0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Small Case Series |

Bilateral Descemet Membrane Detachment Following Cataract Surgery FREE

Zaid Shalchi, MRCP, MSc; David P. S. O’Brart, MD, FRCS, FRCOphth; Luca Ilari, FRCOphth
[+] Author Affiliations

Author Affiliations: Department of Ophthalmology, St Thomas' Hospital, Westminster Bridge Road, London, England.


JAMA Ophthalmol. 2013;131(4):533-535. doi:10.1001/2013.jamaophthalmol.368.
Text Size: A A A
Published online

Descemet membrane detachment (DMD) is a sight-threatening complication that has been reported after diverse surgical procedures. Unilateral DMD typically arises as the result of engagement of the Descemet membrane during intraocular surgery.13 We report an unusual case of bilateral DMD occurring spontaneously several weeks after sequential uncomplicated phacoemulsification cataract extraction. We review previously reported cases and propose that these eyes share an underlying weakness of Descemet membrane attachment.

A 64-year-old man underwent uncomplicated right phacoemulsification cataract extraction with a temporal clear corneal incision. Although initially excellent, his vision deteriorated 10 days postoperatively. At 2 weeks, visual acuity was 20/120 with superior corneal edema remote from the temporal incision. At 1 month, visual acuity had reduced to count fingers with widespread corneal edema and total DMD (Figure, A and B).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Slitlamp color photographs of both eyes. A and B, Right eye at 6 weeks postoperatively showing widespread corneal haze (A) and a planar Descemet membrane detachment (B). C and D, Right eye 2 weeks after pneumatic descemetopexy with air showing a clear cornea with no edema (C) but a redundant fold in the Descemet membrane off the visual axis (D). E and F, Left cornea preoperatively (E) and after cataract extraction (F) and subsequent pneumatic air descemetopexy.

The patient was referred to the Cornea Service and was seen 8 weeks postoperatively. The total DMD persisted despite medical therapy and the patient underwent an intracameral air injection with postoperative supine posturing. This allowed complete reattachment of the Descemet membrane and visual acuity improved to 20/30 unaided with a clear cornea albeit with a peripheral Descemet fold (Figure, C and D).

After giving informed consent, the patient underwent phacoemulsification cataract extraction in his left eye. Preoperatively, the left cornea was clear (Figure, E). Surgery was uncomplicated. As a precaution, an injection of intracameral air was given at the end of surgery and the patient was postured supine for 6 hours postoperatively. On the first day postoperatively, the cornea was clear with an adherent endothelium. However, at 2 weeks, there was edema of the superior third of the cornea with a partial DMD distant from the temporal corneal incision. Visual acuity was reduced to 20/120. The next day, he underwent an injection of air into the anterior chamber with supine posturing. Postoperatively, his endothelium reattached with an unaided visual acuity of 20/30 (Figure, F). Postoperative specular microscopy revealed healthy endothelial cells, with cell counts of 2018/mm2 and 2275/mm2 in the right and left eyes, respectively.

Unilateral DMD typically occurs at the time of surgery and is thought to be related to poor wound construction and direct Descemet membrane trauma.13 Bilateral, post–cataract extraction DMD, however, is rare and typically occurs in uncomplicated procedures. It has been reported previously in 12 patients.413 In this report, we summarize the clinical characteristics of these cases, together with our own (Table). Median patient age was 77 years with no sex bias. The condition occurs mostly in association with phacoemulsification techniques (21 of 24 eyes where information available [81%]) and clear corneal incisions (14 of 19 eyes [74%]). Descemet membrane detachment was identified either intraoperatively or on the first postoperative day in 10 of 21 eyes (48%), with another 8 (38%) only becoming apparent after 2 weeks. Endothelial guttata were identified in 3 of 13 patients (23%).

Table Graphic Jump LocationTable. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction

Six of the 26 affected eyes (23%) resolved with medical (nonsurgical) therapy alone. The remaining 20 (77%) all underwent pneumatic descemetopexy, which permanently reattached the Descemet membrane in 17 cases (85%). Sulfur hexafluoride was the most commonly used gas. Three eyes (11.5%) required penetrating keratoplasty. Visual outcome was generally good, with a median best-corrected visual acuity of 20/30 (range, 20/20-20/100).

The etiology of bilateral, post–cataract extraction DMD is poorly understood. Although endothelial guttata have been documented in some eyes, most corneae have a normal appearance on slitlamp and specular microscopic examination.

The occurrence of bilateral, post–cataract extraction DMD is rare but its incidence is increasing. The Table shows that only 2 cases were reported before 1990, whereas 6 cases have been described in the last decade alone. This may relate to increasing use of clear corneal incisions in phacoemulsification cataract surgery. We propose there is inherent weakness of adhesion between the Descemet membrane and the underlying stroma in these patients and suggest further investigation be directed at collagen fibrillary attachment and anchoring protein function in affected individuals. Although confocal microscopy and high-resolution anterior segment optical coherence tomography may prove helpful, the ultimate pathology may only be determined through histological examination.

Correspondence: Dr O'Brart, Department of Ophthalmology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, England (davidobrart@aol.com).

