CASE REPORT
Descemet Membrane Detachment After Heavy Silicone Oil Removal From the Anterior Chamber George D. Kymionis, MD, PhD,*† Konstantinos I. Tsoulnaras, MD,* Niki A. Xanthopoulou, MD,* Nektarios E. Klados, MD,* and Miltiadis K. Tsilimbaris, MD, PhD*
Purpose: The aim of this study was to report a case of a central Descemet membrane detachment after heavy silicone oil removal from the anterior chamber.
Methods: This is a case report of a patient operated with scleral buckling and heavy silicone oil implantation for recurrent retinal detachment. In the patient’s follow-up examination, silicone oil was found to completely fill the anterior chamber. He underwent silicone extraction through a paracentesis from the anterior chamber. Immediately after the surgery, a central Descemet membrane detachment combined with corneal edema was identified on slit-lamp examination, and confirmed by anterior segment optical coherence tomography. The detached Descemet membrane was tamponaded successfully with the air bubble injection technique. Results: Four days later, the patient’s cornea appeared to be clear, and the Descemet membrane was found to be attached to the corneal stroma with no presence of silicone oil in the anterior chamber.
Conclusions: Descemet membrane detachment is a possible and rare complication that occurs after heavy silicone oil removal from the anterior chamber. Key Words: Descemet membrane detachment, heavy silicone oil, air bubble, retinal detachment, anterior segment, optical coherence tomography (Cornea 2014;33:317–318)
S
ilicone oil tamponade in surgery for complicated retinal detachment has become a very common technique that increases the postoperative success rate.1 However, silicone oil has been known to emulsify and/or migrate into various locations within the globe, and this property can lead to several complications, such as keratopathy, secondary cataract, and glaucoma.2 To reduce these complications, it is essential to
Received for publication October 29, 2013; revision received November 19, 2013; accepted November 19, 2013. Published online ahead of print January 21, 2014. From the *Department of Ophthalmology, Vardinoyiannion Eye Institute of Crete (VEIC), Faculty of Medicine, University of Crete, Heraklion, Crete, Greece; and †Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL. The authors have no funding or conflicts of interest to disclose. Reprints: George D. Kymionis, Faculty of Medicine, Vardinoyiannion Eye Institute of Crete (VEIC), University of Crete, Heraklion 71003, Crete, Greece (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
Cornea Volume 33, Number 3, March 2014
consider silicone oil removal from the vitreous cavity as soon as stable retinal reattachment has been accomplished.3 The necessity of removal becomes more mandatory with the presence of silicone oil in the anterior chamber and in contact with the corneal endothelium because it can lead to endothelial toxicity and corneal decompensation.4 The major complications of the removal of silicone oil are retinal redetachment (25%), hypotony (16%), and expulsive hemorrhage (1%).5 In recent years, the development of silicone oil with a specific gravity higher than that of water increased the spectrum of the clinical use of silicon oil in complicated retinal detachment surgery.6 Heavy silicone oil can effectively tamponade the inferior part of the retinal periphery, which is something technically very difficult to achieve with conventional silicone oil. In this article, we report Descemet membrane detachment as a new complication associated with heavy silicone oil removal from the anterior chamber and its treatment with intracameral air bubble injection.
