Descemet detachment in a phakic patient

Descemet's membrane is product of synthesis and secretion of endothelial cell layer and is bound to it by hemidesmosome-binding complexes.[1] However, the association between Descemet membrane and stroma is much more labile. This interface has fibrillar bundles of collagen in corneal stroma with particular spatial arrangement. Type IV collagen is also present. Usually surgical trauma is the triggering factor in Descemet detachment. Fluid seeps in pre-Descemet space separating it from stroma. However, as the subsequent discussion will show, surgical trauma is not the only factor in Descemet detachment.

A 42-year-old female patient presented to OPD with complaint of black floater in left eye for 20 days. She had visual acuity of 20/125 both eyes. Intraocular pressure was 14 mm Hg on applanation tonometry. On examination, right eye had macular corneal opacity inferotemporally [Fig. 1a and b]. Lens was clear. Rest anterior segment was unremarkable. Left eye had more opacity than right eye and a Descemet membrane detachment was noticed inferonasally [Fig. 2a and b] Lens was clear and rest anterior segment was unremarkable. On fundus evaluation, both eyes of patient had cup-disc ratio of 0.4:1. There was peripapillary crescent and foveal reflex was dull. Patient had myopic fundus. In left eye, there was posterior vitreous detachment corresponding with her history of black floater. The finding of Descemet membrane detachment was confirmed on anterior segment optical coherence tomography [Fig. 2c]. Both eyes showed scarring on anterior segment optical coherence tomography (ASOCT), [Figs. 1c and 2c] and right eye showed thinning in the area of opacity (pachymetry being 301 micrometer), whereas left eye was 543 micrometer thick. Confocal microscopy was done and altered endothelial pattern was noted [Figs. 1d and 2d]. Since the scarring was not in visual axis and the detachment was not causing any edema, no surgical intervention was done. A refraction was done and vision improved to 20/63 in both the eyes.

Figure 1.

Slit lamp images of right eye showing macular corneal opacity nasally (a and b). ASOCT through opacity showing scarring and thinning (c). Confocal showing altered endothelial pattern (d)

Figure 2.

Slit lamp image of left eye showing macular opacity with Descemet detachment (a) detachment focused in higher magnification (arrow) (b). ASOCT showing cornea with normal pachymetry but scarring and descemet detachment (c). Confocal showing altered endothelial pattern (d)

Discussion

Descemet membrane can detach after surgical intervention. However, detachment in a virgin eye is rare. The Descemet detachment seen here could be due to keratitis and consequential stromal scarring. The Descemet could not conform to the shape of scarred stroma leading to separation. Hollumer et al. has reported hemorrhagic Descemet detachment following syphilitic interstitial keratitis.[2] Macpherson et al. has reported a case of spontaneous hemorrhagic descemet membrane detachment (DMD) in a patient on warfarin.[3] A case of reduplicated Descemet's membrane with partial Descemet detachment secondary to occult deep herpes simplex keratitis has been reported by Banik et al.[4] Descemet detachment has been reported after uncomplicated cataract surgery and that may have resulted from underlying endothelial disorder rather than surgery itself. Fang et al.[5] reported a case of bilateral Descemet detachment with documented preoperative anomalies of corneal endothelium.

Although surgical Descemet detachment is a known entity, noniatrogenic detachment of Descemet membrane is rare. In our case, possibly previous viral keratitis led to stromal scarring separating the Descemet as it could not conform to the altered shape. Possible weak attachment of Descemetwith posterior stroma aided in detachment. Insight regarding risk of Descemet detachment might be helpful to counsel patients undergoing surgery despite an uneventful surgery.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

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