Anterior segment OCT of the left eye confirmed descemet’s membrane detachment (fig 2). The diagnosis of pseudophakic bullous keratopathy with descemet’s membrane detachment was established. Since it was a very late presentation, penetrating keratoplasty was done in the left eye from a suitable healthy donor. The host cornea was removed and the donor cornea was opposed to the host with the help of 16 interrupted 10-0 nylon sutures.

Following a penetrating keratoplasty, oral and topical antibiotic, topical steroids, cycloplegic, hyperosmotic eye drops and lubricants were given. Oral acetazolamide was also given in the first week and intraocular pressure was monitored properly. Good postoperative care is extremely important in these cases for graft survival and visual rehabilitation. Her visual outcome started improving. Graft clarity was 1+ with healthy graft host junction (fig 3 and fig 4). The best corrected visual acuity was improved to 6/9 in two weeks.

Fig 1: left eye cornea showing pseudophakic bullous keratopathy

Fig 2: Left eye anterior segment OCT showing Descemet's membrane detachment

Na⁺-K⁺-ATPase pump in the endothelium prevents corneal hydration and helps in maintaining transparency. Any damage to endothelial cells hampers corneal transparency. Surgically induced trauma, excessive ultrasound energy use in surgery, persistent inflammation and endothelial dystrophies can promote cell loss [1]. When the cell density reaches a critically low value, it results in the development of pseudophakic bullous keratopathy. The pump fails and manifests as stromal edema, which can change in response to intraocular pressure. The aqueous migrates from stroma to epithelium resulting in epithelial edema, blisters and bullae formation. Descemet’s membrane detachment is a serious complication after surgical procedures involving anterior chamber manipulation [7]. Rarely it can occur in the intermediate or late postoperative period after uncomplicated surgery [7]. Of all the procedures involving anterior chamber entry, DMD is reported most commonly after cataract surgery [7]. There are two types of DMD: peripheral and central. Peripheral DMD is small with minimal corneal edema and therefore given conservative management. Central DMD or involving the visual axis requires surgical intervention. Delayed onset DMD should be considered as one of the differentials in cases with late-onset corneal edema post-cataract surgery [7]. Our patient presented late with a gradually progressive diminution of vision after cataract surgery. Penetrating keratoplasty is the gold standard surgery in pseudophakic bullous keratopathy [1].

In this surgery, a full thick host cornea is replaced by a donor cornea which is opposed to the host cornea with interrupted or continuous sutures. Penetrating keratoplasty can salvage vision in late-presented or neglected cases of PBK with DMD. Patient education also plays an important role in managing the case. The patient should be educated regarding the pathology and mechanism behind corneal edema and also regarding the management options.