FIRST CASE REPORT OF MASSIVE BULLOUS EPITHELIAL DETACHMENT IN A PATIENT FOLLOWING ENDOART SURGERY

To describe the first observed case of massive bullous epithelial detachment in a patient with a background of recurrent herpes uveitis and prior Descemet membrane endothelial keratoplasty (DMEK) graft rejection following EndoArt surgery. This report aims to document the clinical features, imaging findings, and morphological changes of this complication using anterior segment OCT (AS-OCT) and in-vivo confocal microscopy (IVCM).

This case was managed and documented at the Ophthalmology Department at Hanusch Hospital Vienna, utilizing AS-OCT and IVCM to monitor this specific post-operative complication.

A single patient with a history of recurrent herpes uveitis and prior DMEK, which resulted in graft rejection, developed a significant bullous epithelial detachment following EndoArt surgery and four subsequent Re-bubblings. The patient was monitored over six months with multiple follow-up visits. Evaluations included slit-lamp examinations, slit-lamp imaging, AS-OCT, and IVCM to assess the extent, depth, and resolution of the epithelial detachment as well as structural corneal changes.

Approximately three months after EndoArt surgery, AS-OCT revealed a pronounced bullous detachment of the epithelial layer, while IVCM allowed for detailed visualization of the epithelial and stromal layers, showing structural disruptions. Specifically, epithelial cells appeared disorganized and swollen, with altered cell borders, while the underlying stromal matrix showed signs of edema and hyper-reflective zones, suggestive of inflammatory cellular infiltrates. Edema within the stromal layer decreased over time, with fewer hyper-reflective zones visible, suggesting a reduction in inflammation.

Following two rounds of epithelial debridement, structural improvement was observed, with partial reattachment of the epithelial layer and an overall enhancement in epithelial integrity, although small central bullae and an inferior detachment remained.

This case represents the first reported instance of massive bullous epithelial detachment following EndoArt surgery in a patient with prior DMEK graft rejection and recurrent herpes uveitis. Detailed imaging insights from AS-OCT and IVCM were crucial for documenting the recovery process and guiding post-operative care. Despite two rounds of epithelial debridement, the persistence of small central bullae and an inferior detachment underscores the need for continued monitoring and, potentially, further interventions to achieve full reattachment. These findings highlight the value of advanced imaging and individualized management in addressing complex corneal healing dynamics following EndoArt interventions.