Repair of Descemet's membrane detachment after intraocular surgery

Sequential Descemet's Membrane Detachments and Intraocular Lens Haze Secondary to SF6 or C3F8

Purpose

To report an unusual complication of treatment in the case of a Descemet's membrane detachment.

Methods

Observational case report.

Results

A 79-year-old woman presented for elective cataract surgery. Ocular risk factors identified preoperatively included moderately shallow anterior chambers bilaterally, previously treated with bilateral YAG peripheral iridotomies. After a clear corneal section during phacoemulsification, large Descemet's tears on introducing the micro finger and phaco probe were noticed. Conversion to an extracapsular technique was necessary because of poor view. Similar peroperative Descemet's detachments were noticed in the contralateral eye during phacoemulsification by a senior surgeon a year later. Postoperatively, the Descemet's detachments were managed by intracameral SF6 and later C3F8 gas. A few weeks later, a fine haze was noticed under the anterior surface of the intraocular lens (IOL). Corneal edema persisted and corneal decompensation ensued. Both eyes needed penetrating keratoplasties. The right eye needed an IOL exchange due to IOL haze.

Conclusions

In this case the SF6 or C3F8 gas may have produced the unexpected effect of an anterior IOL haze. The mechanism of this phenomenon is unknown. To the knowledge of the authors, this effect has not been observed previously with SF6 or C3F8 gas. This haze was visually significant and required an IOL exchange. To the knowledge of the authors this is the first report of this nature. The authors advise caution when using intracameral SF6 or C3F8 gas for repair of Descemet's membrane detachment with this type of IOL.

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.

Descemet's membrane detachments post cataract surgery: a management paradigm

Descemet's membrane detachments (DMD) are relatively common after cataract surgery and most do not require any treatment. However, if large DMD are not treated appropriately, significant visual morbidity can ensue. We aim to develop a guideline for the management of DMD post cataract surgery based on a retrospective review of all cases encountered at the Royal Victorian Eye and Ear Hospital, Melbourne, Australia over a 4-year period from 2010 to 2014. We suggest conservative management if the visual axis is not involved; however, after 3mo surgical intervention may be warranted to prevent corneal sequelae. In cases where the visual axis is involved we suggest early intervention with air tamponade. The main risk factor for irreversible corneal oedema and subsequent endothelial transplant appears to be direct endothelial trauma rather than the DMD itself.

Occult Descemet's membrane detachment after phacoemulsification surgery mimicking pseudophakic bullous keratopathy

We herein report two cases of occult Descemet's membrane detachment (DMD) after phacoemulsification surgery, which initially presented as persistent corneal edema and had been considered as pseudophakic bullous keratopathy. The patients were thus scheduled to receive corneal transplantation. For Case 1, DMD was incidentally detected by slit-lamp examination 2 months postoperatively, only when part of the cornea became clearer. For Case 2, anterior segment optical coherence tomography demonstrated extensive DMD, which had lasted 5 months after the operation. DMDs in both patients had been successfully attached after descemetopexy. Occult DMD should be suspected in patients with persistent severe corneal edema after phacoemulsification surgery. Corneal transplantation may be avoided by timely diagnosis and treatment of DMD.

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 tear due to injector cartridge tip deformity

Foldable intraocular lens (IOL) implantation using an injector system through 2.8-mm clear corneal incision following phacoemulsification provides excellent speedy postoperative recovery. In our reported case, a Sensar AR40e IOL (Abbott Medical Optics, USA) was loaded into Emerald C cartridge, outside the view of the operating microscope, by the first assistant. The surgeon proceeded with the IOL injection through a 2.8-mm clear corneal incision after uneventful phacoemulsification, immediately following which he noted a Descemet's tear with a rolled out flap of about 2 mm near the incision site. Gross downward beaking of the bevelled anterior end of the cartridge was subsequently noticed upon examination under the microscope. We suggest careful preoperative microscopic inspection of all instruments and devices entering the patient's eyes to ensure maximum safety to the patient.

