Descemet’s membrane detachment after cataract extraction surgery

Case Report: "Spontaneous Descemet Membrane Detachment"

INTRODUCTION

We report a case and discuss the clinical characteristics and treatment of spontaneous Descemet membrane detachment (DMD).

CASE DESCRIPTION

We describe a rare case of spontaneous DMD in a patient with prior anterior uveitis and provide a review of the current literature. A 20-year-old woman with a prior history of anterior uveitis presented with vision loss in the left eye. The slit-lamp examination showed corneal edema secondary to DMD, confirmed by anterior segment optical coherence tomography (AS-OCT). The patient underwent an intracameral injection of 20% sulphur hexafluoride (SF₆) with complete resolution of the DMD. Although rare, several cases of spontaneous DMD have been reported in the literature, mostly occurring after intraocular surgery. We searched the Pubmed database (1949-2021) for peer-reviewed publications relevant to the topic of spontaneous DMD.

DISCUSSION

The pathogenesis of spontaneous DMD is complex and depends on several factors. It can occur due to anatomical anomalies, inflammatory disease, trauma, chemical injuries, and surgical or laser procedures. In most cases, early diagnosis and appropriate management led to resolution.

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.

Incidence and Risk Factors of Corneal Endothelial Failure after Phacoemulsification in Patients with Fuchs Endothelial Corneal Dystrophy: A 13-Year Retrospective Cohort

Objective

To evaluate the incidence of corneal endothelial failure (CEF) and determine the risk factors of developing CEF after phacoemulsification in patients with Fuchs endothelial corneal dystrophy (FECD).

Methods

A retrospective chart review of 2873 patients who underwent phacoemulsification with intraocular lens (IOL) implantation was conducted at Ramathibodi Hospital, Bangkok, Thailand from January 2007 to December 2019. Patient baseline characteristics, underlying diseases, levels of nuclear cataract, pre-operative specular microscopic parameters, intraoperative information (cumulative dissipated energy [CDE], mode of phacoemulsification, and complications), and occurrence of CEF were collected. Data were analyzed using Kaplan–Meier (KM) method and Cox proportional hazard model.

Results

Ninety-four patients diagnosed with FECD at follow-up time of more than 6 months were included for analysis. Mean age was 70.3 ± 7.7 years with female predominance (81.91%). Median follow-up time was 3.2 years. Nine (9.57%) patients developed CEF during follow-up period. The overall incidence rate of CEF after phacoemulsification was 26 per 1000 person years (95% confidence interval [CI]; 14 to 49 per 1000 person years). Only intraoperative complications showed significant association with CEF at hazard ratio (HR) of 6.03 (95% CI 1.50 to 26.50). No significant association was found among age, gender, underlying diseases, level of nuclear sclerosis and pre-operative specular microscopic parameters.

Conclusion

Intraoperative complications should be considered as an important risk factor for developing post-operative CEF in FECD patients. Apart from assessing pre-operative parameters, surgeons should also consider the possibility of and try to avoid any intra-operative complications, which could potentially result in CEF after phacoemulsification for each individual patient.

[Descemet's membrane detachment after phacoemulsification: Series of 9 cases]

PURPOSE

Descemet's membrane detachment (DMD) is a rare but potentially serious complication of cataract surgery. Although there are no consensual guidelines regarding the diagnosis or treatment of DMD, incorrect treatment may result in irreversible corneal changes with visual sequellae. The purpose of our study is to describe the diagnosis and treatment of DMD.

METHODS

We report a series of 9 cases of DMD, their diagnosis, treatment and outcomes. We tested the HELP protocol retrospectively against our 9 real-life cases.

RESULTS

Two cases recovered with simple medical management, 4 required air-bubble descemetopexy, and three required keratoplasty. Our study revealed that the main factor associated with poor outcomes is late diagnosis and management.

CONCLUSION

Our series illustrates the importance of proactive management and timely diagnosis by performing anterior segment OCT in the setting of persistent postoperative corneal edema.

Clinical, ultrasonographic, and histopathologic findings in seven horses with Descemet's membrane detachment: A case series

OBJECTIVE

To describe ultrasonography as a diagnostic method of in vivo Descemet's membrane detachment (DMD) in horses.

ANIMALS STUDIED

Seven horses (three Icelandic horses, two Dutch Warmblood horses, one Appaloosa, and one Welsh Pony), presenting with moderate-to-severe focal or diffuse corneal edema, in whom DMD was suspected on ultrasonographic examination and confirmed with histopathology, were studied.

PROCEDURE

A retrospective analysis of case records of horses with suspected DMD was performed.

