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Air bubble technique can be used to repair iatrogenic Descemet's membrane detachment
Intracameral gas injection is avoided with this procedure.
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Iatrogenic Descemet’s membrane detachment is a rare complication of cataract surgery. A Descemet’s membrane tear can progress into a large detachment by continued traction on the torn edge of the Descemet’s membrane by any intraocular instrumentation or manipulation or during introduction of the phaco tip, IOL or device such as a tube shunt.
Inadvertent Descemet’s membrane detachment can result especially when using a blunt, dull surgical blade that does not make a clean incision. Instead, it can push down on the Descemet’s membrane, contributing to a jagged, saw-tooth type of Descemet’s membrane tear with a detachment as the blade further catches on the torn edges and strips it away from the corneal stroma. Such an accident usually occurs so quickly that the surgeon is often unable to reverse or halt the course of action.
Also, a torn Descemet’s membrane edge can be a potential site for irrigating fluid or viscoelastic to be injected, causing a large or total Descemet’s membrane detachment. If a small Descemet’s membrane detachment is noted during surgery, every effort should be made to prevent converting it into a large tear by making sure that the viscoelastic cannula tip is well beyond the site of the tear before injecting the viscoelastic and, similarly, ascertaining that the phaco tip with its sleeve is well past the site of the tear before stepping on the foot pedal to initiate fluid egress through the phaco sleeve tip.
A large Descemet’s membrane detachment can result in stromal and epithelial edema, cloudy cornea and compromised vision postoperatively. Early surgical correction is imperative for optimal postoperative visual recovery and to avoid any potential scarring secondary to prolonged corneal edema and possible inflammation. In extreme cases, prolonged Descemet’s membrane detachment and corneal scarring may occasionally require corneal transplantation, which can be avoided by timely surgical intervention to correct this surgical complication.
Although surgeons have used intracameral gas injection with sulfur hexafluoride or perfluoropropane, caution should be exercised because these gases can result in a significant increase in IOP postoperatively. A rare reported complication of intracameral gas injection is IOL haze that can require IOL exchange.
In this column, I describe a relatively simple surgical technique using air and avoiding intracameral gas injection to repair iatrogenic Descemet’s membrane detachment and reverse corneal edema.
Figure 1. Preoperative slit-lamp photo displaying extensive, diffuse stromal and epithelial edema. Also seen is the previously performed LASIK flap and the flap-stromal interface (arrows).
Images: John T
Case history
A 59-year-old Caucasian woman was referred by her ophthalmologist with a detached Descemet’s membrane and corneal edema in the right eye. The detachment occurred during the implantation of a premium IOL. The IOL haptic appeared to have caught on the cut edge of the Descemet’s membrane at the temporal entry wound site and caused a significant detachment with diffuse stromal and epithelial edema (Figures 1 to 3). The uncorrected vision in the right eye was 20/200 with no pinhole improvement, and the IOP was normal at 13 mm Hg. The patient had LASIK in the right eye (Figures 1 and 3) 12 years before presentation. Slit-lamp view clearly showed the detached Descemet’s membrane (Figure 2). This was confirmed by corneal optical coherence tomography (Figure 3).
Figure 2. Composite slit-lamp photos show the detached Descemet’s membrane (arrows).
Figure 3. Preop OCT images displaying detached Descemet’s membrane (arrows), corneal stromal thickening secondary to stromal edema, and the previous LASIK flap (asterisks) and the flap-stromal interface.
Surgical technique
Under topical anesthesia and monitored anesthesia care, Descemet’s membrane was reattached (Figures 4 to 9).
The anterior chamber was entered with a super blade at the far peripheral cornea close to the limbus, distal to the area of Descemet’s membrane detachment, and a 30-gauge blunt cannula was introduced into the anterior chamber (Figure 4). The cannula tip was advanced toward the central cornea close to the pupil (Figure 4). Air was steadily injected into the anterior chamber to attain a large air bubble, thus re-attaching the detached Descemet’s membrane (Figure 5). Folds in the attached Descemet’s membrane were clearly visible in the central cornea (Figure 6). A muscle hook was used to gently massage the central corneal dome (Figure 6). The muscle hook was moved in various radial directions from the central to the peripheral cornea, applying gentle pressure on the external corneal dome, to iron out any folds and attain a uniform Descemet’s membrane attachment to the patient’s inner corneal stromal surface (Figure 7). This resulted in the uniform attachment of the Descemet’s membrane without any folds or gaps (Figure 8).
Figure 4. A 30-gauge cannula is introduced into the anterior chamber from a peripheral entry wound close to the limbus, distal to the area of Descemet’s membrane detachment. The cannula tip is advanced toward the central cornea close to the pupil.
Figure 5. Air is steadily injected into the anterior chamber to result in a large air bubble, thus re-attaching the detached Descemet’s membrane.
