Descemet membrane detachment during cataract surgery: etiology and management

The role of anterior segment optical coherence tomography in post-cataract surgery Descemet membrane detachment

This review seeks to evaluate anterior segment optical coherence tomography (AS-OCT) in the diagnostic procedure and management of Descemet's membrane detachment (DMD) in cataract surgery. DMD may present diagnostic challenges, particularly in pronounced corneal edema where traditional methods such as slit lamp biomicroscopy may be inadequate in evaluating the corneal layers. The role of AS-OCT in providing high-resolution images in the preoperative, intraoperative, and postoperative phases of cataract surgery is analyzed with a focus on its role in the early diagnosis of DMD and in evaluating the extent, morphology, and topographic localization of DMD allowing for immediate intervention during surgery and precise pneumodescemetopexy procedures where conservative treatment has failed. This review explores the integration of AS-OCT into the standard perioperative diagnostic workflow, highlighting its potential role in the prevention, accurate diagnosis, and prompt management of DMD, a complication of cataract surgery that, while low in incidence, can be highly disruptive when it occurs. The emerging role of artificial intelligence (AI) in AS-OCT analysis of anterior segment conditions and surgical procedures is discussed, though refinement of AI algorithms is warranted.

Descemet's membrane detachment: An updated comprehensive review of etiopathogenesis, diagnosis, and management

The Descemet membrane (DM) is the basement membrane of corneal endothelial cells, which are responsible for maintaining corneal transparency. DM detachment (DMD) can occur due to various reasons, with the most common etiology being post-surgical. Older age, blunt instruments, and faulty surgical technique predispose to the intraoperative or postoperative occurrence of DMD, and one should have a high index of suspicion for DMD in cases with unexplained or an atypical pattern of corneal edema after surgery. Prompt intervention for DMD management is imperative to effect early visual rehabilitation, decrease corneal morbidity, and avoid permanent damage leading to scarring of the cornea. Various classifications of DMD and management protocols have been described. Anterior-segment optical coherence tomography (AS-OCT) imaging is the most effective imaging to detect DMD and quantify its extent. Desmetopexy with air/gas is the initial treatment of choice and could be aided by suture fixation. Non-responsive cases might need endothelial keratoplasty.

Surgical management of complicated Descemet's membrane detachment in corneas without prior endothelial keratoplasty

PURPOSE

To provide insights into morphologic and functional features of eyes with complicated Descemet's membrane detachment (DMD) and report clinical outcomes after surgical intervention.

METHODS

Retrospective study of 18 eyes with complicated DMD between 2010 and 2022. Complicated DMD was defined if any of the following criteria applied: prior penetrating keratoplasty (PKP), corneal thinning, total DMD or persistent DMD after Air/Gas-Descemetopexy. Causes, surgical management, and clinical outcomes were analyzed. Scheimpflug tomography, anterior segment optical coherence tomography (AS-OCT) and histologic examination were performed to characterize corneas with DMD.

RESULTS

Fourteen eyes with prior PKP developed spontaneous DMD after 24.2 ± 12.9 years (range = 18 months - 47 years, median = 25.7 years). Complicated DMD without prior PKP was associated in three eyes after cataract surgery and in one eye after infectious keratitis. In cases with previous PKP, AS-OCT demonstrated rupture of Descemet's membrane (DM) in five eyes and spontaneous reattachment was found in four eyes within 8 weeks of initial diagnosis, with no rupture of DM in any of the cases. There was no rupture of DM in corneas without previous PKP. After prior keratoplasty, definitive surgical treatment was repeat PKP in 13 eyes and Air/Gas-Descemetopexy in one eye. In corneas without prior keratoplasty, three eyes underwent PKP and one eye Air/Gas-Descemetopexy. Histological examination of two corneal explants revealed a severely thinned graft-host junction and a disrupted DM close to the graft-host junction. Visual acuity improved from 1.80 ± 0.58 logMAR to 0.75 ± 0.69 logMAR after prior PKP and from 1.45 ± 0.65 logMAR to 0.85 ± 1.13 logMAR without prior PKP. The postoperative course was uneventful in 16 of 18 eyes.

CONCLUSION

PKP is an effective treatment option for complicated DMD, especially in ectatic corneas, whereas Air/Gas-Descemetopexy or Descemet Membrane Endothelial Keratoplasty do not address the primary issue of the curvature anomaly.

