Sir,
Descemet's membrane detachment (DMD) is a potentially sight threatening complication of cataract surgery.[1] Disturbed anatomical position of Descemet's membrane (DM) in eyes can lead to progressive deterioration of endothelial function and necessitate urgent descemetopexy to protect corneal anatomy and function. Timely intracameral air/gas injection may provide temporary intraocular tamponade leading to repositioning of DM and subsequent clearing of the corneal stroma. Large DMDs particularly require temporary complete intracameral air/gas fill which may be difficult to achieve due to the possibility of air/gas leak during the withdrawal of the needle/cannula used for descemetopexy.[2] This may warrant repeated descemetopexy for successful attachment of DM or sometimes keratoplasty to maintain corneal clarity. In descemetopexy, air is introduced into the anterior chamber through a paracentesis wound created with a microvitreoretinal blade or a 30-G ophthalmic needle. Despite the valvular entry with these instruments, we noticed that withdrawal of the needle or cannula after air injection led to air leak and loss of effective intracameral tamponade. Initially, attempts were made to stop the leak with sterilized cotton-bud or a weck-cell sponge. However, wound distortion due to inadvertent pressure caused by the maneuver resulted in not only suboptimal air fill but also in a sudden gush of air loss upon withdrawal. Therefore, alternative methods were required to close the wound temporarily. Biological ophthalmic sealants seemed to be effective alternatives but were costly and carried a risk of intraocular inflammation and resultant graft failure from accidental intraocular entry.[3] However, when we placed healon (sodium hyaluronate 1%, HEALON® PRO OVD. Santa Ana, Calif. Johnson and Johnson Surgical Vision, Inc) on the wound while the needle was still inside the anterior chamber Fig. 1, we found it as an effective temporary sealant without any associated air leak during needle withdrawal (which was commonly seen with cotton-bud or weck-cell sponge). This was because the cohesive nature of high molecular weight sodium hyaluronate trapped any leaking air bubbles underneath it and prevented air/gas leak and the resultant suboptimal air fill.
Figure 1.
(a) Descemet membrane detachment seen after cataract surgery; (b) Injection of sodium hyaluronate 1% at the site of intracameral air injection during withdrawal of needle; (c) Successfully reattached Descemet's membrane
Viscoelastic substances (VES) including sodium hyaluronate, methylcellulose, chondroitin sulfate, polyacrylamide, and collagen have been used in various intraocular surgeries since the 1970s.[4] Sodium hyaluronate (hyaluronic acid or hyaluronan) is a type of cohesive VES that has become a popular and indispensable VES for use in cataract extraction and corneal transplantation surgery since the introduction of Healon® (sodium hyaluronate 1%, 4 × 106 Daltons) in 1979.[5] However, its extraocular use as a temporary wound sealant is being described for the first time. The cohesive nature of sodium hyaluronate allows it to effectively trap leaking air bubbles, thereby preventing its further seepage during withdrawal of the needle or the cannula. In addition, the formation of a single, small blob due to its cohesive nature not only prevents any inadvertent intraocular entry by binding its particles together but also allows easy wash with balanced salt solution (BSS) once an effective tamponade is achieved.
We have now employed this method of tamponade for more than 30 descemetopexy surgeries (including all types of DMDs) and are convinced that the extraocular use of Healon® is a simple, safe, and effective method of managing air/gas leak during needle withdrawal after intracameral injection of air/gas. Although we started with descemetopexy, we have now expanded its use to almost all intraocular procedures necessitating temporary intracameral air tamponade such as DM tears and detachments associated with acute hydrops, Deep anterior lamellar keratoplasty and endothelial keratoplasties such as Descemet's stripping automated endothelial keratoplasty, and Descemet's membrane endothelial keratoplasty.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
Acknowledgements
We thank our Institute for allowing us to continue with our research work.
References
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