{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T03:02:25Z","timestamp":1779678145431,"version":"3.53.1"},"reference-count":27,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2026,5,24]],"date-time":"2026-05-24T00:00:00Z","timestamp":1779580800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Bullous keratopathy may lead to severe corneal opacity and impaired visualization of anterior segment structures, complicating surgical qualification for endothelial keratoplasty (EK). We report the case of a 67-year-old male with pseudophakic bullous keratopathy and Fuchs endothelial dystrophy presenting with clinically complete corneal opacity and visual acuity limited to hand motion. Slit-lamp examination and anterior segment optical coherence tomography demonstrated marked epithelial remodeling with a dense plaque-like surface lesion obscuring deeper corneal structures. A staged intraoperative approach was undertaken. Following mechanical epithelial debridement, partial restoration of corneal transparency allowed for an intraoperative reassessment of stromal clarity and subsequent Descemet Stripping Automated Endothelial Keratoplasty (DSAEK). Histopathological examination demonstrated reactive epithelial thickening with associated subepithelial fibrosis consistent with chronic bullous keratopathy. Postoperatively, corneal transparency was restored and best-corrected visual acuity improved to 0.7 Snellen (0.15 logMAR), remaining stable during follow-up without graft-related complications or recurrent epithelial abnormalities. This case highlights the importance of considering epithelial contributions to apparent corneal opacity in advanced bullous keratopathy and suggests that staged intraoperative reassessment may support individualized surgical decision-making in selected patients with inconclusive preoperative evaluation.<\/jats:p>","DOI":"10.3390\/jcm15114059","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T01:45:08Z","timestamp":1779673508000},"page":"4059","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Masked Corneal Opacity in Bullous Keratopathy: The Impact of Epithelial Pathology on Surgical Decision-Making\u2014A Case Report"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8266-1803","authenticated-orcid":false,"given":"Wojciech","family":"Lubo\u0144","sequence":"first","affiliation":[{"name":"Department of Ophthalmology, Faculty of Medical Sciences, Medical University of Silesia, 40-514 Katowice, Poland"},{"name":"Department of Ophthalmology, Professor K. Gibi\u0144ski University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"\u0141ukasz","family":"Drzyzga","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, Professor K. Gibi\u0144ski University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wojciech","family":"Rokicki","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, Faculty of Medical Sciences, Medical University of Silesia, 40-514 Katowice, Poland"},{"name":"Department of Ophthalmology, Professor K. Gibi\u0144ski University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5336-3460","authenticated-orcid":false,"given":"Dorota","family":"Wygl\u0119dowska-Promie\u0144ska","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, Faculty of Medical Sciences, Medical University of Silesia, 40-514 Katowice, Poland"},{"name":"Department of Ophthalmology, Professor K. Gibi\u0144ski University Clinical Center, Medical University of Silesia, 40-514 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1097\/IIO.0000000000000315","article-title":"Phacoemulsification in the Setting of Corneal Endotheliopathies: A Review","volume":"60","author":"Chang","year":"2020","journal-title":"Int. Ophthalmol. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1080\/02713683.2023.2259633","article-title":"Identification and Analysis of Primary Cilia in the Corneal Endothelial Cells of Patients with Bullous Keratopathy","volume":"49","author":"Deguchi","year":"2024","journal-title":"Curr. Eye Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"780","DOI":"10.1111\/aos.13126","article-title":"Fuchs\u2019 Endothelial Corneal Dystrophy: A Controlled Prospective Study on Visual Recovery After Endothelial Keratoplasty","volume":"94","author":"Nielsen","year":"2016","journal-title":"Acta Ophthalmol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2361","DOI":"10.1016\/j.ophtha.2009.07.010","article-title":"Descemet\u2019s Membrane Endothelial Keratoplasty: Prospective Multicenter Study of Visual and Refractive Outcomes and Endothelial Survival","volume":"116","author":"Price","year":"2009","journal-title":"Ophthalmology"},{"key":"ref_5","first-page":"CD012097","article-title":"Descemet\u2019s Membrane Endothelial Keratoplasty (DMEK) versus Descemet\u2019s Stripping Automated Endothelial Keratoplasty (DSAEK) for Corneal Endothelial Failure","volume":"6","author":"Stuart","year":"2018","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.ophtha.2017.08.015","article-title":"Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology","volume":"125","author":"Deng","year":"2018","journal-title":"Ophthalmology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1016\/j.ajo.2019.06.012","article-title":"Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty","volume":"207","author":"Woo","year":"2019","journal-title":"Am. J. Ophthalmol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1016\/j.ajo.2022.09.013","article-title":"Systematic Review and Meta-Analysis: Outcomes After Descemet Membrane Endothelial Keratoplasty Versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty","volume":"245","author":"Maier","year":"2023","journal-title":"Am. J. Ophthalmol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.clae.2012.10.066","article-title":"Near Complete Visual Recovery and Refractive Stability in Modern Corneal Transplantation: Descemet Membrane Endothelial Keratoplasty (DMEK)","volume":"36","author":"Ham","year":"2013","journal-title":"Cont. Lens Anterior Eye"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1016\/j.ophtha.2020.02.029","article-title":"Descemet