An alternative technique for persistent Descemet's membrane detachment following phacoemulsification: Our clinical experience

Rahul Bhatia; Nitika Beri; PK Sahu; GK Das

doi:10.4103/ijo.IJO_270_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 1 | Page : 66-68

An alternative technique for persistent Descemet's membrane detachment following phacoemulsification: Our clinical experience

Rahul Bhatia, Nitika Beri, PK Sahu, GK Das
Department of Ophthalmology, GTB Hospital, Delhi, India

Date of Submission	14-Feb-2021
Date of Acceptance	29-Jun-2021
Date of Web Publication	07-Jan-2022

Correspondence Address:
Dr. Rahul Bhatia
Department of Ophthalmology, GTB Hospital, Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_270_21

Abstract

Descemet's membrane detachment (DMD) is an uncommon complication of cataract surgery. The prognosis depends upon the prompt recognition and management of DMD. The use of various modalities such as AS OCT, Schiemflug imaging and pachymetry helps in proper diagnosis and selecting appropriate management options. Majority of the DMD are small and spontaneously resolve on their own. For small and limited DMD, Medical management with observation are suffice. For persistent large DMD, descemetopexy with the use of expansile gases have been used to tamponade the DM. Use of HELP algorithm has led to objective assessment of DMD and thinning the grey line between either going for observation or intervention with various modalities available. If descemetopexy fails, corneal venting incision can be used as a last resort before going for Keratoplasty. Keratoplasty still remain the treatment of choice for long standing and persistent DMD.

Keywords: Descemet's membrane detachment, phacoemulsification, venting incision

How to cite this article:
Bhatia R, Beri N, Sahu P K, Das G K. An alternative technique for persistent Descemet's membrane detachment following phacoemulsification: Our clinical experience. Indian J Ophthalmol Case Rep 2022;2:66-8

How to cite this URL:
Bhatia R, Beri N, Sahu P K, Das G K. An alternative technique for persistent Descemet's membrane detachment following phacoemulsification: Our clinical experience. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 2];2:66-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/66/334940

Descemet's membrane detachment (DMD) is an uncommon complication of cataract surgery, with an incidence between 0.044% and 0.5% following phacoemulsification.^[1]Possible causes include shallow chambers, complicated or repeated procedures, blunt surgical instruments, inadvertent injection of saline, or viscoelastic material in the space between the stroma and Descemet's membrane (DM).^[2]Various treatment options for DMD's include observation, intracameral injection of air, expansile gases such as SF6 or C3F8, transcorneal suturing, and keratoplasty.^{[3],[4] ,[5],[6]}

We report a case of persistent DMD that occurred after phacoemulsification surgery and describe an alternative treatment for the management in a patient who underwent repeated descemetopexy.

Case Report

A 65-year-old female underwent phacoemulsification of the right eye. On postoperative day 1, her best corrected visual acuity (BCVA) was hand movement close to face (HMCF) with accurate projection of rays in all quadrants. The anterior chamber (AC) was deep with generalized corneal edema [Figure 1]. Slit-lamp examination revealed a DMD at the center extending nasally, which was further confirmed with an anterior segment-ocular coherence tomography (AS-OCT) [Figure 1].

Figure 1: Slit-lamp examination showing a Descemets membrane detachment at the center extending nasally.

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Furthermore, 14% C3F8 injection under topical anesthesia with ab-externo stab incision was performed. The vision improved to 20/400 and corneal edema reduced, but the DMD persisted in the pupillary axis. The technique of corneal venting incisions was proposed with informed consent.

Using an AS-OCT, the areas of fluid pockets were identified [Figure 2]. An AC paracentesis was performed with a microvitreoretinal (MVR) blade at the limbus, where the DM remained in contact. The AC was formed with air. A slanted stab incision was made with a 23-gauge needle at a midperipheral region corresponding to the highest point of the detached DM as identified clinically and with AS-OCT. The needle tip stopped as soon as it penetrated the corneal stroma. The pre-Descemet fluid was expressed out by giving gentle pressure toward the stab incision [Figure 3]. Superonasal and inferonasal venting incision were used. The edema reduced with DM reattached. On follow-up, the BCVA was 20/40 and no redetachment event was reported [Figure 4].

