Acute Bilateral Corneal Oedema Following Suspected Toxic Endothelial Insult: An Intriguing Case Report

Visual recovery after a suspected toxic endothelial insult can be partial and uneven despite early improvement. We report a 40-year-old male who developed sudden bilateral blurring of vision with mild ocular discomfort after binge alcohol and marijuana intake, with an additional history of prolonged exposure to vehicle-emitted fumes. There was no history of trauma, contact lens use, ocular surgery, topical medication use, fever, discharge, or previous ocular disease. Examination showed severe bilateral visual reduction, epithelial oedema, diffuse stromal corneal oedema, central haze, and prominent Descemet's membrane folds. The intraocular pressure was normal, and there was no evidence of infective keratitis, uveitis, acute glaucoma, or overt chemical injury. Pachymetry confirmed marked corneal thickening, while specular microscopy showed endothelial compromise, especially in the left eye. After excluding common causes, acute bilateral toxic endothelial dysfunction was considered. The patient was managed with a topical steroid-antibiotic combination, 5% hypertonic saline, and lubricants. Corneal oedema reduced gradually, with vision improving to 6/36 in both eyes by three days and further improvement on follow-up; however, persistent endothelial dysfunction remained in the left eye, requiring planned keratoplasty. This case emphasises that toxic endothelial dysfunction should be considered in sudden bilateral corneal oedema when typical signs of infection, inflammation, raised intraocular pressure, trauma, or chemical burn are absent.