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Bilateral Descemet Membrane Detachment Following Cataract Surgery

Bilateral Descemet Membrane Detachment Following Cataract Surgery 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.1-3 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. Report of a Case 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). View LargeDownload 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. Comment Unilateral DMD typically occurs at the time of surgery and is thought to be related to poor wound construction and direct Descemet membrane trauma.1-3 Bilateral, post–cataract extraction DMD, however, is rare and typically occurs in uncomplicated procedures. It has been reported previously in 12 patients.4-13 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. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction Table. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction View LargeDownload 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. Back to top Article Information 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. References 1. Monroe WM. Gonioscopy after cataract extraction. South Med J. 1971;64(9):1122-11244938078PubMedGoogle ScholarCrossref 2. Samuels B. Detachment of Descemet's membrane. Trans Am Ophthalmol Soc. 1928;26:427-43716692811PubMedGoogle Scholar 3. Payne T. Dull knives and Descemet's membrane detachments. Arch Ophthalmol. 1978;96(3):542629694PubMedGoogle ScholarCrossref 4. Sparks GM. Descemetopexy: surgical reattachment of stripped Descemet's membrane. Arch Ophthalmol. 1967;78(1):31-346027733PubMedGoogle ScholarCrossref 5. Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol. 1977;95(3):459-463843278PubMedGoogle ScholarCrossref 6. Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phaco- emulsification. Cornea. 2001;20(6):670-67111473175PubMedGoogle ScholarCrossref 7. Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet's membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109(12):2325-233012466178PubMedGoogle ScholarCrossref 8. Gault JA, Raber IM. Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;15(5):483-4898862925PubMedGoogle ScholarCrossref 9. Kim T, Sorenson A. Bilateral Descemet membrane detachments. Arch Ophthalmol. 2000;118(9):1302-130310980783PubMedGoogle ScholarCrossref 10. Fang JP, Amesur KB, Baratz KH. Preexisting endothelial abnormalities in bilateral postoperative Descemet membrane detachment. Arch Ophthalmol. 2003;121(6):903-90412796268PubMedGoogle ScholarCrossref 11. 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):758-76017061232PubMedGoogle Scholar 12. 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):778-78119304105PubMedGoogle ScholarCrossref 13. Couch SM, Baratz KH. Delayed, bilateral Descemet's membrane detachments with spontaneous resolution: implications for nonsurgical treatment. Cornea. 2009;28(10):1160-116319770730PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Ophthalmology American Medical Association

Bilateral Descemet Membrane Detachment Following Cataract Surgery

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6165
eISSN
2168-6173
DOI
10.1001/2013.jamaophthalmol.368
Publisher site
See Article on Publisher Site

Abstract

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.1-3 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. Report of a Case 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). View LargeDownload 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. Comment Unilateral DMD typically occurs at the time of surgery and is thought to be related to poor wound construction and direct Descemet membrane trauma.1-3 Bilateral, post–cataract extraction DMD, however, is rare and typically occurs in uncomplicated procedures. It has been reported previously in 12 patients.4-13 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. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction Table. Summary of All Reported Cases of Bilateral Descemet Membrane Detachment After Cataract Extraction View LargeDownload 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. Back to top Article Information 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. References 1. Monroe WM. Gonioscopy after cataract extraction. South Med J. 1971;64(9):1122-11244938078PubMedGoogle ScholarCrossref 2. Samuels B. Detachment of Descemet's membrane. Trans Am Ophthalmol Soc. 1928;26:427-43716692811PubMedGoogle Scholar 3. Payne T. Dull knives and Descemet's membrane detachments. Arch Ophthalmol. 1978;96(3):542629694PubMedGoogle ScholarCrossref 4. Sparks GM. Descemetopexy: surgical reattachment of stripped Descemet's membrane. Arch Ophthalmol. 1967;78(1):31-346027733PubMedGoogle ScholarCrossref 5. Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol. 1977;95(3):459-463843278PubMedGoogle ScholarCrossref 6. Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phaco- emulsification. Cornea. 2001;20(6):670-67111473175PubMedGoogle ScholarCrossref 7. Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet's membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109(12):2325-233012466178PubMedGoogle ScholarCrossref 8. Gault JA, Raber IM. Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;15(5):483-4898862925PubMedGoogle ScholarCrossref 9. Kim T, Sorenson A. Bilateral Descemet membrane detachments. Arch Ophthalmol. 2000;118(9):1302-130310980783PubMedGoogle ScholarCrossref 10. Fang JP, Amesur KB, Baratz KH. Preexisting endothelial abnormalities in bilateral postoperative Descemet membrane detachment. Arch Ophthalmol. 2003;121(6):903-90412796268PubMedGoogle ScholarCrossref 11. 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):758-76017061232PubMedGoogle Scholar 12. 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):778-78119304105PubMedGoogle ScholarCrossref 13. Couch SM, Baratz KH. Delayed, bilateral Descemet's membrane detachments with spontaneous resolution: implications for nonsurgical treatment. Cornea. 2009;28(10):1160-116319770730PubMedGoogle ScholarCrossref

Journal

JAMA OphthalmologyAmerican Medical Association

Published: Apr 1, 2013

Keywords: cataract surgery,descemet's membrane

References

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