Clinical Descemet s membrane detachment is a rare

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1 Descemet s membrane detachment after cataract extraction Jessica Potter, O.D. a and Nadia Zalatimo, O.D. a,b a VA Medical Center, Manchester, New Hampshire and b The New England College of Optometry, Boston, Massachusetts Background: Descemet s membrane detachment is a rare but potentially serious complication of intraocular surgery, most commonly cataract extraction. Small Descemet s membrane detachments typically resolve with topical medical therapy; however, larger detachments require surgical intervention. The most common surgical procedure is a gas fluid exchange with 20% sulfur hexafluoride (SF 6 ) or 14% perfluropropane (C 3 F 8 ), which is typically performed at the biomicroscope and is nontoxic to the endothelium. Case: A 77-year-old man underwent phacoemulsification with a posterior chamber lens implantation by clear corneal incision in the left eye. Visual acuity was 20/40 in the left eye 1 month postoperatively with persistent corneal edema. Visual acuity continued to deteriorate to counting fingers (CF), despite the use of topical hyperosmotics and steroids. At 2 months, a scrolled Descemet s membrane detachment was present from the incision site to the central cornea causing extensive edema. Anterior chamber injection of 14% C 3 F 8 successfully reattached Descemet s membrane. Six weeks after surgery, the gas bubble had resolved, the central cornea was clear, and a curvilinear scar was present from 5:00 to 11:00. Visual acuity remained at CF owing to anterior capsular fibrosis. Anterior YAG capsulotomy improved the vision to 20/40. Conclusion: Descemet s membrane detachment can have a devastating effect on vision. Timely management is imperative to preserve vision. This case shows the successful repair of Descemet s membrane detachment with 14% C 3 F 8 after unsuccessful topical treatment. Key Words: Descemet s membrane detachment, cataract surgery complication, cornea, anterior chamber injections, gas bubble tamponade Potter J, Zalatimo N. Descemet s membrane detachment after cataract extraction. Optometry 2005;76: Clinical Descemet s membrane detachment is a rare but potentially serious complication of intraocular surgery. Cases of Descemet s membrane detachment have been reported, owing to cataract extraction, iridectomy, trabeculectomy, corneal transplantation, pars plana vitrectomy, iridotomy, cyclodialysis, full-thickness lamellar keratoplasty, holmium laser sclerostomy, alkali burn, hydrogen peroxide injury, and viscocanalostomy. 1-9 Descemet s membrane detachments are most commonly diagnosed after cataract extraction. Up to 43% of patients have a Descemet s membrane detachment after cataract extraction, but the majority are subclinical and only detected with gonioscopy. 10 Small, subclinical detachments are likely undetected and underreported because they resolve spontaneously within days after surgery. Larger detachments of Descemet s membrane can lead to more serious postoperative complications, making their recognition and management an important part of the postoperative evaluation. Case Report A 77-year-old man presented with a gradual, painless decrease in visual acuity in both eyes (OU). Examination found cataracts consistent with the patient s best corrected visual acuity of 20/50 in the right eye (O.D.) and 20/50 in the left eye (O.S.). He underwent an uneventful phacoemulsification with a posterior chamber lens implantation by clear corneal incision O.S. Postoperatively it was noted that the lens was decentered and tilted, such that the inferior aspect of the lens was slightly more anteriorly placed compared with the superior aspect of the lens, and the entire lens was superiorly displaced. At the 1-month postoperative visit, best corrected visual acuity was 20/40

Figure1 Corneal scarring S/P gas/fluid exchange. A, Location of original tear. B, Curvilinear scarring after gas fluid exchange. O.S., attributed to Descemet s folds and microcystic edema in the central cornea.

