Descemet’s membrane detachment after phaco could require intervention

Surgeons should avoid making the clear corneal incision with a blunt knife and injecting fluid too deeply when hydrating the incision.

Jagat Ram

Early recognition and resolution of Descemet’s membrane detachment after phacoemulsification significantly improved visual outcomes, a study found.

“Intraoperative and postoperative detection of Descemet’s membrane detachment and its prompt management led to remarkable improvement of visual acuity,” Jagat Ram, MD, the corresponding author, told Ocular Surgery News in an email interview.

Surgeons should suspect Descemet’s membrane detachment in patients with unexpected postoperative corneal edema, the study authors said.

“The most significant finding was the presence of corneal edema in the postoperative period in these patients who have undergone uneventful phacoemulsification and had suspected Descemet’s membrane detachment,” Dr. Ram said.

Localized separation of Descemet’s membrane from the stroma occurs frequently after intraocular surgery and normally resolves spontaneously. However, extensive separation persists for a longer time and might require surgical intervention, Dr. Ram and colleagues said.

Diagnosis and management

The study, published in Ophthalmic Surgery, Lasers and Imaging, included hospital records of 11 eyes of 11 patients with Descemet’s membrane detachment. The study was based at the Advanced Eye Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Mean patient age was 55.7 years.

All eyes underwent standard phacoemulsification performed with the Infiniti phacoemulsification system (Alcon) through a clear corneal incision. All eyes received an AcrySof MA60AC or SN60WF acrylic IOL (Alcon) implanted in the capsular bag. Standard antibiotics and steroids were administered post-operatively.

Three cases of Descemet’s membrane detachment were diagnosed intraoperatively and eight cases were diagnosed during postoperative slit lamp examination. No signs of Descemet’s membrane detachment were detected preoperatively.

All 11 identified cases of Descemet’s membrane detachment originated at the wound site. Mean follow-up was 18 months (range: 6 to 43 months).

In the three cases diagnosed intraoperatively, detachment was attributed to accidental injection of sodium hyaluronate anterior to Descemet’s membrane before IOL insertion in one eye, incision creation in one eye and hydration of the incision at the end of surgery in one eye.

Intracameral injection of perfluoropropane gas resolved Descemet’s membrane detachment in all three eyes; no additional surgical intervention was needed.

The eight eyes diagnosed postoperatively had unexpected corneal edema. Injection of perfluoropropane gas into the anterior chamber resolved Descemet’s membrane detachment in seven eyes. Partial resolution was achieved in one eye.

Two eyes required more than one gas injection. One eye received two gas injections. The other eye had two gas injections and subsequent intracameral injection of Healon GV (Sodium hyaluronate 1.4%, Abbott Medical Optics) to reattach the membrane.

At final follow-up, 10 eyes had clear corneas and one had residual Descemet’s membrane detachment that did not involve the visual axis. All eyes had best corrected visual acuity of 6/12 or better.

Incision, surgical technique

Creation of the clear corneal incision with a blunt knife may increase the risk of intraoperative Descemet’s membrane detachment, Dr. Ram said.

“The operating surgeon should be careful while making clear a corneal incision,” he said. “The blade should be sharp and not blunt.”

Additionally, handling of the phaco tip, viscoelastic and cannula through the incision should be undertaken with extreme caution, Dr. Ram said.

“One should be careful while injecting viscoelastic devices into the anterior chamber, introducing the phaco tip through the incision and when hydrating the lip of the incision at the end of surgery to reduce occurrence of Descemet’s membrane displacement,” he said. “[The] placement of cannula while hydrating the phaco incision at the end of surgery should be at correct depth to avoid injection of fluid at the level of Descemet’s membrane.”

Dehydration of the cornea may be used to detect Descemet’s membrane detachment postoperatively in some cases, Dr. Ram said.

“If slit lamp biomicroscopy fails to detect Descemet’s membrane detachments, we use topical glycerine to temporarily dehydrate the cornea and detect the presence of Descemet’s membrane detachments,” he said.

Ultrasound biomicroscopy may enhance the identification of Descemet’s membrane detachment, Dr. Ram and colleagues said.

Descemet’s stripping endothelial keratoplasty may be considered if relatively conservative measures such as intracameral gas injection or viscoelastic injection fail to resolve Descemet’s membrane detachment, Dr. Ram said. – by Matt Hasson

Reference:

• Sukhija J, Ram J, Kaushik S, Gupta A. Descemet’s membrane detachment following phacoemulsification. Ophthalmic Surg Lasers Imaging. 2010;41(5):512-517.

• Jagat Ram, MD, can be reached at Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; +91-172-275-6111; fax: +91-172-274-7837; email: drjagatram@yahoo.com.
• Disclosure: Dr. Ram has no relevant financial disclosures.

Descemet’s membrane detachment is a rare but potentially serious complication of phacoemulsification. While limited Descemet’s membrane detachments that are away from the visual axis may be managed conservatively, extensive Descemet’s membrane detachments, especially those involving the visual axis, demand early recognition and timely intervention in order to achieve the best possible outcomes. Sukhija and colleagues have demonstrated in their series of 11 cases of post-phacoemulsification Descemet’s membrane detachments that good visual outcomes and reattachment rate are possible even in the very extensive cases if managed properly. Intracameral injection of long-standing gases is a convenient and effective treatment that may be repeated. Special attention should be paid to raised post-injection intraocular pressure as pupillary block glaucoma is a possible complication after gas injection. In cases when Descemet’s membrane detachments are markedly separated from the stroma, folded or curled, surgical unfolding of the membrane, together with gas injection and/or full-thickness corneal sutures are usually required.

— Alex H. Fan, FRCOphth
Assistant Professor, Chinese University of Hong Kong
— Dr. Lijia Chen, PhD
Post-doctoral Fellow, Chinese University of Hong Kong
— Dennis S.C. Lam, MD
OSN Asia-Pacific Edition Associate Editor,
Disclosures: Drs. Fan, Chen and Lam have no relevant financial disclosures.