Figure 2: Anterior segment OCT showing the extent of DMD

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Figure 3: Slanted stab incision, with a 23-gauge needle as a venting incision at a midperipheral place on the cornea corresponding to the highest point of the detached Descemet's membrane as identified clinically and with AS-OCT

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Figure 4: Descemet's membrane was completely reattached to the stroma in the post-op period

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Discussion

DMD is an uncommon complication of cataract surgery with an incidence of 2.6% and 0.5% cases after extracapsular cataract surgery and phacoemulsification, respectively.^[7]

Surgical causes include the use of blunt instruments, poor surgical technique, increased use of clear corneal incisions, misdirection of cannulas while injecting the intracameral drug, saline, or viscoelastic, and difficult intraocular lens (IOL) insertion.^[8]It is usually diagnosed intraoperatively or in the early postoperative period and is rarely seen in the late postoperative period.^[9]The management depends upon the location and the extent of the detachment, the degree of the separation from the stroma, and the duration of the conservative management.^[10]

Prognosis depends on prompt recognition and early treatment of DMD. AS-OCT is effective for early diagnosis, guiding subsequent treatment, and monitoring the progress of DMD.^[11]

Kumar et al. described the HELP algorithm evaluating DMD in terms of height, extent, length, and pupil using an AS-OCT for evaluating and localizing the site and the extent of the DMD. This helps in standardizing the management of DMD.^[12]Despite spontaneous reattachment, many surgeons advocate the early repair of DMD.^[13]

Techniques for reattachment of DM include manual repositioning (with cyclodialysis spatula),^[3] repositioning with viscoelastic^[4] or air,^[5] or suturing DM to the peripheral cornea.^[6]Descemetopexy with either 100% air or iso-expansile gases such as 15%–20% SF₆ or 12%-14% C₃F₈ are used as tamponading agents with a success rate of 90%–95%.^[7],[14]Transcorneal suturing of detached DM has also been tried alone and with intracameral gas in cases of refractory DMD.^[15]

Price et al.^[16] in 2006, described mid-peripheral incisions with the use of a 15° blade in the host-graft interface in descemet stripping endothelial keratoplasty (DSEK). The incisions facilitated graft adhesion by draining interface fluid. Corneal venting incisions have been used in cases of acute corneal hydrops with tears in the DM and multiple intrastromal clefts.^[17]Ghaffariyeh et al.^[18] in 2011, used a 10.0 needle into the detached area to drain the Supra-Descemet's fluid through the needle tract in the cornea. Singh et al.^[19] in 2016, used an intraoperative AS-OCT to locate the fluid pockets and see the instantaneous decrease in the height of the detached membrane. Bhatia et al.^[20] in 2016, used a 20-gauge MVR blade to drain the fluid pockets using an AS-OCT and Scheimpflug imaging along with air tamponade in a case with persistent DMD. Weng et al.^[21] in 2017, used a 23-gauge needle to puncture the peripheral cornea to drain the pre-Descemet fluid with intracameral air tamponade, with an AS-OCT as a guide to plan the site of puncture. Merrick proposed penetrating keratoplasty for persistent DMD.^[22]

Keratoplasty is the last resort for visual rehabilitation with limitations of the nonavailability of corneal tissue, risk of rejection or infection, the requirement of good postoperative care, and regular follow-up.

Conclusion

DMD is an uncommon complication of cataract surgery. The prognosis depends upon prompt recognition and management. The use of modalities such as AS-OCT, Schiemflug imaging, and pachymetry helps in proper diagnosis and selecting appropriate management options. The majority of the DMD is small and spontaneously resolve. For them, medical management with observation is sufficient. For persistent large DMD, descemetopexy with the use of expansile gases has been used to tamponade the DM. The HELP algorithm has led to an objective assessment of DMD and thinning the gray line between either going for observation or intervention with various modalities available. If descemetopexy fails, a corneal venting incision can be used as a last resort before going for keratoplasty. Keratoplasty still remains the treatment of choice for long-standing and persistent DMD.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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