Figure 6. Folds in the attached Descemet’s membrane are clearly visible in the central cornea (left). A muscle hook is used to gently massage the central corneal dome (right).
Figure 7. The muscle hook is moved in various radial directions from the central to the peripheral cornea, applying gentle pressure on to the external corneal dome, to iron out any folds and attain a uniform Descemet’s membrane attachment to the patient’s inner corneal stromal surface.
Figure 8. Notice the uniform attachment of the Descemet’s membrane without any folds or gaps. The air bubble is further enlarged to fully fill the anterior chamber, resulting in a temporary increase in IOP. This large air bubble is left in place for a duration of 3 minutes to allow uniform attachment of the detached Descemet’s membrane.
Figure 9. After 3 minutes, the cannula is reintroduced into the central region of the anterior chamber, and the air bubble size is decreased. No peripheral iridectomy is performed, so it is imperative to reduce the size of the residual air bubble within the anterior chamber.
The air bubble was further enlarged to fully fill the anterior chamber (Figure 8), resulting in a temporary increase in IOP. This large air bubble was left in place for 3 minutes to allow uniform attachment of the detached Descemet’s membrane. After 3 minutes, the cannula was reintroduced into the central region of the anterior chamber, and the air bubble size was decreased (Figure 9). No peripheral iridectomy was performed, so it was imperative to reduce the size of the residual air bubble within the anterior chamber to prevent any potential pupillary block postoperatively. Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb), diclofenac and Besivance (besifloxacin ophthalmic suspension 0.6%, Bausch + Lomb) drops were applied, and the pupil was dilated with homatropine 5% drops. Tobradex ointment (tobramycin and dexamethasone, Alcon) was then applied to the ocular surface, and the eye was patched, along with an eye shield.
Figure 10. Slit-lamp photograph on postoperative day 1 showing uniform attachment of the detached Descemet’s membrane without any gap or false anterior chamber. The cornea is clear and compact with a residual air bubble.
Postoperative result
On day 1 after the procedure, a clear and compact cornea was visible using the slit lamp (Figure 10). Also seen was a residual air bubble superiorly (Figure 10). There was uniform attachment of the Descemet’s membrane to the inner corneal stromal surface without any gaps, false anterior chamber or folds in the Descemet’s membrane (Figures 10 to 12). The premium IOL was clearly seen on postoperative day 1 (Figure 11) through a clear cornea. The patient’s uncorrected vision improved to 20/80 on day 1 with an IOP of 15 mm Hg in the right eye, and uncorrected vision was 20/40 on day 5. Without correction, the patient was able to read and see distant objects clearly. She was pleased with the surgical result.
Figure 11. The premium IOL is seen through the clear cornea on day 1 after the procedure.
Figure 12. Day 1 after surgery, OCT images display uniform attachment of the Descemet’s membrane (arrows) without any folds or gaps between the Descemet’s membrane and the inner corneal stromal surface.
Comment
Corneal edema secondary to iatrogenic Descemet’s membrane detachment can be corrected under topical anesthesia with monitored anesthesia care using a temporary large air bubble to attach the Descemet’s membrane. Unlike Descemet’s membrane endothelial keratoplasty, there is no circular 360° tear in the Descemet’s membrane. The tear in iatrogenic Descemet’s membrane detachment is usually focal in the region of the entry wound, in this case the temporal cataract wound. It is important to make the entry wound in the far peripheral region of the cornea close to the limbus in an attempt to avoid the region of the iatrogenic tear in the Descemet’s membrane. Because there is no complete circular tear in the Descemet’s membrane, unlike DMEK, there is no need to have a large air bubble postoperatively. Therefore, no peripheral iridectomy is needed. However, a 3-minute large air bubble fully filling the anterior chamber is used in combination with gentle uniform massage for optimal Descemet’s membrane attachment while avoiding intracameral gas injection.
References:
- Akin T, Ayata A, Aykan U, Bilge AH. Intracameral perfluoropropane (C3F8) gas in the repair of extensive Descemet’s membrane detachment during phacoemulsification surgery [posted online March 9, 2010]. Ophthalmic Surg Lasers Imaging. doi:10.3928/15428877-20100215-01.
- Fishkind WJ. Facing down the 5 most common cataract complications. Review of Ophthalmology. 2001;8(10):37.
- Kim T, Hasan SA. A new technique for repairing Descemet membrane detachments using intracameral gas injection. Arch Ophthalmol. 2002;120(2):181-183.
- Mannan R, Pruthi A, Om Parkash R, Jhanji V. Descemet membrane detachment during foldable intraocular lens implantation. Eye Contact Lens. 2011;37(2):106-108.
- Nouri M, Pineda R Jr, Azar D. Descemet membrane tear after cataract surgery. Semin Ophthalmol. 2002;17(3-4):115-119.
- 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.
For more information:
- Thomas John, MD, is a clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; email: tjcornea@gmail.com.
- Disclosure: John has no relevant financial disclosures.