2 Figure1 Corneal scarring S/P gas/fluid exchange. A, Location of original tear. B, Curvilinear scarring after gas fluid exchange. O.S., attributed to Descemet s folds and microcystic edema in the central cornea. The patient had tapered and subsequently discontinued all topical medications after his 1-week followup visit as instructed. The patient was treated with hyperosmotic topical medication four times a day (q.i.d.) O.S. The visual acuity was 20/150 O.S. after 2 weeks, consistent with worsening corneal edema. Topical prednisolone acetate 1% was added q.i.d. O.S., and the patient was instructed to continue the hyperosmotic drops q.i.d. O.S. Two weeks later (2 months postoperatively) visual acuity was counting fingers O.S. with persistent corneal folds and edema. A scrolled Descemet s membrane detachment was seen from the incision site into the central cornea O.S. The patient was advised to continue the topical medications and was referred to a corneal specialist. The patient underwent an anterior chamber gas fluid exchange with 14% perfluropropane (C 3 F 8 ). The gas expanded to encompass approximately 60% to 70% of the anterior chamber. One hour after the procedure, the intraocular pressure (IOP) increased to 41 mmhg, and the patient was treated with dorzolamide hydrochloride-timolol maleate twice a day O.S. Moxifloxacin HCl was prescribed 3 times a day O.S. to prevent infection. The patient was instructed to sit at a 45 angle at all times. Six weeks after surgery, the gas bubble had resolved, and the IOP had returned to 18 mmhg without medication. The cornea had no edema, and a curvilinear scar was present from 5:00 to 11:00. Visual acuity was CF due to anterior capsular fibrosis that had contracted to obscure the visual axis. The contracture is believed to have occurred secondary to weak lens zonules noted during cataract surgery. Anterior YAG capsulotomy was performed, and the patient was treated with a topical prednisolone acetate 1% q.i.d. for postoperative inflammation. Two months after the capsulotomy, the best corrected visual acuity was 20/40. The cornea was clear centrally with a linear scar in the midperipheral cornea from the Descemet s membrane detachment that did not affect vision (see Figure 1). The reduced vision was attributed to the displaced lens, because the cornea was clear, and the macula was flat with no sign of edema. Discussion Descemet s membrane detachment is a potentially serious, vision-threatening complication of intraocular surgery. Although the cause is not known, it is thought that mechanical forces applied to the cornea during surgery cause Descemet smembranetoseparatefromthestroma. 11 Descemet s membrane detachments occur at the incision site and can progress toward the central cornea. The stroma anterior to the detachment becomes edematous, and, if the central cornea is involved, significant reduction in visual acuity and bullous keratopathy can occur. 12 Other risk factors have been reported, including soft globe, glaucoma, previous intraocular surgery, and preexisting corneal scarring, but they have never been proven clinically significant It has been suggested that there is an anatomic predisposition to Descemet s membrane detachments, namely, an abnormal attachment between the stroma and Descemet s membrane. This abnormal attachment causes the tissues to separate more easily with the pressures that occur during surgery. 19 Certainsurgicaltechniqueshavebeen reported to have a higher incidence of Descemet s membrane detachment, including small corneal incisions and incisions that are placed more 721

3 Table 1. Classifications of Descemet s detachment 1. A) Planar 1 mm separation between Descemet s and stroma B) Nonplanar 1 mm separation between Descemet s and stroma 2. A) Scrolled Exhibits a rolled edge B) Nonscrolled No rolled edge 3. A) Peripheral Does not involve the visual axis B) Peripheral with central involvement anterior to the limbus. 13,20 However, a retrospective study by Mahmood et al. 14 reported no identifiable risk factors associated with Descemet s membrane detachments. There are 3 types of classification of Descemet s membrane detachments: planar versus nonplanar, 21,22 scrolledversusnonscrolled,andperipheral versus peripheral with central involvement (see Table 1). 23 Planar Descemet s membrane detachments are those in which the separation between the stroma and Descemet s membrane is less than 1 mm. When the separation is greater than 1 mm, the detachment is termed nonplanar. Descemet s membrane detachments that exhibit a rolled edge are described as scrolled, and those without a rolled edge are nonscrolled. Descemet s membrane detachments that are planar or nonscrolled are more likely to resolve without surgical treatment, whereas those with a scrolled edge or those that are nonplanar tend to progress and become visually significant. 24 Determining the class of the detachment is important because it can influence management. Management includes both medical and surgical treatments, depending on the type and severity of the detachment. Medical treatment with topical hyperosmotics and steroids is effective for small Descemet s membrane detachments that do not affect vision. 24 These include detachments without a scrolled edge and those that are separated from the stroma by less than 1 mm. It is hypothesized that endothelial cells continue to function while detached from the stroma, and 722 pump out fluid accumulating between the Descemet s membrane endothelium complex and the stroma. 25 Asthe fluid is pumped out, Descemet s membrane begins to re-approximate the stroma and eventually reattaches itself to the stroma with the production of new basement membranebytheendothelium. 26 Topicalhyperosmotics and steroids aid in the reattachment process by reducing stromal edema. Large, central Descemet s membrane detachments are unlikely to resolve with topical medical treatment and usually require surgical intervention. However, there have been a few reports showing resolution of such detachments with medical treatment only Asaresult, typical management is to start with topical medical therapy for all Descemet s membrane detachments, regardless of size and visual acuity, and consider surgical intervention if there is no improvement Topical medical therapy with hyperosmotics and steroids for up to 10 weeks is recommended by some to allow time for resolution. 25,26 Others have found that persistence of stromal edema for that length of time can cause permanent scarring, fibrosis, and atrophy of tissue, decreasing the potential for reattachment. 16 Therefore, visually significant Descemet s membrane detachments should be repaired surgically in a timely manner. Surgical procedures for repair of Descemet s membrane detachment include surgical repair, anterior chamber injection, and corneal transplantation Surgical repair involves entering the anterior chamber and physically reattaching Descemet s membrane to the stroma with a suture. The edge of the detachment is stretched to the scleral edge and attached with a 10-0 nylon suture. The suture may be removed postoperatively or left in place if not causing complications such as irritation or irregular astigmatism. 11 Anterior chamber injection of liquid or gas is used to mechanically re-oppose Descemet s membrane to the stroma with a tamponade. This technique is performed typically at the biomicroscope, but can also be done in the operating room. 31 Substances injected as tamponades include 100% air, 13,32 viscoelastic material, 14% C 3 F 8, and 20% sulfur hexaflouride (SF 6 ). 24 After injection, patients are required to sit at a 45 angle so that the fluid or gas is properly positioned to push the Descemet s membrane endothelium complex superiorly and anterior simultaneously. Air tends to be the least effec-

4 tive tamponade because it resolves within 3 to 4 days, which is not long enough for reattachment of Descemet s membrane. Viscoelastic material lasts longer than air but has the potential complication of elevated intraocular pressure due to the thick consistency and slow dissolution of the material. Patients treated with viscoelastic material must be monitored closely for an increase in intraocular pressure and may require pressurelowering medications. 32 The gases (SF 6 and C 3 F 8 ) last longer than air and are less likely to cause increased IOP. SF 6 takes 2 to 3 weeks to re-absorb, and C 3 F 8 resolveswithin6weeks. 34 A study conducted in rabbits showed that these gases are nontoxic to the endothelium, and although some mechanical damage occurs, enough endothelial cells remain to maintain a clear, functional cornea Tamponade of Descemet s membrane detachments is effective because both the corneal endothelium and Descemet s membrane maintain most of their structure and function even while detached from the corneal stroma. 39 This is because these structures obtain oxygen and nutrients from the aqueous humor. 39 Patel et al. 40 showed that endothelial pleomorphism and polymegathism improve over time after re-attachment of a Descemet s membrane detachment. Reduced vision after surgical reattachment of Descemet s membrane is believed to be caused by stromal scarring from long-standing corneal edema, rather than endothelial damage. 40 Corneal transplantation is performed to restore visual acuity if all other options have failed. 41 Conclusion Clinical Descemet s membrane detachment, although rare, can be a visually devastating complication of intraocular surgery. There have been many postulated risk factors associated with this condition; however, none have been proven to be significant. Early detection is necessary to preserve vision and prevent permanent damage. Although smaller detachments typically resolve with topical treatment, larger or more progressive detachments require surgical intervention. This case demonstrates successful repair of Descemet s membrane detachment with 14% C 3 F 8 after unsuccessful treatment with topical hyperosmotics and steroids. References 1. Kim CY, Seong GJ, Koh HJ, et al. Descemet s membrane detachment associated with inadvertent viscoelastic injection in viscocanalostomy. Yonsei Med J 2002;43(2): Fujimoto H, Mizoguchi T, Kuroda S, et al. Intracorneal hematoma with Descemet membrane detachment after viscocanalostomy. Am J Ophthalmol 2004;137(1): Luke C, Dietlein T, Jacobi P, et al. Intracorneal inclusion of high-molecular-weight sodium hyaluronate following detachment of Descemet s membrane during viscocanalostomy. Cornea 1999;19: Ocakoglu O, Ustundag C, Devranoglu K, et al. Repair of Descemet s membrane detachment after viscocanalostomy. J Cataract Refract Surg 2002;28: Bergsma DR, McCaa CS. Extensive detachment of Descemet membrane after holmium laser sclerostomy. Ophthalmology 1996;103: Najjar DM, Rapuano CJ, Cohen EJ. Descemet membrane detachment with hemorrhage after alkali burn to the cornea. Am J Ophthalmol 2004;137: Yalvac IS, Sahin M, Eksioglu U, et al. Hemorrhagic Descemet s membrane detachment after viscocanalostomy. 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Stripping of Descemet s membrane associated with intraocular lens implantation. Arch Ophthalmol 1983;101: Makley TA Jr, Keates RH. Detachment of Descemet s membrane with insertion of an intraocular lens. Ophthalmic Surg 1980;11: Fang JP, Amesur KB, Baratz KH. Preexisting endothelial abnormalities in bilateral postoperative Descemet membrane detachment. Arch Ophthalmol 2003;121: Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phacoemulcification. Cornea. 2001;6: Anderson CJ. Gonioscopy in no-stitch cataract incision. J Cataract Refract Surg 1993;19: Menezo V, Choong YF, Hawksworth NR. Reattachment of extensive Descemet s membrane detachment following uneventful phaco-emulsification surgery. Eye 2002; 16: Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol 1977;95:

