Intraoperative Descemet’s membrane detachment in a case of phacomorphic glaucoma

Abstract

A 60-year-old female patient with phacomorphic glaucoma underwent initial medical management to control the intraocular pressure (IOP). After 48 hours, a stable IOP was achieved and subsequently the patient was planned for phacoemulsification followed by intraocular lens implantation. There was initial difficulty while reconstructing the corneal wounds; however, phacoemulsification and IOL implantation were uneventful but during viscoelastic removal, an inadvertent Descemet’s membrane detachment involving the central cornea was noted. Postoperatively corneal oedema persisted till 1 week, following which there was a gradual improvement with topical antibiotics, steroids and hyperosmotic agents. At the end of 6 months, the best corrected visual acuity was 20/25 with a central corneal thickness of 580 µm without any need for additional endothelial replacement surgery.

Background

Descemet’s membrane detachment (DMD) is a rare but serious complication during/following cataract surgery. In 1928, Samuels described DMD in detail in three cases for the first time.¹ There are multiple preoperative (non-surgical) as well as intraoperative risk factors for the development of the DMD.^2–10 Here, in this report, we discuss an unusual clinical scenario of spontaneous intraoperative DMD in a patient who underwent cataract surgery for phacomorphic glaucoma.

Case presentation

A 60-year-old female patient presented to the ocular emergency department with severe pain and loss of vision in the left eye for the past 1 month. Ocular examination revealed visual acuity of perception of light (positive) in the left and 20/20 in the right eye. On slit lamp examination, left eye pupil was mid-dilated, vertically oval and fixed, while in right eye direct response to light was present with the absence of consensual pupil reflex. Slit lamp biomicroscopy of the left eye showed 360° circumciliary congestion, diffuse corneal oedema, significant shallowing of the anterior chamber and 360° peripheral anterior synechiae (PAS) with an intumescent cataractous lens. Other details were not visible clearly because of the corneal oedema.

The right eye was pseudophakic with a clear cornea. Using Goldmann applanation tonometry intraocular pressure (IOP) was 16 mm Hg and 60 mm Hg in the right and left eye, respectively, without any medication. Left eye lens thickness was 4.8 mm; B scan ultrasound for the posterior segment was anechoic with appreciable optic nerve head cupping. Patient was managed medically with antiglaucoma medications to achieve IOP of 18 mm Hg after 48 hours.

The patient was planned for phacoemulsification followed by posterior chamber intraocular lens implantation under peribulbar anaesthesia after obtaining informed consent. Under peribulbar anaesthesia, the cataract surgery was initiated. As the anterior chamber was very shallow with peripheral PAS, the creation of the side port entries was difficult. Phacoemulsification was performed and single-piece foldable intraocular lens was placed. During the aspiration of the viscoelastic material from the anterior chamber, inadvertent aspiration of the Descemet’s membrane was noted at the irrigation–aspiration port from the central area (figure 1A).

Figure 1.

(A) Intraoperatively a sudden membranous occlusion of the aspiration tip during viscoelastic removal (red arrows). The intact Descemet’s membrane detachment margin is visible (yellow arrow). (B) The recovered Descemet’s membrane (red arrow). (C) On a postoperative day, one anterior segment Optical Coherence Tomography (OCT) showing increased corneal thickness along with peripheral residual Descemet’s membrane (yellow arrow).

Immediately, the aspiration was stopped and reflux was initiated during which the Descemet’s membrane escaped through the side port, into the water collection system. Immediately, the surgery was stopped and the Descemet’s membrane was retrieved which had been fragmented into multiple pieces (figure 1B); the subsequent surgical steps were carried out in a routine manner and the wounds were closed. The tissue specimen was sent for histopathological examination and was confirmed to be a Descemet’s membrane. On the first postoperative day, anterior segment OCT showed increased corneal thickness with a peripheral remnant of the Descemet’s membrane (figure 1C). In order to reattach this stump, intraoperative-guided intracameral gas injection (20%, SF₆) was performed under topical anaesthesia. At the end of 1 week, corneal oedema persisted with an intraocular pressure of 14 mm Hg. During subsequent follow-up, the patient was continued with topical antiglaucoma for a week, and topical antibiotics, topical steroids along with frequent hyperosmotic agents tapered over a period of 6 weeks.

