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Air descemetopexy treats Descemet’s membrane detachment
This method may help patients with severe Descemet's membrane detachment avoid keratoplasty.
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More than 60% of patients with severe Descemet’s membrane detachment experienced successful reattachment after undergoing primary air descemetopexy instead of major surgery such as keratoplasty, according to a study.
The anatomic and functional outcomes of patients undergoing primary air descemetopexy for Descemet’s membrane detachment (DMD) were generally positive and well tolerated, Annamalai Odayappan, DNB, told Ocular Surgery News.
“Air descemetopexy is a safe and efficient modality of treatment of DMD and should be tried even in patients with severe DMD before planning a major surgery like endothelial keratoplasty. We believe that when the host tissue can be salvaged, why do we need to place a graft? Endothelial keratoplasty, which has fewer complications than full-thickness keratoplasty, still has complications like graft failure and rejection. Also, it needs a longer duration of topical steroids. All these can be avoided by reattaching the Descemet’s membrane flap with excellent results,” Odayappan said.
However, if the Descemet’s membrane flap is torn, lost or grossly scrolled, it is almost impossible to spread it and reattach without damaging the endothelium. In these cases, endothelial keratoplasty may be necessary, Odayappan said.
Avoiding major surgery
The retrospective study included 110 patients who underwent air descemetopexy for post-cataract surgery sight-threatening Descemet’s membrane detachment; 78 patients had successful reattachment after the procedure.
There was no statistically significant difference in success rates compared with moderate and severe Descemet’s membrane detachment, which should lead to surgeons using air descemetopexy as the first procedure for a Descemet’s membrane detachment, Odayappan said.
“Logically, we may presume that if the detached portion of the Descemet’s membrane is larger, the chances of reattachment and visual recovery are lower. Our results show that even though the success rates are greater in moderate than in severe DMD, it was not statistically significant. So, air descemetopexy should be tried even in patients with severe DMD as the first option before contemplating endothelial keratoplasty,” Odayappan said.
Few complications
Complications were few during air descemetopexy and postoperatively. After the procedure complications included pupillary block with air, appositional angle closure due to migration of the air bubble behind the iris, uveitis due to repeat surgery, persistent Descemet’s membrane detachment and corneal decompensation, but these are easily manageable, Odayappan said.
“The pupillary block typically resolves spontaneously once the air bubble volume decreases with time. Until that time, pressure-lowering medications may be given. Once we dilate the pupil of patients with appositional angle closure, the air bubble behind the iris will come forward, thereby relieving the angle closure. However, if the intraocular pressure did not reduce and the patient was very symptomatic, surgical decompression of air and reformation of the anterior chamber may be necessary. Uveitis is treated with topical steroids, cycloplegics and NSAIDs. We may do a repeat descemetopexy if DMD is found to be persistent. Corneal decompensation needs endothelial keratoplasty,” Odayappan said.
Descemet’s membrane detachment is a rare complication of cataract surgery seen more often in complicated cases or in the hands of trainees. However, air descemetopexy has a high reattachment success rate and may be repeated more than once, Odayappan said.
While the time of the intervention did not affect the reattachment success rate, Odayappan and colleagues agreed that air descemetopexy should be performed within at least 2 weeks of the Descemet’s membrane detachment. – by Robert Linnehan
- Reference:
- Odayappan A, et al. Br J Ophthalmol. 2017;doi:10.1136/bjophthalmol-2016-309766.
- For more information:
- Annamalai Odayappan, DNB, can be reached at Aravind Eye Hospital, Cuddalore main road, Thavalakuppam, Pondicherry – 605007, India; email: oannamalai@gmail.com.
Disclosure: Odayappan reports no relevant financial disclosures.