Conflict of Interest Disclosures: None reported.

Previous Presentation: This work was presented at the Trends in Ophthalmology Meeting; February 3, 2012; London, England.

Monroe WM. Gonioscopy after cataract extraction.  South Med J. 1971;64(9):1122-1124
PubMed   |  Link to Article
Samuels B. Detachment of Descemet's membrane.  Trans Am Ophthalmol Soc. 1928;26:427-437
PubMed
Payne T. Dull knives and Descemet's membrane detachments.  Arch Ophthalmol. 1978;96(3):542
PubMed   |  Link to Article
Sparks GM. Descemetopexy: surgical reattachment of stripped Descemet's membrane.  Arch Ophthalmol. 1967;78(1):31-34
PubMed   |  Link to Article
Mackool RJ, Holtz SJ. Descemet membrane detachment.  Arch Ophthalmol. 1977;95(3):459-463
PubMed   |  Link to Article
Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phaco- emulsification.  Cornea. 2001;20(6):670-671
PubMed   |  Link to Article
Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet's membrane detachment after cataract surgery: management and outcome.  Ophthalmology. 2002;109(12):2325-2330
PubMed   |  Link to Article
Gault JA, Raber IM. Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas.  Cornea. 1996;15(5):483-489
PubMed   |  Link to Article
Kim T, Sorenson A. Bilateral Descemet membrane detachments.  Arch Ophthalmol. 2000;118(9):1302-1303
PubMed   |  Link to Article
Fang JP, Amesur KB, Baratz KH. Preexisting endothelial abnormalities in bilateral postoperative Descemet membrane detachment.  Arch Ophthalmol. 2003;121(6):903-904
PubMed   |  Link to Article
Saeed MU, Singh AJ, Morrell AJ. Sequential Descemet's membrane detachments and intraocular lens haze secondary to SF6 or C3F8.  Eur J Ophthalmol. 2006;16(5):758-760
PubMed
Gatzioufas Z, Schirra F, Löw U, Walter S, Lang M, Seitz B. Spontaneous bilateral late-onset Descemet membrane detachment after successful cataract surgery.  J Cataract Refract Surg. 2009;35(4):778-781
PubMed   |  Link to Article
Couch SM, Baratz KH. Delayed, bilateral Descemet's membrane detachments with spontaneous resolution: implications for nonsurgical treatment.  Cornea. 2009;28(10):1160-1163
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Slitlamp color photographs of both eyes. A and B, Right eye at 6 weeks postoperatively showing widespread corneal haze (A) and a planar Descemet membrane detachment (B). C and D, Right eye 2 weeks after pneumatic descemetopexy with air showing a clear cornea with no edema (C) but a redundant fold in the Descemet membrane off the visual axis (D). E and F, Left cornea preoperatively (E) and after cataract extraction (F) and subsequent pneumatic air descemetopexy.

Tables

Table Graphic Jump LocationTable. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction

References

Monroe WM. Gonioscopy after cataract extraction.  South Med J. 1971;64(9):1122-1124
PubMed   |  Link to Article
Samuels B. Detachment of Descemet's membrane.  Trans Am Ophthalmol Soc. 1928;26:427-437
PubMed
Payne T. Dull knives and Descemet's membrane detachments.  Arch Ophthalmol. 1978;96(3):542
PubMed   |  Link to Article
Sparks GM. Descemetopexy: surgical reattachment of stripped Descemet's membrane.  Arch Ophthalmol. 1967;78(1):31-34
PubMed   |  Link to Article
Mackool RJ, Holtz SJ. Descemet membrane detachment.  Arch Ophthalmol. 1977;95(3):459-463
PubMed   |  Link to Article
Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phaco- emulsification.  Cornea. 2001;20(6):670-671
PubMed   |  Link to Article
Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet's membrane detachment after cataract surgery: management and outcome.  Ophthalmology. 2002;109(12):2325-2330
PubMed   |  Link to Article
Gault JA, Raber IM. Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas.  Cornea. 1996;15(5):483-489
PubMed   |  Link to Article
Kim T, Sorenson A. Bilateral Descemet membrane detachments.  Arch Ophthalmol. 2000;118(9):1302-1303
PubMed   |  Link to Article
Fang JP, Amesur KB, Baratz KH. Preexisting endothelial abnormalities in bilateral postoperative Descemet membrane detachment.  Arch Ophthalmol. 2003;121(6):903-904
PubMed   |  Link to Article
Saeed MU, Singh AJ, Morrell AJ. Sequential Descemet's membrane detachments and intraocular lens haze secondary to SF6 or C3F8.  Eur J Ophthalmol. 2006;16(5):758-760
PubMed
Gatzioufas Z, Schirra F, Löw U, Walter S, Lang M, Seitz B. Spontaneous bilateral late-onset Descemet membrane detachment after successful cataract surgery.  J Cataract Refract Surg. 2009;35(4):778-781
PubMed   |  Link to Article
Couch SM, Baratz KH. Delayed, bilateral Descemet's membrane detachments with spontaneous resolution: implications for nonsurgical treatment.  Cornea. 2009;28(10):1160-1163
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles