Phaco produces corneal bulla rare case

Cataract surgery is usually discussed in terms of lens removal, ultrasound energy, and endothelial damage. But this case was about the corneal surface itself — and about how a tiny fluid-path failure can suddenly wreck the surgeon’s view. In JAMA Ophthalmology, Sheng-Chi Yang and Rong-Kung Tsai described a 68-year-old woman who developed a transparent corneal epithelial blister during phacoemulsification on March 12, 2026. The bulla expanded fast enough to distort the operative field, then collapsed after puncture, with the cornea reattaching and vision reaching 20/20 a week later. ### What actually formed here? This was an intracorneal epithelial bulla — basically a pocket of fluid that split the corneal epithelium from the layer beneath it. That is different from the more familiar postoperative bullous keratopathy people worry about after endothelial injury. Here, the problem appeared during surgery, at the epithelial-basement membrane interface, and it behaved like trapped irrigation fluid rather than generalized corneal swelling. ### When did it happen? It happened during the phacoemulsification-chop step, not later in recovery. A localized transparent blister appeared next to the main incision and then enlarged toward the central cornea. That matters because the timing points away from slow toxic or inflammatory edema and toward an immediate mechanical or fluidic event happening right at the wound. ### Why is the sleeve the key suspect? The authors’ explanation is simple and pretty convincing — a microperforation in the phaco sleeve likely let irrigation fluid track into the epithelial interface. Think of a pinhole in a pressurized hose aimed into the wrong tissue plane. If fluid gets forced under fragile epithelium, it can balloon the surface instead of staying in the anterior chamber where it belongs. ### Is this totally unheard of? Not exactly, but it is unusual enough to stand out. A 2009 anterior-segment OCT study of 60 eyes found epithelial bulla at the incision region in 2 eyes, or 3%, one day after phacoemulsification. That is not the same thing as a dramatic intraoperative ballooning event, but it shows that clear-corneal wounds can create epithelial separation around the incision even in otherwise routine surgery. ### Why would some corneas be more vulnerable? The corneal epithelium is easy to injure mechanically. Ocular surgery itself, dryness, diabetes, neurotrophic states, and other epithelial-compromising conditions can make the surface less robust. There is also evidence that phaco causes a temporary postoperative increase in epithelial thickness in general, with slower epithelial recovery in diabetic patients respond badly to surgical stress. ### What did the surgeons do? They confirmed the lesion by gentle pressure and then punctured it with a Fukasaku snapper hook, which released the trapped fluid promptly. The immediate goal was not cosmetic — it was to restore the view and let the operation continue safely. The short-term outcome was reassuring: the loosened epithelium reattached within a week and the eye reached 20/20 vision. ### What should surgeons take from it? The practical lesson is to think about wound mechanics, not just ultrasound settings. If the corneal surface suddenly hazes or balloons near the incision, the problem may be epithelial fluid dissection from the sleeve or wound rather than classic endothelial edema. That means checking the sleeve, handling the incision gently, and recognizing that a rare-looking complication can have a very physical, fixable cause. ### Bottom line? This case matters because it turns a weird intraoperative surprise into a concrete teaching point. The rare part was the dramatic ballooning. The useful part is that the mechanism seems understandable — and maybe preventable.