5 23. Mulhern M, Barry P, Condon P. A case of Descemet s membrane detachment during phacoemulsification surgery. Br J Ophthalmol 1996;80: Assi EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet s membrane detachment. J Cataract Refract Surg 1995;21: Iradier MT, Moreno E, Aranguez C, et al. Late spontaneous resolution of a massive detachment of Descemet s membrane after phacoemulsification. J Cataract Refract Surg 2002;28: Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet s membrane following phacoemulsification. Arch Ophthalmol 1994;112: Ball JL, Stewart O, Taylor R. Comment on: Spontaneous reattachment of extensive Descemet s membrane detachment following uneventful phacoemulsification surgery. Eye 2004;18: Zeiter HJ, Zeiter JT. Descemet s membrane separation during five hundred forty-four intraocular lens implantations Am Intra-Ocular Implant Soc J 1983; 9: Donzis PB, Karcioglu ZA, Insler MS. Sodium hyaluronate in the surgical repair of Descemet s membrane detachment. Ophthalmic Surg 1986;17: Zussman NB, Waring GO III, Najarian LV, et al. Sulfur hexafluoride gas in the repair of intractable Descemet s membrane detachment. Am J Ophthalmol 1987;104: Kim T, Hasan SA. A new technique for repairing Descemet membrane detachments using intracameral gas injection. Arch Ophthalmol 2002;120: Amaral CE, Palay DA. Technique for repair of Descemet membrane detachment. Am J Ophthalmol 1999; 127: Kim T, Sorenson A. Bilateral Descemet membrane detachments. Arch Ophthalmol 2000;118: Macsai MS, Grainer KM, Chisholm L. Repair of Descemet s membrane detachment with perfluropropane (C 3 F 8 ). Cornea 1998;17: Shah M, Bathia J, Lothari K. Repair of late Descemet s membrane detachment with perfluoropropane gas. J Cataract Refract Surg 2003;29: Van Hron DL, Edelhauser HF, Pederson HJ. In vivo effects of air and sulfur hexaflouride gas on rabbit corneal endothelium. Arch Ophthalmol 1987;105: Lee DA, Wilson MR, Yoshizumi MO, et al. The ocular effects of gases when injected into the anterior chamber of rabbit eyes. Arch Ophthalmol 1991;109: Fould GN, dejuan E, Hatchell DL, et al. The effect of perfluoropropane on the cornea in rabbits and cats. Arch Ophthalmol 1987;105: Marcon AS, Rapuano CJ, Jones MR, et al. Descemet s membrane detachment after cataract surgery: management and outcome. Ophthalmol 2002;109: Patel DV, Phang KL, Grupcheva CN, et al. Surgical detachment of Descemet s membrane and endothelium imaged over time by in vivo confocal microscopy. Clin Exp Ophthalmol 2004;32: Merrick C. Descemet s membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg 1991;22: Corresponding author: Jessica Potter, O.D. c/o Eye Clinic 718 Smyth Road Manchester, New Hampshire jessicalynpotter@yahoo.com 724

Tractional Descemet s membrane detachment after ocular alkali burns: case reports and review of literature

Zhang et al. BMC Ophthalmology (2018) 18:256 https://doi.org/10.1186/s12886-018-0924-x CASE REPORT Open Access Tractional Descemet s membrane detachment after ocular alkali burns: case reports and review