreased significantly by corneal edema or when pain
becomes intractable
 Full thickness corneal transplant or endothelial Keratoplasty ( DSEK)
 Conjunctival Flap or Amniontic Membrane Graft