A Simple Repair Algorithm for Descemet's Membrane Detachment Performed at the Slit Lamp

Our study aims to investigate a simple repair algorithm for Descemet's membrane detachment (DMD) following phacoemulsification with Pentacam and anterior segment optical coherence tomography (AS-OCT). Twelve patients with DMD were included in this retrospective study. All cases had persistent corneal edema after phacoemulsification and no improved response to conservative treatment. The repair algorithm consisted of delineating the DMD with the Pentacam and AS-OCT, paracentesis, and intracameral air bubble performed at the slit lamp, followed by immediate supine position. At one month, the final status of Descemet's membrane (DM), best-corrected visual acuity, and incidence of complications were noted. DMD was involved in the visual axis in all cases. The mean interval between phacoemulsification and repair was 5.3 ± 1.2 days. Complete reattachment of DM and corneal clarity occurred in all 12 eyes. Eleven (91.7%) eyes underwent one repair procedure, while one eye (8.3%) underwent a repeat procedure. No adverse events were found. Minor post-intervention complications included temporary increased intraocular pressure due to pupillary block in one eye (8.3%). In conclusion, our modified and simplified repair algorithm for DMD can be performed safely as an outpatient procedure, with accurate delineation using a Pentacam and AS-OCT. It may provide new insight into the timely diagnosis, evaluation, and management of DMD.

Central and bullous Descemet membrane detachment during cataract wound hydration: an insightful complication in a post-DALK eye

A 54-year-old man, with history of undergoing deep anterior lamellar keratoplasty (DALK) 20 months ago, presented with mature senile cataract in the same eye. While undergoing phacoemulsification, a large, central Descemet membrane detachment (DMD) was noted, separating the donor cornea from the host predescemetic layer. No DM tears were noted. Stromal puncture was done at the graft host junction to reduce the extent of DMD. This was followed by a large intracameral air bubble insertion, which resulted in complete resolution of DMD on the first postoperative day. DMD during hydration of wound is a unique complication to be anticipated while doing cataract surgery in an operated DALK eye.

Incidence of Incision-Related Descemet Membrane Detachment Using Phacoemulsification With Trapezoid vs Conventional 2.2-mm Clear Corneal Incision: A Randomized Clinical Trial

Importance

The conventional 2.2-mm clear corneal incision is relatively narrow compared with the sleeves of Phaco handpieces, resulting in friction at the incision site and increased risk of incision-related Descemet membrane detachment (DMD). The modified 2.2-mm incision only enlarged internal width to 3.0 mm, forming a trapezoid incision shape, which may reduce the friction of surgical instruments and decrease the risk of incisional DMD.

Objective

To compare the incidence of incision-related DMD between eyes undergoing modified vs conventional 2.2-mm incision phacoemulsification for hard nuclear age-related cataract.

Design, Setting, and Participants

This double-masked, parallel randomized clinical trial was conducted from July 22, 2019, to January 22, 2020, at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. The study included patients with age-related cataract and nuclear opalescence grade of 4.0 or greater based on the Lens Opacities Classification System III. Patients were enrolled in this study according to the following inclusion criteria: (1) age between 65 to 90 years; (2) pupil size of 6 mm or greater after dilation; (3) Lens Opacities Classification System III nuclear opalescence grade of 4.0 or more; and (4) corneal endothelial cell density greater than 1500 cells/mm2.

Interventions

Modified (enlarged internal width to 3.0 mm) or conventional 2.2-mm incision phacoemulsification with intraocular lens implantation.

Main Outcomes and Measures

Incidence of incision-related DMD at postoperative day 1.

Results

A total of 130 eyes of 130 patients were randomized into the conventional group (n = 65) or the modified group (n = 65). The mean (SD) age of participants was 74.5 (5.9) years and 74.3 (6.0) years in the conventional and modified groups, respectively. A total of 26 participants in the conventional group (40%) and 27 in the modified group (42%) were men. Compared with eyes in the conventional group, the incidence of DMD in eyes in the modified group was significantly lower at postoperative day 1 (difference, 26.15; 95% CI, 9.60-42.71; P = .003). The difference at postoperative day 7 was 16.92 (95% CI, 2.91-30.94; P = .02). The length of DMD (postoperative day 1: difference, 0.188; 95% CI, 0.075-0.301; P = .002) and maximal corneal thickness at incision site (postoperative day 1: difference, 0.032; 95% CI, 0.006-0.057; P = .02; postoperative day 7: difference, 0.019; 95% CI, 0.003-0.035; P = .02) were lower in the modified group, while visual quality parameter modulation transfer function (postoperative day 1: difference, -0.033; 95% CI, -0.064 to -0.001; P = .04) was higher. No difference was observed between the 2 groups in best-corrected visual acuity, central corneal endothelium loss, or surgically induced astigmatism at any follow-up time. There were no intraoperative complications in the 2 groups.

