FECD-like Histopathological Features of Descemet’s Membrane in Bullous Keratopathy Associated with Primary Angle Closure

Purpose To investigate the histopathological features of Descemet’s membrane (DM) in eyes with bullous keratopathy associated with primary angle closure (PAC), with or without a history of argon laser iridotomy. Methods This multicenter, retrospective, observational study included eyes that underwent endothelial keratoplasty for corneal endothelial failure. Eyes with clinically diagnosed Fuchs endothelial corneal dystrophy (FECD) were excluded. DM specimens excised from eyes with PAC-associated endothelial failure were flat-mounted and examined using phase-contrast microscopy. The presence and spatial distribution of corneal guttae were evaluated and compared with those of reference specimens from FECD. Results In total, 13 eyes with PAC-associated endothelial failure were included in this study. Guttae were identified on the excised DM in 9 of the 13 eyes. Of these, four eyes exhibited an atypical peripheral-predominant distribution of guttae with relative sparing of the central DM, differing from the typical central-predominant pattern observed in FECD. Additionally, guttae identified in the affected eyes were not consistently accompanied by corresponding guttae in the fellow eyes. Conclusion These findings suggest that a subset of eyes with PAC-associated endothelial failure may reflect the underlying endothelial vulnerability, manifested as FECD- or FECD-like changes at the level of the DM. Notably, such FECD-like changes do not necessarily represent classical genetically determined FECD. This endothelial vulnerability may represent a contributing background factor in the development of bullous keratopathy in the context of PAC, with or without a history of argon laser iridotomy. However, this interpretation remains speculative and warrants further investigation.