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

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.

Correlation Between Degree of Lens Opacity and the Phacoemulsification Energy Parameters Using Different Imaging Methods in Age-Related Cataract

Purpose

To compare the correlation between degree of lens opacity and the phacoemulsification energy parameter in patients with age-related cataract as determined by slit lamp, 25-MHz ultrasound biomicroscopy (UBM), and Scheimpflug imaging (Pentacam) and to evaluate the application of these three methods to measuring lens opacification.

Methods

This observational study was conducted in 319 patients (381 eyes) with different types of age-related cataract. The average age of patients was 67.3 ± 11.4 years. The degree of lens opacity acquired by slit lamp, 25-MHz UBM, and Pentacam was determined by the Lens Opacity Classification System III (LOCSIII), pixel units calculated by ImageJ, and lens density, respectively. We primarily analyzed and compared the correlation between lens opacity and the cumulative dissipated energy (CDE) values of phacoemulsification.

Results

Cortical, nuclear, and posterior subcapsular (PSC) cataracts were evaluated as follows: LOCSIII grades 3.31 ± 1.42, 3.29 ± 1.49, and 0.91 ± 0.83; pixel units 120.91 ± 22.8, 93.2 ± 15.9, and 99.7 ± 13.0; and lens density 51.8 ± 31.2, 21.2 ± 6.10, and 53.3 ± 35.3, respectively. The CDE values were 12.1 ± 12.4, 13.5 ± 9.11, and 3.93 ± 1.96. In cortical cataract, there was a linear correlation among LOCSIII, pixel units, and CDE value (r = 0.560, r = 0.832, and r = 0.582, respectively; both P < 0.05), but lens density had no correlation with other parameters. In nuclear cataract, there was a linear correlation among LOCSIII, lens density, and CDE value (r = 0.747, r = 0.865, and r = 0.906, respectively; both P < 0.05), but pixel units had no correlation with other parameters. In PSC, only pixel units and LOCSIII showed a correlation.

Conclusions

The various imaging methods offered different advantages in terms of determining lens opacity, a feature related to types of age-related cataracts. Choosing the most suitable imaging method to evaluate lens opacification based on the type of age-related cataract is important for accurately predicting the phacoemulsification parameters for cataract surgery.

Translational Relevance

Determining the appropriate phacoemulsification strategy depends on quantitative analysis of the degree of lens opacity to reduce intraoperative and postoperative complications and to obtain the optimal postoperative visual outcome.

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.

Evaluation of phacoemulsification (ultrasound) cataract surgery on the dynamics of the anterior segment of primary angle closure by AS-OCT

OBJECTIVE

To explore the changes of anatomical biological parameters and dynamic parameters of the anterior segment (AS) before and after primary angle closure glaucoma (PACG) surgery.

METHODS

The clinical data of 82 patients (82 eyes) who underwent phacoemulsification in our hospital were retrospectively analyzed and divided into group A (angle closure, n = 38) and group B (normal open angle, n = 44). The anatomical biological parameters and dynamic parameters were compared between the two groups before and after surgery.

RESULTS

Compared with group B, group A had smaller anterior chamber depth, higher vaulting, greater iris curvature, and smaller TISA500. Compared with group B, group A had smaller ΔTISA500 and ΔI-area. Compared with group B, the TISA500 was smaller in group A preoperatively, at 1 week, and 1 month after surgery (P < 0.05). The iris curvature was larger in group A (P < 0.05). The ΔI-area was significantly reduced in group B at 1 week and 1 month after surgery. Group B exhibited smaller ΔI-curv than group A at 1 week and 1 month after surgery (P < 0.05).

CONCLUSION

Anterior segment optical coherence tomography (AS-OCT) can effectively monitor the dynamic changes (DC) of the AS caused by phacoemulsification in patients with primary angle closure (PAC). Phacoemulsification can open the primary of PAC patients. However, their iris area does not change significantly. The biological characteristics of the iris itself may be a risk factor leading to PAC.

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.

[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 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.