Repeat Descemetopexy after Descemet's Membrane Detachment following Phacoemulsification

Double bubble pneumo-descemetopexy for the management of Descemet membrane detachment: An innovative technique

A 62-year-old woman was referred with poor vision following manual small incision cataract surgery. On presentation, the uncorrected distance visual acuity in the involved eye was 3/60, whereas slit-lamp examination revealed a central corneal edema with the peripheral cornea relatively clear. Direct focal examination with a narrow slit upper border and lower margin of detached rolled up Descemet's membrane (DM) could be visualized. We performed a novel surgical approach, "double-bubble pneumo-descemetopexy." The surgical procedure included unrolling of DM with "small air bubble" and descemetopexy with "big bubble." No postoperative complications were observed, and best corrected distance visual acuity improved to 6/9 at 6 weeks. The patient had a clear cornea and maintained BCVA 6/9 during 18 months at follow-up. Double-bubble pneumo-descemetopexy, a more controlled technique, provides a satisfactory anatomical and visual outcome in DMD without the need for endothelial keratoplasty (Descemet's stripping endothelial keratoplasty or DMEK) or penetrating keratoplasty.

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 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.

Hydrophilic intraocular lens opacification after repeated intracameral gas injection for Descemet membrane detachment

Descemet membrane detachment (DMD) is a complication of a variety of eye procedures that can result in severe visual loss. We report a new case of the condition, in a highly myopic patient that had undergone cataract surgery, and presented a macular hemorrhage during the intervention. DMD was successfully treated with a combined technique of intracameral gas injection and transcorneal suturing. Following resolution of this complication, intraocular lens opacification was observed.

Study on the classification of Descemet membrane detachment after cataract surgery with AS-OCT

In this article, the significance of anterior segment optical coherence tomography (AS-OCT) to aid the clinical diagnosis and treatment of Descemet membrane (DM) detachment after phacoemulsification combined with intraocular lens implantation was retrospectively analyzed using 26 patients (26 eyes). The location and scope of DM detachment, its causative factors and the percentage of each detachment type are considered for clinical treatments. Based on the location and scope, the detachment can be divided into three types: (1) simple, (2) symmetrical and (3) complete DM detachment. Simple detachment, confined to the area of surgical incision (detachment range <1/4 corneal area), occurred in 69.20 % of cases (18/26), in which the DM detachment in the anterior lip accounted for 42.30% (11/26) and in the posterior lip accounted for 26.90% (7/26). Symmetrical DM detachment, referring to detachment (1/4 cornea area < detached area <1/2 corneal area) that appeared symmetrically on the surgical incision and the opposite site, accounted for 19.20% (5/26). Complete DM detachment (>1/2 of the corneal area), accounted for 11.50% (3/26). Interestingly, our findings suggest that the DM detachment after phacoemulsification is closely related to the location (simple and symmetrical DM detachment) and the skillfulness (complete DM detachment) of the surgical incision. Therefore, appropriate classification of DM detachment by AS-OCT and wise selection of surgical location can better guide cataract surgery in the future.

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.

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.

Intraoperative OCT assisted descemetopexy with stromal vent incisions and intracameral gas injection for case of non-resolving Descemet's membrane detachment

Descemet's membrane detachment (DMD) though uncommon in the present day scenario of advancing surgical techniques is a significant complication that requires prompt diagnosis and management. A middle-aged man presented to our hospital with poor gain of vision following cataract surgery. There was significant corneal oedema with DMD which was confirmed on anterior segment optical coherence tomography. We describe a modified continuous intraoperative-guided approach for the management of DMD in cases with oedematous hazy corneas. The aim of this technique is to allow early reattachment of Descemet's membrane in chronic cases where fluid pockets prevent reattachment of the posterior layer of cornea. Our technique involves the use of full thickness stromal vent incisions in the paracentral cornea along with intracameral isoexpansile concentration of gas for the successful settlement of the detached Descemet's membrane.

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.

Glaucoma with Descemet's membrane detachment in five horses

PURPOSE

To describe the clinical and histopathologic features of glaucoma associated with Descemet's membrane (DM) detachment in five horses without prior history of intraocular surgery.

ANIMALS STUDIED

Three Appaloosa horses and two Thoroughbreds were included in this study. The affected horses ranged in age from 16 to 27 years and presented with severe diffuse corneal edema.

PROCEDURE

Five eyes were enucleated due to intraocular hypertension and/or chronic corneal ulceration. The enucleated globes were evaluated by the Comparative Ocular Pathology Laboratory of Wisconsin (COPLOW). Each globe was routinely processed for histopathology and analyzed by light microscopy. A histologic diagnosis of glaucoma was reached by demonstrating a loss of optic nerve axonal tissue by measuring neurofilament-immunopositive axons with automated image analysis software.

RESULTS

All five horses presented with unilateral severe diffuse corneal edema that had developed between 2 and 16 weeks prior to enucleation. Intraocular pressures for the affected eyes were between 9 and 87 mmHg prior to enucleation. Descemet's membrane detachment was identified histopathologically in all five globes (5/5, 100%). All five eyes had an avascular spindle cell proliferation filling the space between the displaced peripheral DM and the corneal stroma. Neurofilament immunostaining revealed axonal loss consistent with glaucoma.

CONCLUSION

Equine glaucoma may be associated with Descemet's membrane detachment. This detachment and glaucoma is a possible differential diagnosis for severe equine corneal edema. In this case series, an eye with a DM detachment had a poor prognosis for retention.

A case of Descemet's membrane detachments and tears during phacoemulsification

Descemet’s membrane detachment is an important reason for corneal endothelial decompensation after intraocular surgery. During cataract surgery, it is an unusual complication. We report a case of Descemet’s membrane detachment in which approximately 60% of Descemet’s membrane (DM) involving approximately the upper two-thirds of the cornea was torn out during a routine phacoemulsification. It caused diffuse corneal edema and blurred vision in the 2 months following the surgery. Topical prednisolone acetate (1%) and sodium chloride (5%) had been used for treatment, with slow improvement in the patient’s symptoms and vision. Interestingly, the cornea regained clarity 2 months after surgery without further surgical treatment.