Conclusions and Relevance

These findings suggest that modified 2.2-mm trapezoid incision phacoemulsification reduces the incidence of DMD for hard nuclear age-related cataract at postoperative day 1 and might be considered in patients at high risk of incision-related DMD, although the clinical relevance cannot be determined with certainty from this trial.

Trial Registration

ClinicalTrials.gov identifier: NCT04014699.

Spontaneous attachment of complex Descemet's membrane detachment following multiple failed interventions

We describe a case with complex Descemet membrane detachment (DMD) which persisted despite initial two failed surgical attempts to appose the ocular tissues. However, over time, tissue alignment was obtained spontaneously. A 60-year-old woman, operated trabeculectomy, had a total DMD intraoperatively during a complicated cataract surgery. Initial attempt to DM repositioning with intracameral air injection failed. Anterior Segment Optical Coherence Tomography (ASOCT) showed detachment of both DM and pre-Descemet's layer (PDL). After consultation with a corneal surgeon, patient was again attempted for Intra-operative Optical Coherence Tomography (iOCT)-guided settlement of DMD with intracameral air which again failed. So, the patient was registered for lamellar corneal transplant, but at 3 months follow-up, DM had spontaneously attached, confirmed on ASOCT. This case shows for the first time that even complex DMDs involving PDL, can spontaneously appose despite failed surgical interventions.

A Comparative Study between Air Bubble Tamponade Alone versus Air Bubble Tamponade with Internal Fluid Aspiration for Nonplanar Descemet's Membrane Detachment after Phacoemulsification

Purpose

To compare the efficacy of air bubble tamponade alone versus air bubble tamponade with internal fluid aspiration for nonplanar Descemet's membrane detachment after clear corneal incision phacoemulsification.

Methods

This study is a prospective, intervention, comparative randomised clinical trial, conducted at a private eye centre, Ismailia, Egypt, from March 2019 to March 2020. It contained 30 eyes of 24 patients who had postphacoemulsification nonplanar Descemet's membrane detachment involving the periphery and the central area of the cornea (>50% of the cornea) with corneal oedema. The patients were divided into two groups: group A: patients with nonplanar DMD affecting the central cornea treated by air bubble tamponade only and group B: patients with nonplanar DMD affecting the central cornea treated by air bubble tamponade augmented by internal fluid aspiration. Trial Registration: This trial was registered at www.pactr.org and the identification number for the registry is PACTR202006612296119.

Results

During the 12-month study period, this study included 30 eyes (24 patients) out of 1356 phaco surgeries with postphacoemulsification nonplanar Descemet's membrane detachment. Six patients had DMD in both eyes, eight patients had DMD in the right eye, and ten patients had DMD in the left eye. All patients have successful surgeries without complications. The calculated incidence rate for visually significant DMD was 2.2% per year. The mean ± SD time interval from cataract surgery to the primary intervention was 4.2 ± 1.1 days. Descemet's membrane was attached in 56.25% of patients in group A (9 out of 16 eyes) and 92.6% of patients in group B (13 out of 14 eyes) with a minimum of one-month follow-up.

Conclusion

Air descemetopexy combined with the internal fluid aspiration demonstrated to be more efficient than air descemetopexy only to treat Descemet's membrane detachment following phacoemulsification. It should be tried before planning other major surgeries in patients with severe Descemet's membrane detachment.

Descemet's Membrane Detachment: An Intraoperative Complication in Cataract Surgery with Phacoemulsification

Descemet’s membrane detachment (DMD) is a complication fundamentally associated with cataract surgery, the subclinical presentation being higher than expected. There are many varied treatments, from simple observation to penetrating keratoplasty. We present a case report of a 78-year-old male patient, without comorbidities, who underwent cataract surgery with phacoemulsification plus intraocular lens implantation in the capsular bag of the left eye. During the intraoperative procedure, he presented a DMD (height of 350 um and length of 3 mm in Zone 1 according to the HELP algorithm), managed with adaptive viscoelastic under the soft-shell technique in the same operative act, injection of iso-expansile SF6 (20%) intracameral plus postural positioning for 2 hours carried out 48 hours after surgery plus intensive topical treatment with hypertonic sodium chloride and steroidal anti-inflammatory drugs. At 72 hours after the operation of the application of the gas bubble, he presented with a transparent cornea and a best-corrected visual acuity of 20/80, which finally for his ophthalmological control at 8 weeks presented definitive resolution of the case in the AS-OCT and with a BCVA of 20/30.

