An 87-year-old woman seeks another opinion regarding corneal transplantation OD. She has already seen 2 surgeons, one recommended penetrating keratoplasty and the other did not because of poor visual potential. The patient reports deteriorating vision OD for 7 months. Her past ocular history is significant for pseudophakia OU, retinal detachment repair OU, and optic atrophy OS. Her BSCVA is hand motions OD and counting fingers at 3 feet OS, IOP is normal, pupils are surgical and the view is poor due to cloudy corneas. Slit lamp exam shows a thickened cloudy cornea OD and corneal edema with band keratopathy OS. The anterior chambers are deep with an AC IOL OD and PC IOL OS. There is a red reflex OD with no view of the fundus. The optic nerve is pale and there is a scar in the macula OS.
Slit lamp view of cornea OD
Slit lamp view of cornea OS
Careful inspection of the cornea OD revealed the clouding to be a large confluent subepithelial scar rather than severe stromal edema. Therefore, the patient underwent a superficial keratectomy at the slit lamp with a blunt spatula and forceps. The scar tissue was easily peeled off of Bowman’s membrane in one piece like an enormous Salzmann’s nodule. The underlying cornea was relatively clear with only mild edema. The patient immediately attained 20/60 visual acuity.
Slit lamp view of cornea OD after scar removal
Unfortunately, the corneal edema increased, painful bullae developed, and the scar tissue recurred within a year, even after another debridement with mitomycin-C. The patient subsequently underwent penetrating keratoplasty for the pseudophakic bullous keratopathy (PBK).
Discussion: This case of corneal scarring demonstrates an end stage appearance of chronic corneal edema. The characteristic presentation of PBK is corneal edema with epithelial blebs and/or bullae. Patients may develop significant pain and are usually managed initially with a bandage contact lens, sometimes with anterior stromal puncture, but often require a corneal transplant if the visual potential is good or a Gunderson flap if there is no visual potential. However, without surgical intervention the cornea eventually develops a subepithelial pannus with epithelial scarring and resolution of the painful bullae. It is rare to see this late sequela of chronic corneal edema because most patients seek medical attention earlier in the course of the disease.