Extensive Descemet membrane detachment (DMD) is a rare complication of intraocular surgery that can lead to corneal decompensation.1Although DMD may resolve spontaneously, surgical repair frequently is required. The diagnosis may be difficult because corneal edema can obscure visualization of the Descemet membrane (DM). Ultrasonographic biomicroscopy (UBM) has been the standard for imaging DMD in patients with corneal opacity.2Anterior segment optical coherence tomography (OCT) is a new technique for imaging anterior segment anatomy to evaluate narrow angles, flaps created with laser-assisted in situ keratomileusis, and corneas after DM-stripping automated endothelial keratoplasty.3We report 2 cases of extensive DMD in which both UBM (model P45 ultrasonographic biomicroscope; Paradigm Medical, Inc, Salt Lake City, Utah; VuMax ultrasonographic biomicroscope; Sonomed, Inc, Lake Success, New York) and anterior segment OCT (Visante optical coherence tomographer; Carl Zeiss Meditec, Inc, Dublin, California) were used to image the DMD before surgical repair.
A 73-year-old man underwent cataract extraction via phacoemulsification with a temporal clear corneal incision. He had a history of tamsulosin hydrochloride (Flomax) use, and iris hooks were placed to manage intraoperative floppy iris syndrome. On postoperative day 1, visual acuity was 20/40; however, within 24 hours, visual acuity decreased to 20/400 and substantial corneal edema had developed. There were no signs of intraocular infection, and combined treatment with prednisolone acetate, 1%, and a sodium chloride solution, 5%, was started. The patient's condition did not improve during the next 2 weeks, and he was referred to our institution for evaluation of possible pseudophakic bullous keratopathy. Visual acuity was still 20/400, without an afferent pupillary defect. Intraocular pressure was normal. Slitlamp examination revealed quiet conjunctiva and diffuse corneal edema with a quiltlike pattern of deep stromal folds (Figure, A). Through the hazy view, there was the suggestion of a large DMD. The remainder of the ophthalmologic examination yielded unremarkable findings. The patient underwent both UBM (Figure, B) and anterior segment OCT (Figure, C), which confirmed a large, planar, nonscrolled DMD involving almost the entire cornea. After an initial intracameral injection of sulfur hexafluoride, 20%, failed to enable reattachment of the DM, a second, larger injection of sulfur hexafluoride, 20%, was administered. One month postoperatively, there was complete resolution of the DMD (Figure, D) and visual acuity was 20/30.
A 90-year-old woman underwent cataract surgery via phacoemulsification. At the end of the procedure, the surgeon discovered a large DMD and injected filtered air into the anterior chamber in an attempt to tamponade the DM against the corneal stroma. On postoperative day 1, the air bubble had been absorbed but the DM remained detached, with substantial corneal edema. After combined treatment with prednisolone acetate, 1%, and sodium chloride, 5%, for 1 month, the patient was referred to our institution for repair of the DMD. Visual acuity was 20/400. Pupil reactivity was normal, as were results of tonometry. Slitlamp examination revealed a large, central, nonplanar DMD with a slightly scrolled temporal edge (Figure, G) and diffuse corneal edema with deep stromal folds in a quiltlike pattern (Figure, E). The remainder of the examination yielded unremarkable findings. The patient underwent UBM (Figure, F) and anterior segment OCT (Figure, G) before repair of the DMD, with injection of octafluoropropane, 14%, into the anterior chamber. One month after surgery, the DMD had completely resolved (Figure, H) and visual acuity was 20/50.
Although small, localized DMDs are commonly seen in modern cataract surgery, large detachments are rare and can be visually devastating. Mechanisms such as engaging the DM with the irrigation-aspiration probe, mechanically stripping the DM with the intraocular lens during implantation, and inadvertently injecting viscoelastic between the DM and the stroma have been proposed.1Kansal and Sugar4suggest that some patients, especially those with bilateral DMD after surgery, may have abnormalities of the fibrillar bundles of collagen that attach the DM to the posterior stroma.
To aid in prognosis, DMD can be classified as planar (<1 mm separating the DM from stroma) or nonplanar (>1 mm separating the DM from stroma), with scrolled or nonscrolled edges.1Planar, nonscrolled DMD has the best prognosis for spontaneous resolution, whereas nonplanar or scrolled DMD typically requires surgical correction.1
Although DMD may spontaneously reattach within weeks to months, many authors advocate early surgery to prevent fibrosis that can be associated with long-standing corneal edema.1,5Options include manual repositioning; suturing of the DM to the peripheral cornea; or mechanical tamponade with an intracameral injection of air, sulfur hexafluoride, octafluoropropane, or viscoelastic.1,2,4,5Injection of isoexpansile sulfur hexafluoride, 20%, or octafluoropropane, 14%, may be preferable in most cases because air often reabsorbs before the DM is reattached and viscoelastics can cause prolonged intraocular pressure elevation.5In addition, this procedure can be performed at the slitlamp and may be repeated if necessary.
As in case 1, diffuse corneal edema can obscure the slitlamp view into the anterior chamber, making the diagnosis and subsequent surgical planning difficult. Ultrasonographic biomicroscopy has been advocated as a means of imaging DMD through an opaque cornea, but this procedure requires a skilled technician, a cooperative patient, and substantial time investment.2Anterior segment OCT may be a superior alternative to UBM because of the speed and ease of image acquisition, the ability to acquire images without direct corneal contact, and the ability to image patients in the upright position.3Optical coherence tomography provides higher-resolution images (18 μm with Visante OCT vs 20-50 μm with UBM) and can accommodate multiple angles of incidence to the tissues, whereas UBM gives the best reflectance and, therefore, signal when the tissue planes are perpendicular to the sound energy.3Optical coherence tomography may be of particular benefit in the early postoperative period because it does not require immersion of the eye in solution and thus reduces the risk of infection. In our series, the image quality of the anterior segment with OCT was clearly superior to that with UBM. In our experience, anterior segment OCT was also helpful in determining areas of peripheral DM attachment, where injection of gas tamponade could be performed safely and effectively.
In summary, DMD as a cause of severe corneal edema after cataract surgery can be difficult to diagnose. The noncontact, high-resolution imaging provided byanterior segment OCT enables improved visualization that can aid in better diagnosis and optimal surgical planning.
Patients 1 and 2, respectively. A and E, Slitlamp view shows diffuse corneal edema in a quiltlike pattern. B and F, Horizontal ultrasonographic biomicroscopic image through the central cornea demonstrates a large central Descemet membrane detachment. C and G, Corresponding horizontal image obtained with anterior segment optical coherence tomography before repair. D and H, Horizontal anterior segment optical coherence tomographic image obtained 6 months after repair demonstrates complete resolution of the Descemet membrane detachment.
Correspondence: Dr Lin, Beckman Vision Center, University of California, San Francisco, San Francisco, CA 94143-0730 (LinS@vision.ucsf.edu).
Financial Disclosure: None reported.
Funding/Support: This study was supported by core grant P30 EY002162 from the National Institutes of Health and by an unrestricted grant from That Man May See, Inc.
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