Clinical course of lens capsule fragment adherent to the posterior corneal surface after cataract surgery

PURPOSE

The purpose of the study was to evaluate the clinical features and outcomes of lens capsule fragment (LCF) adherent to the posterior corneal surface after cataract surgery. Methods A total of 12 eyes from 12 patients were included with a mean follow-up duration of 19.4 ± 12.6 months. Demographics and clinical features were collected by reviewing medical records and slitlamp photographs. Outcome parameters included corrected distance visual acuity (CDVA), central corneal thickness, and anterior segment optical coherence tomography (AS-OCT) features. Results All LCF located centrally and remained fixed and turned to semitransparent in a mean time of 28.7 ± 20.1 days. The AS-OCT revealed an extra membrane at the posterior corneal surface, with an underlying intact Descemet membrane in 9 eyes. All patients experienced corneal edema associated with LCF, which was medically managed and resolved in a mean time of 58.1 ± 40.2 days. CDVA improved from logarithm of minimum angle of resolution scores of 0.91 ± 0.63 preoperatively to 0.25 ± 0.18 at 2 months after surgery. None of the patients expressed subjective visual complaints. Conclusions LCF adherent to the posterior corneal surface caused prolonged corneal edema after cataract surgery, but exhibited no clinically significant complications in the midterm follow-up. AS-OCT provided useful diagnostics and differentiating features.

[Treatment of Descemet's membrane detachment after cataract surgery : Successful visual recovery by repeated injection of air into the anterior chamber]

Descemet's membrane detachment (DMD) is a rare complication following cataract surgery. The characteristic clinical sign is a severe persisting corneal edema early after surgery without spontaneous improvement. Descemet's membrane can sometimes be seen partially floating in the anterior chamber. Optical coherence tomography of the anterior segment can help to determine the extent of DMD. The decision to choose a conservative watch and wait approach or a surgical intervention depends on the height, length and extent of the detachment as well as the localization in relation to the optical axis. Detachments of greater extent require surgical treatment and the first line treatment should be descemetopexy by injection of air into the anterior chamber of the eye. Subsequently, regular controls are necessary as DMD may require repeated air injections until reattachment of Descemet's membrane is achieved and the cornea becomes clear again.

Management of Descemet’s Membrane Detachment after Cataract Surgery—A Case Series

Descemet’s membrane detachment (DMD) is an uncommon, vision-threatening, ocular surface complication of cataract surgery. Among several treatment strategies, sulfur hexafluoride (SF6) descemetopexy is the standard of care. Herein, we report three cases of DMD after cataract surgery managed with SF6 descemetopexy, showing different outcomes. Anatomical success was achieved in cases 1 and 2 while intraocular pressure (IOP) was elevated in case 2. In case 3, despite SF6 descemetopexy, recurrent DMD was observed. Due to persistent corneal edema and possible corneal decompensation in case 3, Descemet’s stripping automated endothelial keratoplasty was performed and a clear graft was found at the final visit. In conclusion, descemetopexy with 20 % SF6 is an effective and safe procedure for repairing DMD in most cases. Pupillary block with elevated IOP is another concern and prophylactic peripheral iridectomy is recommended. For recurrent DMDs, repeat descemetopexy could be considered. However, close monitoring is advocated since secondary management, such as endothelial keratoplasty, may be required.

Descemet membrane detachment

Descemet membrane detachment (DMD) is a potential vision-threatening complication that occurs most commonly after cataract surgery. DMD has also been reported to occur in various other surgeries such as keratoplasty, iridectomy, vitrectomy, trabeculectomy, holmium laser sclerostomy, alkali burn, and viscocanalostomy. Major risk factors include advanced age, preexisting endothelial diseases like Fuchs dystrophy or abnormality in the Descemet membrane and stromal interface, hard cataract, prolonged surgical time, ragged clear corneal incisions, and inadvertent trauma with blunt instruments or phacoemulsification probe. Most DMDs are peripheral and resolve spontaneously. Large, central DMDs if not managed appropriately may lead to corneal decompensation and opacification. Several authors have classified DMD depending on its configuration, height, extent, length, and position with respect to pupil. Anterior segment optical coherence tomography has been used to confirm and classify DMD and can also aid in deciding the management plan. Spontaneous reattachment of the DM with conservative management may occur in cases with small, peripheral, planar DMD with nonscrolled edges. Cases with nonplanar, central DMD, scrolled edges, and length >2 mm, however, have to be managed surgically. Descemetopexy is the gold standard for the management of DMD. Other management options include mechanical tamponade, suture fixation, descemetotomy, interface drainage, and keratoplasty. Prompt diagnosis and timely management often leads to a good visual outcome.

