Descemet's membrane detachment by sodium hyaluronate

Spontaneous resolution of recurrent Descemet's membrane detachment after trabeculectomy: A case report

Purpose

We report a rare case of recurrent Descemet's membrane detachment (DMD) post-trabeculectomy which was resolved spontaneously without surgical intervention.

Observations

A 66-year-old patient with a history of acute angle closure glaucoma in his right eye presented to our hospital. The intraocular pressure (IOP) of his right was 40 mm Hg, and the visual acuity was10/20. After trabeculectomy of the affected eye, a severe Descemet's membrane detachment was found by AS-OCT. Part of Descemet's membrane was lying in front of the iris and lens. Surgical repair was performed, and viscoelastics and sterile air were injected into the anterior chamber to return the detached Descemet's membrane. AS-OCT showed that the DMD was successfully resolved. However, on the 7th day of follow-up, the DMD was detached again as seen on AS-OCT images. The patient refused reoperation to repair the DMD. Six months later, the patient visited our hospital again, and, interestingly, the DMD was completely resolved spontaneously without reoperation.

Conclusions and importance

Descemet's membrane is the basement membrane that lies between the stroma and the endothelial layer of the cornea. Minor DMD may be resolved spontaneously within a period of time without surgery, but large DMD is difficult to recover spontaneously. We believe that this is a rare case with spontaneous recovery of extensive DMD after trabeculectomy. But, despite all this, we still remain of the view that DMD should be treated immediately once it occurs.

Corneal Opacification and Spontaneous Recovery following Injection of Healon5 into the Corneal Stroma during Intervention for Postoperative Hypotony

We report the self-limited nature of corneal opacification after accidental injection of Healon5 into the corneal stroma. A 52-year-old male with a new diagnosis of severe stage, primary open-angle glaucoma underwent successful trabeculectomy OS, which was complicated by ocular hypotony and shallow anterior chamber (AC) on postoperative day 1. Healon5, a hyaluronic acid-containing viscoelastic device, was accidentally introduced into the corneal stroma during attempted injection into the AC. The cornea hydrodissected and opacified, leading to precipitous loss of best-corrected visual acuity (BCVA). The corneal opacification spontaneously resolved over a 7-month period without specific intervention. During this period, the patient also underwent cataract extraction with posterior chamber intraocular lens placement and YAG capsulotomy, after which his BCVA returned to approximately baseline. Though intrastromal injection of sodium hyaluronate-containing material has been reported elsewhere, this complication with Healon5 use specifically has yet to be described in the literature and may occur in any procedure involving Healon5 in the AC. This case report is important, since the precipitous loss of BCVA can be alarming to the ophthalmologist and the patient. The affected patient may be counseled that the opacification should improve with time.

Descemet's membrane detachments, ruptures, and separations in ten adult horses: Clinical signs, diagnostics, treatment options, and preliminary results

OBJECTIVE

To describe the clinical presentation, diagnostic imaging results, and treatment outcomes of a series of presumed spontaneous Descemet's membrane detachments (DMD), ruptures, or separations (DMRS) in the adult horse.

ANIMALS STUDIED

Ten adult horses of various breeds with DMD or DMRS.

PROCEDURES

Descemet's membrane detachments/DMRS were diagnosed via slit lamp biomicroscopy, ultrasound biomicroscopy (UBM), and/or optical coherence tomography (OCT). Penetrating keratoplasty (PK) with heterologous corneal donor tissue (n = 1), superficial lamellar keratectomy, and Gundersen inlay flaps alone (GF, n = 1) or with subsequent intracamerally assisted corneal tissue welding (CTW, n = 2), or CTW alone (n = 5) were performed in 9/10 horses. One horse underwent spontaneous resolution (n = 1).

RESULTS

Ten horses were diagnosed with either unilateral DMD (n = 4) or DMRS (n = 6). Seven of ten eyes remained visual during the follow-up period (8.16 ± 6.57 months). Graft transparency was good for the eye treated with PK. The horse that underwent GF alone was functionally blind due to persistent corneal edema. The clinical signs resolved in 3/5 horses that underwent CTW alone, but 2/5 eyes were enucleated due to corneal perforation. Both eyes treated with combined GF/CTW had significant corneal clearing with one having evidence of reattachment on UBM and OCT.

CONCLUSIONS

Descemet's membrane detachments separations presents differently than typical DMD and advanced corneal imaging modalities may aid in their diagnosis. Corneal tissue welding using infraCG as the photosensitive agent, or in combination with Gundersen inlay flaps, represents a feasible treatment option for management of equine DMD/DMRS as described in the present case series.

Recognizing and Managing Bullous Descemet Detachment Secondary to Accidental Hydroseparation During Phacoemulsification/Cataract Surgery by Relaxing Descemetotomy

PURPOSE

To report a new technique called relaxing Descemetotomy for treatment of bullous Descemet detachment (BDD) secondary to accidental hydroseparation of Descemet membrane (DM) during stromal hydration in cataract surgery.

METHODS

A clear corneal keratome entry was created close to the limbus extending inward to create a relaxing cut (ab externo relaxing Descemetotomy) on taut DM, thus creating an egress route for supra-Descemetic fluid (SDF). This was followed by pneumodescemetopexy to drain SDF internally.

RESULTS

Three patients with a history of unsuccessful pneumodescemetopexy and with planar or mildly convex separation of DM without break on anterior segment optical coherence tomography (ASOCT) underwent this procedure. All had successful reapposition of DM clinically and on ASOCT. All showed resolution of stromal edema and improved uncorrected and best-corrected visual acuity postoperatively.

CONCLUSIONS

Rarely stromal hydration performed with an irrigating cannula positioned too close to the posterior stroma can result in hydroseparation of DM creating BDD, seen intraoperatively as a fluid wave propagating across the posterior aspect of the cornea. Large folds, free mobility, and DM tear classically seen with rhegmatogenous Descemet detachment are not seen clinically or on ASOCT in BDD. Pneumodescemetopexy alone cannot resolve BDD because without a DM tear, SDF cannot evacuate. Combining relaxing Descemetotomy with pneumodescemetopexy allows SDF to drain internally and Descemet detachment to resolve. This technique has numerous advantages over classical venting incisions in terms of ease, preferable limbal location, larger incision size, absence of complications such as visual axis scars, irregular astigmatism, epithelial ingrowth, infectious keratitis, etc.

Corneal edema after phacoemulsification

Phacoemulsification is the most commonly performed cataract surgery in this era. With all the recent advances in investigations and management of cataract through phacoemulsification, most of the patients are able to achieve excellent visual outcome. Corneal edema after phacoemulsification in the immediate postoperative period often leads to patient dissatisfaction and worsening of outcome. Delayed onset corneal edema often warrants endothelial keratoplasty. This review highlights the etiopathogenesis, risk factors, and management of corneal edema in the acute phase including descemet's membrane detachment (DMD) and toxic anterior segment syndrome. Various investigative modalities such as pachymetry, specular microscopy, anterior segment optical coherence tomography, and confocal microscopy have been discussed briefly.

Descemet's Membrane Dehiscence Resulting From Misdirected Viscoelastic During Anterior Chamber Reformation

We report a case of Descemet's membrane detachment after inadvertent intrastromal injection of hyaluronic acid. Surgical removal was attempted with minimal but slow improvement. Near-complete resolution occurred with subsequent conservative management within 6 weeks.

Height-, extent-, length-, and pupil-based (HELP) algorithm to manage post-phacoemulsification Descemet membrane detachment

PURPOSE

To analyze the functional and anatomic outcomes of management of Descemet membrane detachment after phacoemulsification using a protocol based on the detachment's height, extent, and chord length and its relation to the pupil.

SETTING

Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India.

DESIGN

Prospective comparative case series.

METHODS

Eyes with post-phacoemulsification Descemet membrane detachment were managed surgically or medically based on the detachment's height, extent, length (chord), and relation to the pupil (HELP protocol). Central corneal thickness (CCT), chord length, and detachment height were determined by anterior segment optical coherence tomography (AS-OCT) (Visante).

RESULTS

Of 161 eyes, 96 were treated surgically (Group 1) and 65 medically (Group 2). The mean length and mean height of Descemet membrane detachment were 2.4 mm ± 1.4 (SD) and 266 ± 189.8 μm, respectively, in Group 1 and 1.03 ± 0.4 mm and 153.3 ± 60.8 μm, respectively, in Group 2. The complete reattachment rate was 95.8% in Group 1 and 96.9% in Group 2. The corrected distance visual acuity (CDVA) was 20/40 or better in 83.3% of eyes in Group 1 and 92.3% of eyes in Group 2. No eye lost CDVA as a result of a Descemet membrane scar in the central 5.0 mm of the cornea. The AS-OCT allowed visualization of the detachment in all eyes with a CCT of more than 800 μm. There was no difference in the final CDVA between Group 1 and Group 2.

CONCLUSIONS

The AS-OCT-based algorithm was effective for managing post-surgical Descemet membrane detachment in eyes with dense corneal edema. Early surgical intervention for detachments in the central cornea can reduce scarring-induced visual loss.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Descemet membrane detachment after phacoemulsification surgery: risk factors and success of air bubble tamponade

PURPOSE

To evaluate the efficacy of air bubble (AB) tamponade for Descemet membrane detachment (DMD) after clear corneal incision phacoemulsification surgery and to evaluate the risk factors for DMD.

METHODS

This is a retrospective analysis of patients with DMD managed with AB tamponade, within 42 postoperative days (PODs), over a 4-year period. Data collected were as follows: demographics, cataract density (Lens Opacities Classification System III), visual acuity, AB technique, clinical outcome, and total surgeries over the time period. Successful end points were DM reattachment and corneal clarity. Risk factors were assessed using a case-control study, with univariate and multivariate logistic regression analyses (significance at P < 0.05).

RESULTS

Incidence rate of DMD was 0.044% per year. Sixteen patients (mean age of 76 years) had AB tamponade for DMD, with corneal clarity restored in 14 cases (87.5%; n = 11 with 1 AB procedure, n = 3 with 2 AB procedures). The main clear corneal incision was the major site of DMD (n = 14, 87.5%). Pre-AB visual acuity was 20/100 and at 1 month, 20/40. Corneal clarity occurred by 30 days (range: 4-82 days) and remained clear throughout the median follow-up of 12.9 months. Significant univariate factors were as follows: age >65 years, nuclear sclerosis grade ≥4 (Lens Opacities Classification System III), preexisting endothelial disease, and first POD corneal edema. Multivariate logistic regression analyses revealed endothelial disease (odds ratio = 18.66) and first POD edema (odds ratio = 7.88) as significant independent risk factors for DMD occurrence (P < 0.05).

CONCLUSIONS

AB tamponade for DMD effectively restored corneal clarity in 87.5% of cases (14 of 16 eyes). Significant risk factors included endothelial disease and first POD corneal edema.

Descemet's Membrane Detachment Caused by the Improper Injection of Sodium Hyaluronate

A case of a Descemet's membrane detachment (DMD) caused by the inadvertent intracorneal injection of sodium hyaluronate was presented. This was concluded after chemical analysis of a viscous substance found in a patient's cornea showed to be a breakdown product of sodium hyaluronate. Surgical correction of the detachment included removing the viscous substance and tamponading the detachment with an air bubble. Although other gases such as sulfur hexafluoride (SF6) provide longer means of tamponade, they have increased postoperative risks like glaucoma associated with their use. Air can provide an effective means of tamponade with minimal postoperative risks.

Descemet's membrane detachment caused by inadvertent vancomycin injection

Descemet′s membrane detachment is a condition with a wide range of etiologies. The most common cause is a localized detachment occurring after cataract surgery. We report a case of vancomycin injection-induced Descemet′s membrane detachment as a complication following a routine cataract surgery and its management.

A Combined Technique for Surgical Repair of Descemet’s Membrane Detachments

BACKGROUND AND OBJECTIVE

Descemet's membrane detachments are an uncommon complication after cataract surgery that can result in severe visual loss. A combined technique of intracameral gas injection and transcorneal suturing for the repair of Descemet's membrane detachments is described.

PATIENTS AND METHODS

In this interventional case series, four cases of Descemet's membrane detachments with associated corneal edema observed following cataract surgery were successfully repaired using a combined technique of intracameral gas injection and transcorneal suturing.

RESULTS

In all cases, Descemet's membranes were successfully reattached using the aforementioned technique. In three cases, the associated corneal edema resolved postoperatively. In the fourth case, the patient required a penetrating keratoplasty for persistent corneal edema despite immediate anatomical success following reattachment.

CONCLUSIONS

Combined intracameral gas and transcorneal suturing appears to be an effective technique in the repair of Descemet's membrane detachments. Early intervention may prevent persistent or recurrent corneal edema.

Descemet’s membrane detachment after cataract extraction

BACKGROUND

Descemet's membrane detachment is a rare but potentially serious complication of intraocular surgery, most commonly cataract extraction. Small Descemet's membrane detachments typically resolve with topical medical therapy; however, larger detachments require surgical intervention. The most common surgical procedure is a gas-fluid exchange with 20% sulfur hexafluoride (SF6) or 14% perfluropropane (C3F8), which is typically performed at the biomicroscope and is nontoxic to the endothelium.

CASE

A 77-year-old man underwent phacoemulsification with a posterior chamber lens implantation by clear corneal incision in the left eye. Visual acuity was 20/40 in the left eye 1 month postoperatively with persistent corneal edema. Visual acuity continued to deteriorate to counting fingers (CF), despite the use of topical hyperosmotics and steroids. At 2 months, a scrolled Descemet's membrane detachment was present from the incision site to the central cornea causing extensive edema. Anterior chamber injection of 14% C3F8 successfully reattached Descemet's membrane. Six weeks after surgery, the gas bubble had resolved, the central cornea was clear, and a curvilinear scar was present from 5:00 to 11:00. Visual acuity remained at CF owing to anterior capsular fibrosis. Anterior YAG capsulotomy improved the vision to 20/40.

CONCLUSION

Descemet's membrane detachment can have a devastating effect on vision. Timely management is imperative to preserve vision. This case shows the successful repair of Descemet's membrane detachment with 14% C3F8 after unsuccessful topical treatment.

Corneal edema resolution after "descemetorhexis"

A 79-year-old woman had left eye phacoemulsification complicated by inadvertent excision of Descemet's membrane (DM). One day postoperatively, the visual acuity was counting fingers with diffuse corneal edema. The patient was treated medically, with gradual resolution of the corneal edema over a 6-month period. The torn edge of DM could be visualized as the edema cleared, and no endothelial cell count could be obtained centrally. Approximately 1 year postoperatively, the central endothelial cell count was 2114 cells/mm(2) in the right eye and 827 cells/mm(2) in the left eye. The decreased cell count, increased polymegethism, and pleomorphism suggested that endothelial cells migrated to cover the stromal surface area in the absence of DM.

Repair of late Descemet's membrane detachment with perfluoropropane gas

We report 3 cases of Descemet's membrane detachment detected 2 to 3 weeks after surgery that was treated by intracameral injection of perfluoropropane 14% (C(3)F(8)) isoexpansile mixture. We looked at the predisposing factors, the best method of treatment, and the final outcome in cases of Descemet's membrane detachment following phacoemulsification.

Descemet's membrane detachment after cataract surgery: management and outcome

OBJECTIVE

To analyze the possible causes of Descemet's membrane detachment (DMD) and the treatment and outcome of patients after cataract surgery.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Fifteen eyes of 12 patients.

METHODS

We reviewed clinical data on 15 eyes of 12 patients with nonscrolled DMD after cataract surgery who presented to the Cornea Service at Wills Eye Hospital from 1986 to 2001. Institutional review board/ethics committee approval was obtained.

MAIN OUTCOME MEASURES

Visual acuity and reattachment of Descemet's membrane.

RESULTS

Cataract procedures involved nine clear-corneal eyes, four limbal incisions, one trabeculectomy/combined phacoemulsification, and one extracapsular cataract extraction. From 1986 to 1990, we had 1 patient; from 1991 to 1995, no patients; and from 1996 to 2001, 11 patients (including all clear-corneal eyes). Of the 15 eyes, 8 resolved with medical treatment alone, with a mean time to resolution of 9.8 weeks. One patient was lost to follow-up while improving on medical treatment, and another required a penetrating keratoplasty (PK) after medical treatment failed. Five eyes received anterior-chamber SF(6) gas injection. Of these eyes, three DMDs resolved, one underwent repeated injection (not improving after 10 weeks), and another required a PK.

CONCLUSIONS

Referrals for DMD seem to be increasing. This may be explained by the increase in clear-corneal cataract procedures. Medical treatment seems to be adequate in many cases and may be appropriate initial therapy. When needed, SF(6) gas injection may also be successful, but not in all cases.

Repair of Descemet's membrane detachment after viscocanalostomy

We report an alternative descemetopexy technique in a case of Descemet's membrane detachment after viscocanalostomy, possibly caused by high-molecular-weight viscoelastic material.

Descemet membrane detachment after nonpenetrating filtering surgery

PURPOSE

To make surgeons performing nonpenetrating filtering surgery aware of an unusual complication namely Descemet membrane detachment.

METHODS

We retrospectively reviewed nine eyes of nine patients seen in our hospital with Descemet membrane detachment occurring after nonpenetrating filtering surgery from January 1994 to December 2000.

RESULTS

Both planar and nonplanar detachments were reported. Neither scrolls nor tears in the Descemet membrane were observed in any patient. After viscocanalostomy (four patients), the detachment was generally noticed shortly after the procedure and the cornea maintained its clarity. After deep sclerectomy with a collagen implant (five patients), it developed weeks to months postoperatively with adjacent corneal edema. Four patients had descemetopexy. None required more than one procedure. However, at the last visit, two detachments persisted although they had diminished in size: one after viscocanalostomy and conservative treatment and one after descemetopexy after deep sclerectomy with a collagen implant. To date otherwise, no signs of significant corneal damage could be observed clinically nor by specular microscopy and pachymetry.

CONCLUSIONS

The diagnosis of Descemet membrane detachment can be easily overlooked or misdiagnosed. The clinical presentation, clinical course, and pathogenesis depend on the type of nonpenetrating filtering surgery performed. Ophthalmologists should be aware of this unusual complication, which is likely to be more common after nonpenetrating filtering surgery than after trabeculectomy. A period of observation before attempting descemetopexy is recommended.

Separation of corneal stroma and Descemet's membrane during deep lamellar keratoplasty

PURPOSE

To study the interface of the corneal stroma and Descemet's membrane and to report the histologic findings of the deep corneal stromal tissue removed during deep lamellar keratoplasty (DLKP).

METHODS

The deep stromal tissues of four corneas were removed during DLKP and were examined histologically by light microscopy (LM) and transmission electron microscopy (TEM).

RESULTS

Descemet's membrane appeared as a smooth surface under the surgical microscope during the removal of deep corneal stroma. Two of the four excised tissues showed a thin layer attachment to the deep stromal tissue by LM and TEM. The layer measured approximately 3.0 to 4.0 microm and was observed as a striated structure attached to the stromal tissue of both specimens. The other two specimens contained only stromal tissue.

CONCLUSIONS

Separation of the deep stromal tissue from Descemet's membrane may occur within the Descemet's membrane, and the separation is probably between the anterior banded and the posterior nonbanded layer of Descemet's membrane in some cases during DLKP. The lamellar structure of the delaminated region suggests a mechanically weak segment of Descemet's membrane. The smooth surface of Descemet's membrane observed under a surgical microscope is not the actual interface of corneal stroma and Descemet's membrane.

Detachment of Descemet's membrane

PURPOSE

To determine predisposing factors, best method of treatment, and the final outcome in cases of Descemet's membrane detachment.

SETTING

A tertiary care teaching eye hospital.

METHODS

All cases of Descemet's detachment from January 1986 to May 1994 were retrospectively reviewed. Twelve eyes of 11 patients with partial or total detachment of Descemet's membrane were identified. Patients with small localized detachments at the incision area were excluded.

RESULTS

All but one patient had surgical repair. Ten eyes had successful reattachment after up to four attempts at repair. Methods of repair included intracameral air or sulfur hexafluoride (SF6) 20% gas, with or without corneal sutures. After a followup of 3 to 79 months, eight eyes retained clear corneas, four eyes developed corneal edema and scarring, and two required penetrating keratoplasty. No definite predisposing factor could be identified, although four eyes had preoperative diagnoses of glaucoma and recent corneal edema.

CONCLUSION

Surgical repair with injection of intracameral air or SF6 20% was successful in most cases of Descemet's membrane detachment. A preoperative diagnosis of glaucoma and a recent episode of corneal edema may increase the risk of detachment.

Extensive detachment of Descemet membrane after holmium laser sclerostomy

PURPOSE

To describe a corneal complication and its surgical repair after holmium laser sclerostomy.

METHOD

A 63-year-old woman had extensive detachment of Descemet membrane 3 months after holmium laser sclerostomy. The authors describe the case history of a detached Descemet membrane secondary to holmium laser sclerostomy and its subsequent repair.

RESULTS

The patient achieved a visual acuity of 20/20 in the involved eye after descemetopexy with sodium hyaluronate and air combined with suturing.

CONCLUSIONS

Detachment of the Descemet membrane should be recognized as a potential complication of holmium laser sclerostomy. Suturing should be considered as a method of repair if there is not spontaneous reattachment of the Descemet membrane.

