This patient-education article is written by the cornea service at Suraj Eye Institute, Nagpur.

What is Pseudophakic Bullous Keratopathy?

Pseudophakic bullous keratopathy (PBK) is corneal swelling that develops in an eye that has had cataract surgery and now has an artificial intraocular lens (a pseudophakic eye). The swelling results from damage to the corneal endothelium — the single layer of pump-cells that keeps the cornea clear. When too many of those cells are lost, the cornea can no longer be kept de-turgesced and it absorbs fluid, blurs, and eventually develops painful surface blisters (bullae).

Pseudophakic Bullous Keratopathy — Cross-section

Pseudophakic Bullous Keratopathy — Cross-Section

Epithelial bullae (painful)

Oedematous stroma (swollen)

Sparse endothelium

Iris

Intraocular lens (IOL)

Anterior chamber

Cornea ~700–900 µm (normally ~540 µm)

Figure 1. In pseudophakic bullous keratopathy, the corneal endothelium has been depleted by previous cataract surgery and can no longer keep the cornea dry. The stroma swells (oedema) and small blister-like elevations of the surface epithelium (bullae) develop. The intraocular lens implanted at the time of cataract surgery is visible in the posterior chamber. Central corneal thickness rises well above the normal 540 µm.

Why PBK Happens

The corneal endothelium does not regenerate. Any procedure that damages it — or any eye that begins with a low cell count — can decompensate over time. PBK is more likely when:

  • The pre-operative endothelial cell count was already low (e.g. Fuchs dystrophy, advanced age, previous trauma or intraocular surgery)
  • The cataract was very dense and required prolonged phacoemulsification
  • The intraocular lens is malpositioned or in the anterior chamber (anterior chamber lens, vitreous touch)
  • There was a surgical complication or post-operative inflammation

Symptoms

Patients typically describe gradual blurring of vision in the operated eye over months, with a characteristic pattern: vision is worse on waking and clears slightly through the day in the early stages. Once epithelial bullae develop, the eye becomes uncomfortable or painful, especially when a bulla bursts.

How PBK is Diagnosed

Diagnosis is made by examining the cornea at the slit-lamp and by two non-contact tests:

  • Specular microscopy typically shows a very low endothelial cell density. The advice to proceed to endothelial transplant is primarily clinical — based on corneal swelling and visual deterioration, with or without discomfort — supported by the cell count, the cornea being at high risk of decompensation as the count falls below roughly 500–700 cells/mm².
  • Anterior segment OCT shows increased corneal thickness and confirms intraocular lens position.

Treatment

Early PBK can be managed temporarily with hypertonic saline drops and, if epithelial breakdown is troublesome, a soft bandage contact lens. Definitive treatment is surgical:

  • Endothelial keratoplasty (DSAEK or DMEK) selectively replaces the damaged endothelium with healthy donor tissue. Visual rehabilitation is rapid and the procedure preserves the patient’s own anterior cornea.
  • Combined IOL exchange / endothelial keratoplasty in eyes where the intraocular lens is malpositioned or is itself contributing to endothelial damage.
✔ PBK Care at Suraj Eye Institute

We routinely measure pre-operative endothelial cell counts in at-risk cataract surgery patients, use endothelial-protective phacoemulsification techniques, and offer DSAEK and DMEK for established PBK. Where intraocular lens malposition is also a factor, we combine endothelial keratoplasty with IOL exchange or repositioning in a single operation.

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Frequently Asked Questions

Why did this happen after my cataract surgery?
PBK is uncommon and is usually a combination of vulnerable corneal endothelium (low pre-existing cell count, Fuchs dystrophy or advanced age) and the unavoidable stress of intraocular surgery. It is not an indication of a poor outcome of your cataract surgery overall — it reflects the cornea’s reserve at the time of surgery.

Can my vision be restored?
Yes, in the great majority of patients. Endothelial keratoplasty (DSAEK or DMEK) replaces only the damaged inner layer of the cornea with healthy donor tissue. Vision improves over a few weeks for DMEK and a few months for DSAEK.

Will I need the intraocular lens removed?
Usually not. The artificial lens is usually left in place. If the lens is malpositioned (for example tilted or in the anterior chamber), it can be exchanged or repositioned at the same time as the endothelial transplant.

What is the difference between DSAEK and DMEK?
Both procedures replace only the inner layer of the cornea. DMEK transplants a thinner tissue, gives faster visual recovery and slightly better final vision; DSAEK is technically more forgiving and remains a good choice in complex eyes.

Could PBK have been prevented?
PBK risk is reduced by careful pre-operative measurement of endothelial cell density, gentle phacoemulsification technique with viscoelastic protection of the endothelium, and individualised IOL planning. In the highest-risk eyes (low ECD or Fuchs dystrophy) we sometimes plan combined cataract surgery with endothelial transplant from the outset.

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