Keratopathy bullous

Ophthalmic-Transient stinging and burning corneal clouding persistent bullous keratopathy retinal detachment transient ciliary and conjunctival injection ciliary spasm with resultant temporary decrease of visual acuity. 

Mansour et al. (2004) carried out a prospective study of 24 consecutive patients with bullous keratopathy, who were not immediate surgical candidates. One drop of honey was applied to the cornea after informed consent had been obtained. Patients were instructed to use topical honey three or four times daily. 

Bullous keratopathy is a major complication of cataract surgery. In the past, penetrating keratoplasty was considered the most effective therapy for the symptomatic stage of the disease. Other surgical options have included conjunctival flaps, enucleation (reserved for blind, painful eyes) and, more recently, deep phototherapeutic keratectomy and amniotic membrane transplantation. Medical therapy of bullous keratopathy using hypertonic saline (Nad 5%) has been of marginal benefit due to its relatively weak osmotic effect. 

Mansour, A.M., Zein, W., Haddad, R., and Khoury, J., Bullous keratopathy treated with honey, Acta Ophthalmol. Scand., 82, 312-313, 2004. 

Topical application of glycerin in concentrations from 50% to 100% results in a significant reduction of corneal edema within 1 to 2 minutes. Because application to the eye is painful, a topical anesthetic must be instilled before use. It is useful in ophthalmoscopic and gonioscopic examination of the eye in acute angle-closure glaucoma, bullous keratopathy, and Fuchs endothelial dystrophy. 

Figure 26-8 Diagram of the deep lamellar endothelial keratoplasty procedure for patients with Fuchs corneal dystrophy and pseudophakic bullous keratopathy. (Diagram courtesy of Dr. Mark Terry of the Devers Eye Institute in Portland, Oregon.)...

Although cataract surgery is a potential precursor to bullous keratopathy, there are many other causes. Fuchs endothelial dystrophy, infection, trauma, retained foreign body, posterior polymorphous dystrophy, chronic uveitis, chronically elevated intraocular pressure (lOP), and vitreous touch are all known causes of bullous keratopathy. Other less common causes of bullous keratopathy include corneal thermal injury secondary to carbon dioxide laser skin resurfacing, air bag trauma, the use of topical dorzolamide hydrochloride in glaucoma patients with endothelial compromise, and use of mitomycin C during trabeculectomy surgery. 

Figure 26-12 Bullous keratopathy bullae arrows). (Courtesy of Pat Caroline.)...

Subjectively, the patient with bullous keratopathy reports tearing, foreign body sensation, and pain. The pain is caused by either the exposure of nerves with the eruption of the bullae or the stretching of nerves as they pass through swollen edematous epithelium. Another common symptom is decreased vision due to edema and distortion of the anterior corneal surface. 

A thorough examination should be performed to determine the cause of bullous keratopathy. The specific treatment plan depends on both the cause and severity. Examination of the endothelium, internal structures, and fundus can be enhanced by the use of topical hyperos-motics to decrease epithelial edema. Internal examination is essential to determine if there is corneal touch by the intraocular lens or vitreous face and to rule out cystoid macular edema or intraocular inflammation. 

Long-term use of prophylactic antibiotics has been associated with an increased risk of ulcerative keratitis in patients with bullous keratopathy. This may simply be secondary to a relatively increased use of prophylactic antibiotics in these patients who are more susceptible to developing infectious keratitis, or it is also possible that there is an increased risk of developing colonization with antibiotic-resistant bacteria. To diminish this possibility, prophylactic antibiotics should only be used when epithelial breaks are present.Topical corticosteroid use is also a strong risk fector for the development of ulcerative keratitis and should be avoided. 

Because even normal lOP can force fluid into the cornea if the endothelium is not functioning properly, many authors suggest the use of topical or oral medications to decrease the lOP in patients with bullous keratopathy. 

Patients with bullous keratopathy should have their lOP measured (even though corneal edema results in underestimated lOP) because angle-closure glaucoma can cause similar corneal edema. In addition, patients with Fuchs dystrophy have an increased risk of developing open-angle glaucoma in addition to the bullous keratopathy. Topical carbonic anhydrase inhibitors should be avoided in these patients because of the potential of worsening the corneal decompensation. 

Follow-up far patients with bullous keratopathy varies depending on therapeutic contact lens wear and the severity of the disease. Most patients should be monitored every 1 to 6 months. 

There are many other causes of RCE, but they occur much less frequently. Among these causes are chemical or thermal burns, herpes simplex keratitis, neuroparalytic keratitis, bullous keratopathy, severe dry eyes, nocturnal lagophthalmos, diabetes mellitus, meibomian gland dysfunction, ocular rosacea, and Alport syndrome. Approximately 5% to 30% of RCEs occur spontaneously without any known predisposing fector. 

Yuen HK, Rassier CE, Jardeleza MS, et al. A morphologic study of Fuchs dystrophy and bullous keratopathy. Cornea 2005 24 319-327. 

Cataract patients, in general, have relatively little immediate postoperative pain. This absence of pain is, at least in part, due to the long duration of action (up to 12 hours) of bupivacaine used in retrobulbar anesthesia. Some practitioners recommend the use of oral analgesics, such as acetaminophen or ibuprofen, as needed, if the patient experiences minor discomfort in the immediate postsur-gical period.Topical NSAIDs are also reported to decrease immediate postoperative pain. Significant or persistent postoperative pain is considered to be abnormal and may be a symptom of such complications as corneal abrasion, bullous keratopathy, high lOP, or endophthalmitis. 

In the absence of other pathology, the patient s vision should be fully correctable within a few weeks after cataract surgery. Vision that is initially clear after cataract extraction but then deteriorates is suggestive of a postoperative complication, such as capsular opacification, bullous keratopathy, CME, or retinal detachment. 

Accidental use of cetrimide solution 0.1% as an irrigation solution during cataract surgery in two cases resulted in immediate corneal edema, which in turn resulted in a severe bullous keratopathy (2). 

Epithelial and stromal edema of the cornea and a diffuse bullous keratopathy developed in a 39-year-old woman 2 weeks after a preoperative disinfection of the face with an alcoholic chlorhexidine solution. This led to penetrating keratoplasty 10 months later (20). 

Topical ciclosporin may be useful in treating bullous keratopathy (idiopathic primary edema) in the horse and can be effective in the management of type 2 viral keratitis. 

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