RESULTS

Median age at presentation was 14 years (range 11-24). Clinical signs in eyes with DMD were unilateral in all horses and included blepharospasm and epiphora (6/7), buphthalmos (5/7), moderate-to-severe focal or diffuse corneal edema (7/7), corneal epithelial bullae (4/7), corneal neovascularization (4/7), Haab's striae (2/7), corneal endothelial precipitates (1/7), fibrin in the anterior chamber (1/7), focal cataract (2/7), and pigment deposits on the anterior lens capsule (1/7). During transpalpebral ultrasonography, a distinct linear echogenic structure was noted in the anterior chamber, initially diverging from, and later running parallel to, the posterior lining of the cornea in all eyes studied. In all cases, the cornea was severely thickened and echogenic, consistent with edema, and DMD was suspected. In all horses, the clinical signs progressed and the affected eye was eventually enucleated. Histopathology revealed DMD (7/7), spindle cell proliferation (4/7), Descemet's membrane reformation (3/7), and inflammation of the anterior uvea (5/7). Overall incidence was 1.04%.

CONCLUSIONS

Ultrasonography is an adequate tool in diagnosing DMD in horses. Descemet's membrane detachment should be included in the differential diagnosis in horses with dense focal or diffuse corneal edema.

Tractional Descemet's membrane detachment after ocular alkali burns: case reports and review of literature

BACKGROUND

Descemet's membrane detachment (DMD) is a rare complication after ocular chemical injury and its pathogenesis remains unclear. In this study, we reported two cases of DMD with traction demonstrated on Anterior segment optical coherence tomography (AS-OCT).

CASE PRESENTATION

Two patients sustained ocular chemical injury with 50% sodium hydroxide. In both cases, AS-OCT revealed detached Descemet's membrane that was adherent to the underlying iris tissue in the inferior quadrant at 45 days and 34 days after the injury respectively. The first case received intracameral tamponade with 12% C₃F₈ gas and the second case received corticosteroid and sodium chloride 5% eye drops. However, DMD persisted in both cases.

CONCLUSIONS

The atypical features of DMD on anterior segment optical coherence tomography in our cases suggested the presence of an inflammatory component caused adhesions and traction of iris to Descemet's membrane and prevented reattachment of DMD even with gas tamponade.

An alternative technique for Descemet's membrane detachment following phacoemulsification: case report and review of literature

Background

Descemet’s membrane detachment (DMD) is one of the most serious complications of modern cataract surgery. We present an alternative technique for management of DMD with a review of the literature on current strategies for the treatment of DMD.

Case presentation

A 74-year-old woman developed DMD after phacoemulsification and failed the first descemetopexy with air tamponade. An alternative method was used to drain the pre-descematic fluid and reposition the detached Descemet’s membrane in this rare case. This technique involved completely filling the anterior chamber with an intracameral air injection, followed by using a 23-gauge needle to puncture the peripheral cornea to drain the pre-descematic fluid. The Descemet’s membrane was completely reattached to the stroma during the follow-up.

Conclusions

Drainage of pre-descematic fluid combined with intracameral air tamponading was used as an alternative surgical option for the management of this severe case of DMD.

Descemet membrane detachment during cataract surgery: etiology and management

PURPOSE OF REVIEW

The review updates the mechanisms, clinical presentations, diagnoses, and managements of Descemet membrane detachment during cataract surgery.

RECENT FINDINGS

The advent of new imaging techniques such as anterior segment optical coherence tomography and better comprehension of the clinical and pathological aspects of detachment have improved the diagnosis and treatment of this complication to the extent that the first algorithms and protocols have been proposed.

SUMMARY

Though infrequent, Descemet membrane detachment is a complication of intraocular surgery, including cataract surgery and phacoemulsification. Since the first systematic description and classification in the literature by Samuels in 1928 and its characterization as a potential sight-threatening condition by Scheie in 1964, plenty of retrospective and anecdotal evidence contribute to uncertainty and debate. The main controversy still lies in the choice between conservative treatment in hopes of spontaneaous reattachment and surgical treatment in a timely manner to maximize visual recovery.

Unusually delayed presentation of persistent Descemet's membrane tear and detachment after cataract surgery

A 51-year-old male who had undergone phacoemulsification in his left eye 11 months prior presented with complaint of sudden onset of blurred vision in the same eye. Review of his clinical course, slit-lamp exam, pachymetry, and specular endothelial microscopy led to the diagnosis of acute hydrops caused by Descemet’s membrane dehiscence at the site of the incision. He was initially managed with medical treatment and observation. In the subsequent months of follow-up, the corneal edema and the patient’s visual acuity did not improve. Intracameral gas injection was performed 7 months after presentation, but because of persistent corneal edema and nonattached Descemet’s membrane, penetrating keratoplasty was performed. Histopathologic examination confirmed the diagnosis. The patient has had a clear corneal graft since then. Although Descemet’s membrane detachment is a rather common complication after intraocular surgery, its unusually delayed presentation can also occur, and should not be confused with pseudophakic bullous keratopathy. Many mechanisms have been studied for the development of early tears and detachments after cataract surgery, but little is known about late presentations. The authors explore possible causes, and highlight the importance of instructing patients to avoid eye rubbing and any other type of trauma to the cornea after intraocular surgery.

