Spontaneous attachment of detached Descemet membrane following deep anterior lamellar keratoplasty

Delayed spontaneous resolution of a double anterior chamber following deep anterior lamellar keratoplasty (DALK)

BACKGROUND

This study reports a rare case of delayed spontaneous resolution of double anterior chambers (AC) resulting from non-rhegmatogenous Descemet membrane detachment (DMD) after deep anterior lamellar keratoplasty (DALK). Currently, management guidelines for this condition have not been established.

CASE PRESENTATION

A 65-year-old woman with lattice corneal dystrophy underwent uncomplicated DALK, during which an unrecognized type 2 big bubble was present. On postoperative day 1, a total DMD was observed, and descemetopexy was attempted. After an unsuccessful air-filled descemetopexy, we opted for observation without further intervention. Spontaneous reattachment of Descemet membrane with a clear cornea was achieved at 3 months postoperatively. The endothelial cell count was 2,165 cells/ mm2.

CONCLUSIONS

The spontaneous resolution of double AC in patients with DMD without visible perforation after DALK suggests that a "wait and observe" approach can be a reasonable and effective management strategy.

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.

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.