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

Descemet's Membrane Detachment during Phacocanaloplasty: Case Series and In-Depth Literature Review

This article presents three cases of Descemet's membrane detachment (DMD) occurring during 'ab externo' phacocanaloplasty procedures in three patients with uncontrolled primary open-angle glaucoma (OAG) and discusses the management of this condition by reviewing the available literature. Following a successful 360° cannulation of Schlemm's canal (SC), the microcatheter was withdrawn while an ophthalmic viscosurgical device (OVD) was injected into the canal. During passage through the inferonasal quadrant, a spontaneous separation of the posterior layer of the cornea was observed. Each case was managed differently after diagnosis, with the third case being drained intraoperatively based on experience gained from the previous cases. On the first postoperative day, slit-lamp biomicroscopy (BMC) revealed multiple DMDs in case one and a hyphema in the lower third of a deep anterior chamber. In the other two cases, a single DMD was observed. The second case developed hemorrhagic Descemet membrane detachment (HDMD), while the other two were non-hemorrhagic. In all three cases, anterior segment optical coherence tomography (AS-OCT) revealed the presence of retrocorneal hyperreflective membranes indicative of DMDs. These membranes were located in the periphery of the cornea and did not impact the visual axis. After evaluation, a small incision was made in the inferotemporal DMD of the first case. However, for the two remaining cases, a strategy of watchful waiting was deemed appropriate due to the location and size of the DMDs, as they did not affect the best-corrected visual acuity (BCVA). Over time, the patients demonstrated progressive improvement with a gradual reduction in the size of the DMDs.

Manual schism and intracameral air injection for impacted Descemet's membrane detachment

A woman in her 60s was referred to us for management of poor vision following cataract surgery in the right eye. She had undergone manual small incision cataract surgery 12 weeks earlier. Slit-lamp biomicroscopy revealed corneal oedema, a horizontal line at the upper border and the adhered inferior border of detached Descemet's membrane (DM). Clinical diagnosis of impacted Descemet's membrane detachment (DMD) was considered.Surgical intervention with manual schisis and intracameral injection of air was planned. Using the 'push technique,' we tried to place the tip of the 27 gauge cannula between the back of the cornea and detached DM. The tip of the 27 gauge cannula was behind the impacted DM, and air injection was unsuccessful. Using the back-up the 'pull technique,' bent tip of the 27 gauge cannula was used to pull the impacted DMD. This manoeuvre, disimpacted the inferior border and the air bubble, was injected using the 27 gauge cannula. The air bubble unfolded and reattached the DM successfully.

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.

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.

Supra-Descemetic Venting Incision in the Management of Spontaneous Descemet Membrane Detachment in an Old Penetrating Keratoplasty Graft

PURPOSE

To report a case of late spontaneous detachment of Descemet membrane (DM) in a donor penetrating keratoplasty (PKP) graft and its successful management using a supra-Descemetic venting incision combined with gas descemetopexy.

METHODS

Case report with review of literature.

RESULTS

A 56-year-old man who had undergone PKP after acute hydrops in pellucid marginal degeneration 27 years before presentation experienced sudden onset vision loss. Clinical features mimicked acute graft rejection but detailed evaluation and anterior segment optical coherence tomography showed a DM detachment (DMD) of the graft. Ten weeks after the onset of DMD, he underwent descemetopexy with a supra-Descemetic stromal venting incision and sulfur hexafluoride gas tamponade. DM reattached with complete resolution of graft edema.

CONCLUSIONS

Late spontaneous DMD of the graft after PKP is very uncommon and must be differentiated from acute graft rejection. Anterior segment optical coherence tomography may help to diagnose this entity that can be managed successfully despite late intervention. The addition of a venting incision that drains fluid from the supra-Descemetic space can increase the chance of success of descemetopexy when compared with descemetopexy with air or gas alone.

[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.

Descemet Membrane Suturing for Large Descemet Membrane Detachment After Cataract Surgery

PURPOSE

To study the outcomes of Descemet membrane (DM) suturing for moderate to severe Descemet membrane detachment (DMD) after cataract surgery.

METHODS

This is a retrospective case review of all patients who underwent DM suturing for moderate to severe DMD after cataract surgery in a tertiary training eye care hospital from January 2017 to December 2017. Demographic details, type of cataract, type of cataract surgery, intraoperative complications, severity of DMD, time to repair, and post-DM suturing visual and clinical outcomes were documented.

RESULTS

Forty-nine patients were included during the study period with a mean age of 67.7 ± 9.7 years. In total, 79.5% had immature cataracts. Median precataract LogMAR visual acuity was 0.78 (IQR 0.69-1.13). In total, 61.2% underwent manual small-incision cataract surgery, 32.6% had phacoemulsification, 2% had extracapsular cataract extraction (ECCE), and 6% underwent small-incision cataract surgery with trabeculectomy. In total, 44.9% were operated on by trainees and 55.1% were operated on by consultants. In total, 22.4% had primary air descemetopexy during the cataract surgery and failed treatment. All patients had attached DM in the immediate postoperative period. None of them had secondary angle closure glaucoma. At the final follow-up, 42 (85.7%) had clear corneas and 7 (14.3%) had corneal decompensation needing endothelial keratoplasty. Of these 7 patients, 2 (28.5%) had Fuchs dystrophy and 3 (42.8%) had associated DM loss. The median LogMAR visual acuity at the final follow-up was 0.39 (IQR 0.3-0.78).

CONCLUSIONS

DM suturing can reattach DM, especially in moderate to severe, recurrent DMD with fewer postoperative complications and thereby reduce the need for corneal transplantation.

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.

Successful treatment of late onset post-phacoemulsification Descemet's membrane detachment

Purpose:

To present a case with the late-onset post-phacoemulsification Descemet’s membrane detachment that has been treated successfully.

Methods:

Case report.

Results:

A 68-year-old female patient presented with the complaint of decreased vision in her pseudophakic left eye after a 4-week silent post-phacoemulsification period. In the biomicroscopy, corneal oedema was seen to be prominent on the nasal incision side. Anterior segment optical coherence tomography objectively revealed the presence of Descemet’s membrane detachment. Treatment of descemetopexy was applied by injecting 0.3-mL perfluoropropane gas into the anterior chamber. No complication associated with descemetopexy was noticed during recovery. Total Descemet’s membrane detachment reattachment was achieved and perfluoropropane gas resorption from the anterior chamber was completed by the end of 1-month post-injection. The cornea was transparent and best corrected visual acuity increased to 20/20.

Discussion:

DMD is a rare complication following phacoemulsification and this patient had not any preoperative, intraoperative, or postoperative risk factors for DMD.It generally occurs in early-postoperative period and late-onset DMDs have been reported less frequently.The success rates with intracameral gas injections in similar cases have been reported to be 90% - 95%.

Conclusion:

To the best of our knowledge, this is one of the latest onset post-phacoemulsification Descemet’s membrane detachment cases in literature that has been treated successfully. The results of this case showed that descemetopexy is a safe and effective treatment method for late-onset post-phacoemulsification DMD.

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.