Management of intra-Descemet membrane air bubble in big-bubble deep anterior lamellar keratoplasty

PURPOSE

To report the recognition and management of intra-Descemet membrane air bubble (IDMA) as a complication of big-bubble deep anterior lamellar keratoplasty (DALK).

METHODS

IDMA was present intraoperatively in 8 eyes after DALK. Indications for surgery were healed keratitis (n = 4), macular dystrophy (n = 2), and keratoconus (n = 2). The IDMA was present between the anterior banded layer and posterior nonbanded layer of Descemet membrane (DM). They were slid and displaced toward the peripheral cornea using 27-gauge cannula and punctured taking care that underlying DM was not ruptured.

RESULTS

DM was bared in all eyes, and DALK was completed in 7 cases. One patient required conversion to penetrating keratoplasty because of macroperforation. No case had double anterior chamber. Mean follow-up was 13.9 ± 4.1 months. A DM fold was noted in 1 eye. Seven cases had postoperative best-corrected visual acuity of 20/60 or better.

CONCLUSIONS

Prompt recognition of the IDMA intraoperatively is required, which can be managed successfully.

Anatomic and visual outcomes of descemetopexy in post-cataract surgery descemet's membrane detachment

OBJECTIVE

To study the anatomic and visual outcomes of descemetopexy in Descemet's membrane detachment (DMD) after cataract surgery.

DESIGN

Retrospective case series.

PARTICIPANTS

Clinical notes of 60 patients who underwent DMD after cataract surgery between 2007 and 2011.

METHODS

Descemetopexy was performed with air or 14% isoexpansile perfluoropropane (C3F8).

MAIN OUTCOME MEASURES

Anatomical (reattachment rates) and functional results (best-corrected visual acuity) were studied. Secondary outcome measures were assessment of surgical complications and association of various factors with final visual outcome.

RESULTS

The mean age of the patients was 64.3 ± 8.3 years, and the male:female ratio was 21:39. At 1 month, the mean logarithm of the minimum angle of resolution (logMAR) interval visual acuity (IVA) improved from 1.27 ± 0.8 to 0.42 ± 0.49 (P < 0.001). Five patients (8.3%) obtained 20/20 vision, and 37 of 60 patients (61.6%) achieved IVA of ≥ 20/40. Ninety-five percent (57/60) of patients had successful reattachment of the Descemet's membrane (DM) after the intervention. Multiple linear regression analysis showed that patients with a cataract score of 5 (estimate = 0.38; P=0.014), with a cataract score of 4 with compromised visibility due to a corneal opacity (estimate = 0.45; P=0.039), and prolonged duration between cataract surgery and descemetopexy (estimate = 0.012; P=0.007) were associated with a significantly poorer final visual outcome. No association of final visual outcome was observed with age; sex; eye treated; cataract scores 2, 3, and 4; preoperative visual acuity; and involvement of the visual axis (P > 0.5). The eyes in which air was used for descemetopexy (estimate = -0.2; P=0.009) had statistically significantly better final visual outcomes. Three patients (5%) had treatment failures and required subsequent endothelial transplantation. Pupillary block was observed in the early postoperative period in 7 patients (11.66%) in whom C3F8 had been used and was not seen with air (P=0.02).

CONCLUSIONS

This study suggests that DMD after cataract surgery can be treated effectively and good visual outcomes can be expected if the patient is treated in time with anterior chamber injection of gas. Air has advantages of better efficacy than C3F8 without the risk of pupillary block and thus should be preferred.

Treatment of inferior Descemet membrane detachment secondary to cataract surgery with air injection and supine head position

PURPOSE

To describe a case of a patient with inferior Descemet membrane detachment that resolved after injection of small air bubble and supine positioning.

METHODS

A patient presented two weeks after cataract surgery with inferior persistent corneal edema. A Descemet membrane detachment involving the inferior cornea was revealed. Injection of small air bubble was performed and the patient was advised to stay in a supine position for the next two hours and then as much as reasonably possible to allow the air bubble to press the Descemet to the posterior corneal stroma.

RESULTS

Five days after injection, the Descemet membrane was reattached to the corneal stroma and the cornea became clear without any evidence of edema. One month post-air injection the cornea remained clear and the Descement membrane attached.

CONCLUSIONS

Air injection with supine position was efficient for the resolution of inferior partial Descemet detachment after cataract surgery. The edema resolved without any further intervention.

Anatomy and physiology of the cornea

The importance of the cornea to the ocular structure and visual system is often overlooked because of the cornea's unassuming transparent nature. The cornea lacks the neurobiological sophistication of the retina and the dynamic movement of the lens; yet, without its clarity, the eye would not be able to perform its necessary functions. The complexity of structure and function necessary to maintain such elegant simplicity is the wonder that draws us to one of the most important components of our visual system.