[DMEK à chaud]

PURPOSE

This article reports a case of unintended excision of Descemet's membrane (DM) during a routine cataract extraction (CE), which was successfully treated by Desecemet membrane endothelial keratoplasty (DMEK).

MATERIAL AND METHODS

During routine CE of a 91-year old male patient the DM was almost completely detached and excised.

RESULTS

The DMEK was successfully performed, the cornea cleared and visual acuity increased from cc 0.02 to cc 0.8.

CONCLUSION

Unintended excision of DM can be successfully treated by DMEK at short notice.

Visual Outcome of Descemet Membrane Endothelial Keratoplasty during the Learning Curve in Initial Fifty Cases

This study was performed to evaluate the clinical outcomes of the first fifty patients who underwent Descemet membrane endothelial keratoplasty (DMEK) during the 3-month postoperative period and to describe the challenges encountered during the learning curve. In this retrospective study, we reviewed the charts of patients who underwent DMEK. All information regarding patient demographics, indication for surgery, preoperative and postoperative visual acuity at 3 months, donor age, and complications encountered intraoperatively and postoperatively was recorded. Donor endothelial cell count at the time of surgery and during the 3-month follow-up was noted. Data were analyzed using SPSS version 17. Fifty eyes of 49 patients were included in the study with majority being female patients (male : female = 2 : 3). Mean age of patients was 56.8 ± 11.4 years with the age range of 22–78 years. The common indications for DMEK were pseudophakic bullous keratopathy –57.1%, Fuchs endothelial dystrophy-34.7%, failed grafts-6.1% (Descemet stripping endothelial keratoplasty (DSEK) and failed penetrating keratoplasty), and others. Preoperative best spectacle-corrected visual acuity was <20/400 in 88% cases. Postoperative best spectacle-corrected visual acuity at 3 months was >20/63 in 41.8% of the cases, and 93% had visual acuity of 20/200 or better. Donor size was 8 mm, and average donor endothelial cell count (ECC) was 2919 ± 253 cells/mm². Average ECC at 3 months postoperatively was 1750 ± 664 cells/mm², which showed a 40% decrease in ECC. The most common encountered complication was graft detachment, which occurred in 16% cases for which rebubbling was done. Regular follow-up and timely identification of graft detachment may prevent the need for retransplantation.

Intraoperative Descemet's membrane detachment in a case of phacomorphic glaucoma

A 60-year-old female patient with phacomorphic glaucoma underwent initial medical management to control the intraocular pressure (IOP). After 48 hours, a stable IOP was achieved and subsequently the patient was planned for phacoemulsification followed by intraocular lens implantation. There was initial difficulty while reconstructing the corneal wounds; however, phacoemulsification and IOL implantation were uneventful but during viscoelastic removal, an inadvertent Descemet's membrane detachment involving the central cornea was noted. Postoperatively corneal oedema persisted till 1 week, following which there was a gradual improvement with topical antibiotics, steroids and hyperosmotic agents. At the end of 6 months, the best corrected visual acuity was 20/25 with a central corneal thickness of 580 µm without any need for additional endothelial replacement surgery.

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 membrane detachment in femtosecond laser-assisted cataract surgery: a case report

Background

Femtosecond laser-assisted cataract surgery (FLACS) has grown in popularity among ophthalmologists as a novel technique. However, descemet membrane detachment (DMD) began to be found as the complication after FLACS. We report a case of serious DMD following FLACS due to the inappropriate incision design.

Case presentation

An 85-year-old man with apparent cornea arcus senilis underwent femtosecond laser-assisted cataract surgery in his right eye. A biplanar model was chosen for the main incision. A serious descemet membrane detachment (DMD) occurred at the end of phacoemulsification, which was connected with the main incision. However, the surgeon confused it with the transient swelling of corneal endothelium, and did not treated DMD timely. DMD was confirmed by anterior segment optical coherence tomography (AS-OCT) at the postoperative 1-month follow-up. Eventually DMD was resolved by intracameral perfluropropane (C3F8) gas injection.

Conclusions

This case suggests that a careful incision separation and a triplanar incision design in FLACS may reduce the incidence of DMD in cataract surgery.