Outcome and follow-up

At the end of 6 months, the central corneal thickness measured around 580 µm with a peripherally attached residual Descemet’s membrane and the cornea remained clear (figure 2A,B).

Figure 2.

(A) At the end of 6months, anterior segment OCT showing clear cornea with a corneal thickness of 580 μm and the peripherally remnant Descemet’s membrane can be visualised (red arrows). (B) Completely resolved corneal oedema at the end of 6 months with well-attached peripheral residual Descemet’s membrane (red arrow).

Discussion

DMD can occur following various surgical procedures such as iridectomy, cyclodialysis, pars plana vitrectomy, viscocanalostomy and penetrating keratoplasty.^2–4 Similarly, other risk factors like shallow anterior chamber, abnormal fibrillar adhesions between the Descemet’s and corneal stroma intraoperative manoeuvres at the level of the corneal stroma and Descemet’s membrane with blunt surgical instruments, or viscoelastic injection between the Descemet’s and stroma may all lead to inadvertent separation between the Descemet’s membrane and the overlying stroma.^5–10

The DMD’s can be classified as planar when the separation between the stroma and Descemet’s is less than 1 mm and non-planar when the separation is more than 1 mm.⁵ Similarly, Assia et al classified DMD’s as with and without rolled scroll and suggested that the DMD’s with scrolled edges have less tendency for resolution, in contrast, the one without scrolled edges.⁶

The current management strategy for such cases is not clearly defined; thus, each case needs a tailored approach. In general, they can be managed medically by just regular observation along with topical hyperosmotic agents and steroids. However, minimally invasive procedures like intracameral gas/air injection, viscoelastic injection or transcorneal suturing may be necessary to achieve residual descemetopexy in the intraoperative or immediate postoperative period.^7–10 However, the size and location of DMD are an important factor which will decide the subsequent clinical course and outcomes.

The current patient under discussion had phacomorphic glaucoma with severely compromised anterior chamber depth which itself is a risk factor for DMD.^8–10 Due to this, there was inherent procedural difficulty in creation of limbal/far peripheral corneal wounds; thus, the entry wounds were more anterior along the clear peripheral cornea and also the intended phaco entry might have been single planar rather than triplanar incision leading to increased risk of DMD. However, the untoward complication did not happen during any the crucial steps of phacoemulsification (maybe due to optimal antigravity pressure exerted by the viscoelastic in the anterior chamber) even though it was a hard cataract, but following viscoelastic removal during irrigation and aspiration the antigravity support to the Descemet’s tissue might have been lost, leading to sudden detachment and entrapment of the tissue in to the aspiration probe. In our case, by looking at the extent of endothelial loss, postoperative significant corneal decompensation and subsequent need for lamellar corneal procedure are anticipated. However, may be due to remaining surrounding endothelial cell hypertrophy and redistribution, the corneal clarity was maintained. To support this, there are isolated case reports showing such results following large DMD’s with favourable outcomes but without any need for endothelial replacement surgery.

To conclude, DMD in our case resulted from multiple risk factors coexisting with the primary disease process and the same was managed medically to achieve surprising anatomical and visual at the end of 6 months. The exact mechanism involved in this unexpected positive outcome is not clearly known but cataract surgeons operating under difficult situations should be aware of this complication and their probable outcomes.

Learning points.

• Intraoperative Descemet’s membrane detachment (DMD) involving the central cornea to a large extent is quite unusual. Under such circumstances, remaining surgical manoeuvring should be intended towards the minimisation of the trauma and an effort to achieve perfect adhesion between the detached Descemet’s and the stroma.

• Subsequently, during immediate postoperative period, medical management along with minimally invasive descemetopexy procedures can be undertaken depending on the individual patient profile.

• Large central DMD with favourable clinical outcome in the absence of any added lamellar full-thickness corneal surgeries has been rarely documented. And the exact mechanism involved in this unexpected outcome is poorly understood.