Membrane Endothelial Keratoplasty versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty: A Multicenter Randomized Controlled Clinical Trial","volume":"127","author":"Dunker","year":"2020","journal-title":"Ophthalmology"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Castellucci, M., Novara, C., Casuccio, A., Cillino, G., Giordano, C., Failla, V., Bonfiglio, V., Vadal\u00e0, M., and Cillino, S. (2021). Bilateral Ultrathin Descemet\u2019s Stripping Automated Endothelial Keratoplasty vs. Bilateral Penetrating Keratoplasty in Fuchs\u2019 Dystrophy: Corneal Higher-Order Aberrations, Contrast Sensitivity and Quality of Life. Medicina, 57.","DOI":"10.3390\/medicina57020133"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Levy, I., Habib, L., Morgan, S., Mukhija, R., and Nanavaty, M.A. (2026). Epithelial Thickness Changes After Descemet Membrane Endothelial Keratoplasty (DMEK): An Observational Study. J. Clin. Med., 15.","DOI":"10.3390\/jcm15051984"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Salari, F., Beikmarzehei, A., Liu, G., Zarei-Ghanavati, M., and Liu, C. (2022). Superficial Keratectomy: A Review of Literature. Front. Med., 9.","DOI":"10.3389\/fmed.2022.915284"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"946","DOI":"10.1016\/j.ophtha.2019.02.007","article-title":"Corneal Higher-Order Aberrations in Descemet Membrane Endothelial Keratoplasty Versus Ultrathin DSAEK in the Descemet Endothelial Thickness Comparison Trial: A Randomized Clinical Trial","volume":"126","author":"Duggan","year":"2019","journal-title":"Ophthalmology"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"400","DOI":"10.21873\/invivo.13092","article-title":"Ultrathin-Descemet Stripping Automated Endothelial Keratoplasty Versus Descemet Membrane Endothelial Keratoplasty: A Systematic Review and Meta-Analysis","volume":"37","author":"Dimtsas","year":"2023","journal-title":"In Vivo"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e001397","DOI":"10.1136\/bmjophth-2023-001397","article-title":"Descemet Membrane Endothelial Keratoplasty Compared with Ultrathin Descemet Stripping Automated Endothelial Keratoplasty: A Meta-Analysis","volume":"8","author":"Sela","year":"2023","journal-title":"BMJ Open Ophthalmol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"853","DOI":"10.1097\/ICO.0000000000003434","article-title":"Mediators of Visual Acuity in Descemet Membrane Endothelial Keratoplasty and Ultrathin Descemet Stripping Automated Endothelial Keratoplasty","volume":"43","author":"Lin","year":"2024","journal-title":"Cornea"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1016\/j.ophtha.2011.09.019","article-title":"Risk of Corneal Transplant Rejection Significantly Reduced with Descemet\u2019s Membrane Endothelial Keratoplasty","volume":"119","author":"Anshu","year":"2012","journal-title":"Ophthalmology"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1016\/j.ophtha.2016.12.017","article-title":"Incidence and Clinical Course of Immune Reactions after Descemet Membrane Endothelial Keratoplasty: Retrospective Analysis of 1000 Consecutive Eyes","volume":"124","author":"Hos","year":"2017","journal-title":"Ophthalmology"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"22210","DOI":"10.1038\/s41598-022-26679-w","article-title":"The Predictability of Graft Thickness for Descemet\u2019s Stripping Automated Endothelial Keratoplasty Using a Mechanical Microkeratome System","volume":"12","author":"Nishisako","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Geber, A., Masnec, S., Kalauz, M., Be\u0161li\u0107, I., \u0160kegro, I., Ga\u0107ina, D.L., Jandrokovi\u0107, S., Meter, A., and Kuzman, T. (2025). Comparative Analysis of Corneal Morphological and Optical Parameters in Predicting DSAEK Surgery Outcome. Medicina, 61.","DOI":"10.3390\/medicina61061022"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1467","DOI":"10.1097\/ICO.0000000000003517","article-title":"Cornea Classics: Melles, Ong, Ververs, and van der Wees, \u201cDescemet Membrane Endothelial Keratoplasty (DMEK)\u201d (2006)","volume":"43","author":"Colby","year":"2024","journal-title":"Cornea"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1016\/j.ajo.2011.12.012","article-title":"Descemet Membrane Endothelial Keratoplasty Versus Descemet Stripping Automated Endothelial Keratoplasty","volume":"153","author":"Tourtas","year":"2012","journal-title":"Am. J. Ophthalmol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1192","DOI":"10.1001\/jamaophthalmol.2014.1710","article-title":"Multicenter Study of Descemet Membrane Endothelial Keratoplasty: First Case Series of 18 Surgeons","volume":"132","author":"Monnereau","year":"2014","journal-title":"JAMA Ophthalmol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1016\/j.ophtha.2008.11.004","article-title":"Endothelial Keratoplasty for Fuchs\u2019 Dystrophy with Cataract: Complications and Clinical Results with the New Triple Procedure","volume":"116","author":"Terry","year":"2009","journal-title":"Ophthalmology"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1177\/1120672118757431","article-title":"DMEK versus DSAEK for Fuchs\u2019 Endothelial Dystrophy: A Meta-Analysis","volume":"29","author":"Marques","year":"2019","journal-title":"Eur. J. Ophthalmol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"339","DOI":"10.3928\/1081-597X-20050701-07","article-title":"Descemet\u2019s Stripping with Endothelial Keratoplasty in 50 Eyes: A Refractive Neutral Corneal Transplant","volume":"21","author":"Price","year":"2005","journal-title":"J. Refract. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4059\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T02:06:53Z","timestamp":1779674813000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4059"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,24]]},"references-count":27,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcm15114059"],"URL":"https:\/\/doi.org\/10.3390\/jcm15114059","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,24]]}}}