Intracameral Perfluoropropane (C(3)F(8)) Gas in the Repair of Extensive Descemet's Membrane Detachment During Phacoemulsification Surgery

Descemet's membrane detachment (DMD) is one of the rare complications seen during or after cataract surgery. It can cause permanent corneal decompensation if untreated or not reattached spontaneously. A patient with an extensive DMD (involving approximately upper two-thirds of the cornea) during uncomplicated phacoemulsification surgery is reported. After the aspiration of cortical remnants, Descemet's membrane was detached progressively from the clear corneal incision. Descemet's membrane was reattached at the end of the procedure using an air bubble injection. However, DMD was observed again the day after surgery. It was successfully treated with intracameral injection of 0.2 mL volume of 14% perfluoropropane (C(3)F(8)) gas with resultant immediate resolution of his corneal edema. It is believed that early surgical intervention (if possible intraoperatively) with intracameral injection of 14% isoexpansile mixture of C(3)F(8) is a safe and efficient treatment modality for DMD. Appropriate and prompt management may prevent the complications and visual loss.

Spontaneous resolution of descemet membrane detachment after deep anterior lamellar keratoplasty

PURPOSE

To describe a patient whose Descemet membrane detachment following deep lamellar keratoplasty failed to respond to 2 attempts at gas tamponade but later resolved spontaneously.

METHODS

A 77-year-old woman with bilateral anterior corneal stromal scarring underwent a right deep lamellar keratoplasty with the Melles technique. Postoperatively, she developed an inferior Descemet membrane detachment, presumably due to a peripheral inferior microperforation. Two attempts at gas tamponade with sulfur hexafluoride (SF6) and 12% perfluropropane (C3F8) were made.

RESULTS

Gas tamponade was unsuccessful. Five months after deep lamellar keratoplasty, the detachment resolved spontaneously. One year after deep lamellar keratoplasty, the donor cornea was clear, and best corrected visual acuity in the right eye was 20/40 with -2.75/+2.50 x 55.

CONCLUSIONS

Descemet membrane detachment after deep anterior lamellar keratoplasty can resolve spontaneously, even after failed attempts at gas tamponade. Those due to peripheral inferior perforations may be less likely to respond to tamponade than central or superior perforations.

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 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.

Descemet membrane tear after cataract surgery

Descemet membrane detachment is a potentially devastating complication of cataract surgery. Small localized detachments are rarely problematic, however persistent extensive detachments can affect visual acuity. In severe cases penetrating keratoplasty may be required for restoration of vision. One case of a persistent descemets membrane tear is presented and the progress after surgical repair via suture and injection of air is described. The patient was followed for 5 months after repair with persistent haze and mild corneal edema, though vision improved to 20/25+.

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.

Transplantation of Descemet's membrane carrying viable endothelium through a small scleral incision

PURPOSE

To design a technique for transplantation of the Descemet's membrane (DM) as a carrier for its endothelium, while maintaining the low-astigmatic recipient anterior corneal curvature.

METHODS

In a human eye bank eye model, recipient eyes (n = 15) had a 5.0-mm scleral tunnel incision made, extending 1.0 mm into the peripheral cornea. A 9.0-mm-diameter Descemeto rhexis was created, i.e., a circular portion of DM was stripped from the posterior stroma. With use of a custom-made inserter, a 9.0-mm-diameter donor DM carrying autologous donor endothelium was brought into the anterior chamber and positioned against the recipient posterior stroma. The procedure was evaluated by keratometry, endothelial vital and supravital staining, and light microscopy.

RESULTS

Mean postoperative astigmatism was 1.0 D (+/-0.6 D). Implanted donor DM showed an intact endothelial cell layer, with 3.4% (+/-1.1%) dispersed focal cell death. Microscopy showed normal endothelial cell morphology and complete apposition of the donor DM against the recipient posterior stroma.

CONCLUSIONS

DM can be transplanted in vitro with acceptable damage to the donor endothelium and with little induced astigmatism.

Fixed dilated pupil (Urrets-Zavalia syndrome) after air/gas injection after deep lamellar keratoplasty for keratoconus

PURPOSE

To describe three cases of fixed dilated pupil and presumed iris ischemia (Urrets-Zavalia syndrome) after anterior chamber air/gas injection after deep lamellar keratoplasty for keratoconus.

METHODS

Interventional case series. Three eyes of three patients with keratoconus underwent deep lamellar keratoplasty and intraoperative or postoperative injection of air/gas in the anterior chamber to appose the host-donor lamellar graft interface.

