Pbk case presentation

1. Case presentation
853775

2. 77yr old
Nun sister
Ernakulam
Presenting complaint
-diminution of vision LE 1 year
-associated watering from LE 3 months

3. History of presenting illness
Complaints of gradual onset of diminution of vision in left eye since 1
year.
This was associated with recurrent episodes of photophobia, mild
redness , coloured halos.
This is also associated with watering from left eye since 3 months.
Symptoms are pronounced during the morning hours
Patient consulted elsewere and was advised topical medication-
symptoms persisting, worsening since 4 months, hence came here for
further management
No associated discharge, itching
No h/o trauma/ injury to eye
No h/o flashes/ floaters

4. Past history
h/o BE- cataract surgery- 10 yrs before
h/o DM –10 years , on OHA, insulin
Dementia

5. Family history
No h/o similar illness in the family / any significant ocular illness in the
family

6. Personal history
Sleep and appetite normal
Normal bowel and bladder habits
No addictions

7. General examination
Conscious cooperative and well oriented in time
space and person
Moderately built and nourished
PR-70/mt ,
BP 110/70mmHg right arm sitting posture

8. Systemic examination
CVS: S1 and S2 heard. no added sounds
Resp: Normal vesicular breath sounds heard.
CNS: WNL
P/A :Soft , non tender

9. Ocular examination
Head posture :Normal
Ocular position: Orthotropic
RIGHT EYE LEFT EYE
VISION DISTANCE 6/18 HM+
NEAR N6 <N36
Pinhole
RETINOSCOPY(undilated) Red glow+ DULL GLOW
Acceptance -1.25DC*90
+2.75

10. Anterior segment examination
RIGHT EYE LEFT EYE
LIDS AND LACRIMAL
APPARATUS
Normal ,Roplas negative Normal,Roplas negative.
CONJUNCTIVA Normal Mild congestion
SCLERA Normal Normal

13. RIGHT EYE LEFT EYE
CORNE
A
Normal in size, shape, lusture
Corneal sensation normal
Normal in size, shape
Microcystic epithelial oedema seen
diffusely with scattered epithelial
bullae, grayish white opacity seen
paracentrally 4x 1.5 mm in size 4mm
from the 6’o clock position suggestive
of scar,
On slit beam view, there is increase in
thickness of stroma suggestive of
stromal oedema
multiple linear folds seen more
centrally-DM
Pigments on endothelium present
diffusely
Superficial corneal vascularization
seen in all quadrants
Corneal sensation reduced

16. ANTERIOR
CHAMBER
VH grade III
No cells/ flare
VH Grade III
No cells/ flare
IRIS Normal in colour and
pattern
V shaped opening
seen at 11 o clock
position ,
retroillumination
present- ? Surgical PI
which is patent
Normal in colour and
pattern
PUPIL
Direct
Consensual
Near
3mm round & regular
Reacting briskly
3mm round & regular
Reacting briskly
LENS PCIOL PCIOL
IOP WITH AT 14mmHg 12mmHg

17. RIGHT EYE LEFT EYE
DISTANT DIRECT
OPHTHALMOSCOPY
RED GLOW DULL GLOW
SLIT LAMP BIOMICROSCOPY
WITH 90D
Media clear
Disc & vessels seen
Vertical CDR of 0.3
NRR even & pink
Vessels arising centrally &
branching dichotomously
with AV ratio of 2:3
Yellowish irregular areas
seen near the foveal
suggestive of RPE changes
NO DR changes
Media hazy
Disc seen hazily
Retina on
INDIRECT
OPHTHALMOSCOPY
Periphery within normal
limits
Hazy view

18. PROVISIONAL DIAGNOSIS
OU –Pseudophakia
OD- surgical PI
OS- Pseudophakic Bullous Keratopathy
DM

19. THANK YOU

20. PBK
Development of irreversible corneal oedema following cataract surgery,
which initially develops in the stroma- progressing towards epithelial
region- bullae
1. Corneal stromal oedema
2. Epithelial & sub epithelial bullae
3. Due to cell loss & endothelial
decompensation through trauma in cataract
surgery

21. Corneal transparency -dehydrated state
• Corneal epithelium & endothelium are both
semipermeable membranes that create a barrier to the
flow of water and other electrolytes.
The major factor which prevents corneal hydration is
Na+K+ATPase pump which lies within lateral cell membrane
in endothelial layer of cornea
PATHOPHYSSIOLOGY

22. development of PBK is damage to corneal
endothelium when cell density reaches to critically
low level of about 300-500 cells / mm2

23. • rearrangement of remaining cells to cover posterior
corneal surface –Polymegatism and pleomorphism
. • Descemet’s membrane is produced in excess amount.
• Endothelial pump fails and stromal edema develops
• Later on epithelial edema ensues because of anterior
movement of aqueous and fluid in stroma leading to
formation of blisters and bullae

24. Surgical trauma to endothelium
Type of cataract surgery
IOL-Lenses made of PMMA
Viscoelastics- HPMC is not as protective as sodium
hyaluronate during phacoemulsification
Descemet's detachment
INTRAOPERATIVE RISK
FACTORS

25. POSTOPERATIVE CAUSES
• Routine uncomplicated phacoemulsification results in
9% endothelial cell loss at 1 year postoperatively
• ACIOL IOL
Iris supported lenses -greater endothelial - contact with
endothelium during ocular saccades.

26. CLINICAL FEATURE
Diminution of vision
Watering & pain
photophobias
Specular microscopy
pachymetry

27. MANAGEMENT
Topical hyperosmotic agent
Bandage contact lens
Cauterisation of bowman’s membrane
Corneal transplantaion