Neodymium:YAG laser optical opening for retained Descemet's membrane after penetrating keratoplasty

A 78-year-old woman who had intracapsular cataract extraction and anterior chamber intraocular lens implantation 8 years earlier presented with decreased visual acuity (20/400) and discomfort of 2 years duration in the operated eye. Penetrating keratoplasty was done to improve visual function and reduce discomfort; however, at 6 months postoperative, visual acuity was 20/800, due in part to retained opacified host corneal tissue. A retrograft (duplicate) membrane was identified at the posterior aspect of the graft/host junction. The neodymium:YAG laser was used to create a central 3.5 mm circular opening in the duplicate membrane. There were no complications from the laser treatment. The donor cornea remained thin and clear, and visual acuity improved to 20/40 with spectacle correction. It is imperative to confirm complete removal of host corneal tissue before implanting donor tissue; however, vision can be restored, and a corneal graft can remain clear following laser membranotomy.

Management of Descemet's membrane detachment

Detachment of Descemet's membrane is a rare but serious complication of cataract surgery. Most surgeons attempt to reposition the membrane by injecting air, slow-reabsorbing gases, or viscoelastic substances into the anterior chamber. We describe five cases of subtotal detachment without rolled scroll. These cases recovered spontaneously after two to three months. We believe that conservative treatment in such cases is indicated and has a good chance of favorable outcome.

Repair of Descemet's membrane detachment after intraocular surgery

We repaired three unselected cases of Descemet's membrane detachment. A visually successful outcome was achieved in one case, an anatomically successful outcome in another, and no improvement in the last. We believe that large detachments should be repaired early rather than waiting for possible spontaneous reattachment, and we advocate sulfur hexafluoride fluid-gas exchange as the procedure of choice.

Hyaluronic acid. A review of its pharmacology and use as a surgical aid in ophthalmology, and its therapeutic potential in joint disease and wound healing

Hyaluronic acid is a naturally occurring polysaccharide with distinct physicochemical properties which underlie its application as a viscoelastic tool in ophthalmological surgery. In cataract surgery the role of hyaluronic acid in facilitating procedures and protecting the corneal endothelium is well established. Some benefit has also been gained with the use of hyaluronic acid in penetrating keratoplasty, trabeculectomy, retinal reattachment and trauma surgery, although its efficacy in these indications is less well-defined in the published literature. In addition to its lubricating and cushioning properties, demonstration of some in vitro anti-inflammatory activity and a possible disease-modifying effect for hyaluronic acid in animals has prompted its investigation as a treatment in osteoarthritis and, to a much lesser extent, in rheumatoid arthritis. Hyaluronic acid 20 mg, as weekly intra-articular injections for 3 to 7 weeks, improved knee pain and joint motion in patients with osteoarthritis. Although this occurred to a greater degree than with placebo in most comparisons, the effects of hyaluronic acid was similar to those of placebo in the largest trial. In the few available comparisons with other agents, hyaluronic acid appeared equivalent to methylprednisolone 40 mg (for 3 weeks) and to a single injection of triamcinolone 40 mg. Hyaluronic acid was distinguished from other therapies by providing a sustained effect after treatment discontinuation. Together with its very good tolerability profile, these properties justify further study of hyaluronic acid in patients with osteoarthritis. Some limited evidence of improvement in patients with rheumatoid arthritis, and a possible healing effect of hyaluronic acid on tympanic membrane perforations, represent additional areas of interest for future investigation. In summary, hyaluronic acid is a well-established adjunct to cataract surgery and may prove to be a promising option in the treatment of patients with osteoarthritis. Its very good tolerability provides further impetus for examination of its potential role in an extended scope of arthritic and ophthalmological indications, and in wound healing.

Gonioscopy in no-stitch cataract incisions

To evaluate the internal appearance of the no-stitch cataract incision, gonioscopy was performed in 68 of 78 consecutive eyes of cataract surgical patients with no-stitch incisions. All incisions were located anterior to Schwalbe's line, and 32 (42%) had smooth linear internal incisions. In another 32 (42%), small tags or curls were located along the internal incision. Four eyes (5%) had discernible Descemet's membrane detachments visible by gonioscopy but not slitlamp biomicroscopy. The Descemet's detachments were less than 2mm long in three patients and more than 2 mm in one patient. The width of the detachments were 1 mm or less. The detachments did not lead to clinically significant sequela such as filtration blebs or persistent corneal edema.