RESULTS

Urrets-Zavalia syndrome was diagnosed on clinical grounds in three cases and was associated with the Descemet membrane microperforation intraoperatively and introduction of air/gas into the anterior chamber intraoperatively or postoperatively.

CONCLUSION

A fixed dilated pupil is an uncommon complication of penetrating keratoplasty for keratoconus that can also develop after deep lamellar keratoplasty. Leaving an air or gas bubble in the anterior chamber of a phakic eye after deep lamellar keratoplasty is a risk factor and should therefore be avoided.

Phacoemulsification and modern cataract surgery

The techniques and results of cataract surgery have changed dramatically during the past three decades. In the USA, we have moved from intracapsular cataract extraction as the preferred technique to almost exclusively extracapsular techniques. Smaller incisions have become the standard, with phacoemulsification now being the method of choice for most surgeons. Along with these advances have come improved intraocular lens materials and designs, especially well suited for use with smaller incisions. Phacoemulsification as a method to remove the cataractous lens was first proposed more than 20 years ago. Advances in techniques and equipment have led to a dramatic increase in the popularity of phacoemulsification with increased safety and efficiency. Viscoelastic agents have been developed synchronously with modern phacoemulsification techniques, playing an integral role in the success of this new technology. Improved surgical techniques for removing the anterior lens capsule have decreased the incidence of both intraoperative and postoperative capsular complications. Nucleus removal, formerly performed primarily in the anterior chamber, is now performed in the posterior chamber, decreasing damage to the corneal endothelium. Improved wound construction allows many wounds to be left unsutured, and smaller wounds allow shorter recovery time and greater intraoperative control and safety. Intraocular lenses can have smaller optic sizes and still maintain accurate centration. Foldable intraocular lenses can take advantage of the smaller incision, even further shortening the time to visual recovery. Continual evolution of this technology promises to further improve patient outcomes after cataract surgery.

Management of coincident corneal disease and cataract

The status of the cornea is crucial to a good outcome with cataract extraction. Preexisting corneal disease must be managed appropriately to get the high-quality results that we have come to expect with cataract surgery. It is now more common to perform cataract surgery on patients with previous corneal refractive surgery, and in these patients intraocular-lens power calculation is more challenging. Complications following cataract surgery and intraocular-lens implantation that involve the cornea are uncommon because of advances in surgical techniques. Corneal complications can include mechanical or toxic injury of the endothelium, stripped Descemet's membrane, epithelial toxicity and disruption, infectious keratitis, and epithelial ingrowth. Endothelial-cell survival after cataract extraction and lens implantation is still the major concern. Healing of the cornea following clear corneal incisions has become more important, as this technique is more frequently used. Patients with ocular surface disease still require extra lubrication and management of blepharitis to prevent epithelial toxicity at the time of surgery as well as postoperatively. Clear corneal cataract extraction and lens implantation causes minimal disruption of the conjunctiva, allowing cataract surgery to be performed in patients with severe ocular surface disease such as ocular cicatricial pemphigoid. Overall, modern-day cataract extraction is very safe for the cornea.

Technique for repair of Descemet membrane detachment

PURPOSE

To demonstrate a successful repair of an intractable Descemet membrane detachment.

METHODS

Case report. We used transcorneal mattress sutures to fixate Descemet membrane to the cornea in combination with intracameral air injection.

RESULT

This technique resulted in reattachment of Descemet membrane and a substantial visual acuity improvement after complete resolution of corneal edema.

CONCLUSIONS

Surgical repair may be needed in cases of large Descemet membrane detachment. This technique provides an additional surgical alternative to repair intractable Descemet membrane detachment without causing excessive anterior chamber disruption; it may also prevent the need for a penetrating keratoplasty.

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.

Sulfur hexafluoride injection for Descemet's membrane detachment in cataract surgery

Extensive Descemet's membrane detachment persisted after small incision cataract surgery in three patients. Unfolding and repositioning of Descemet's membrane by sodium hyaluronate (Healon) were followed by injection of sulfur hexafluoride 20% gas mixed with air to fill the anterior chamber. Initially, the gas bubble filled most of the anterior chamber; it disappeared over 7 to 9 days. Descemet's membrane remained attached, and the corneal edema cleared.