Masked Corneal Opacity in Bullous Keratopathy: The Impact of Epithelial Pathology on Surgical Decision-Making-A Case Report.

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.