CASE REPORT A 63-year-old male patient presented with retinal detachment in his left eye. The patient’s ocular history in the left eye includes complicated cataract operation with a break of the posterior lens capsule and the implantation of the lens in the sulcus. He had been operated twice for recurrent retinal detachments; the first was treated 9 months ago and included vitrectomy, cryotherapy, and intraocular injection of silicone oil (polydimethylsiloxane, Oxane 1300; Bausch and Lomb), whereas the second one was treated 5 months later and included vitrectomy, silicone oil removal, endolaser coagulation, and injection of heavy silicone oil (Silicone Oil 5.700 mPas–RMN3 mixture, Oxane Hd, Bausch and Lomb). Because of recurrent retinal detachment in his left eye, the patient underwent scleral buckling with the placement of a hard silicone buckling element 12 mm from the scleral limbus inferiorly. The operation was completed uneventfully. On the first postoperative day, an ophthalmic examination revealed a clear cornea, whereas the anterior chamber was completely filled with silicone oil, probably because of the diffusion of silicone oil through the ruptured posterior capsular bag, while the intraocular lens was placed in the sulcus. The endothelial cell density was 1727 cells per square millimeter, and the intraocular pressure was 45 mm Hg. Because of the increased intraocular pressure, the patient was operated for silicone removal from the anterior chamber. On the third postoperative day, an anterior chamber maintainer was placed inferior temporally, and an incision was made in the sclerocorneal limbus with a 19-G surgical blade in the 12-o’clock position. The exit of silicone oil from the anterior chamber was observed with the passive exchange of the oil with balanced salt solution. The process was completed uneventfully. www.corneajrnl.com |
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Kymionis et al
FIGURE 1. High-resolution anterior segment corneal optical coherence tomography scan in the horizontal meridian, visualizing the patient’s corneal edema and the large central Descemet membrane detachment. Immediately after the operation, slit-lamp examination revealed a hazy cornea with severe corneal edema and a large central Descemet membrane detachment. The detached area was starting to develop centrally and extended to the periphery of the cornea. Anterior segment optical coherence tomography confirmed these findings (Fig. 1). To reattach and tamponade the membrane to the corneal stroma, an intracameral air bubble was injected with a 27-G needle (Shandong Zibo Shanchuan Medical Instrument Co, China) posteriorly to the detached Descemet membrane, and the patient was advised to keep his head facing up for the rest of the day. Despite the posterior capsule bag being ruptured, injected air was maintained at the anterior chamber, probably because of the barrier of the vitreous cavity that was completely filled by heavy silicone oil. At the fourth follow-up day, slit-lamp examination showed that Descemet membrane was attached to the corneal stroma while edema was resolved. The endothelial cell density was 1698 cells per square millimeter, and the intraocular pressure was 8 mm Hg. No silicone oil could be detected in the anterior chamber. Posterior segment biomicroscopy revealed an attached retina.
DISCUSSION Descemet membrane detachment occurs as a rare complication of ocular trauma or intraocular surgery such as cataract surgery and trabeculectomy.7–9 Although the cause is not clear, several probable reasons are as follows: shallow anterior chamber, accidental insertion of the instruments between stroma and Descemet membrane, use of blunt microkeratomes, shelved incisions, inadvertent injection of saline or viscoelastic into the space between the deep stroma and Descemet membrane, or weak adhesions between these layers that may be caused by a genetic disorder.7–9
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In our case report, none of the previously described causative factors was present. It seems that the patient’s Descemet membrane detachment was directly related to the silicone oil removal because it was detected right after the surgery. Descemet membrane detachment related to the incision and accidental insertion of the instruments between the deep corneal stroma and the Descemet membrane layer would detach Descemet membrane in the periphery; in our case, the detachment was central. Therefore, a possibly strong adhesion of the silicone oil to the endothelium layer caused Descemet membrane detachment during the operation when silicone oil was removed from the anterior chamber. Heavy silicone oil is known to have a very high affinity for ocular tissues such as the retinal surface. This can result in difficulties encountered during heavy silicone oil removal from the vitreous cavity leading to the inability to remove the silicone from the retinal surface.10 It is possible that such a high affinity for the corneal endothelium led to the complication described here. To the best of our knowledge, our case report presents a new complication of heavy silicone oil removal from the anterior chamber, Descemet membrane detachment. It is of great importance for both corneal and retinal specialists to be aware of this complication, and additional considerations should be made about injecting heavy silicone oil for retinal detachment in aphakia or in eyes with no capsular barrier. However, Descemet membrane detachment could be successfully treated with the intracameral air bubble injection technique. REFERENCES 1. Norman BC, Oliver J, Cheeks L, et al. Corneal endothelium permeability after anterior chamber silicone oil. Ophthalmology. 1990;97:1671–1677. 2. Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology. 1988;95:870–876. 3. Hutton WL, Azen SP, Blumenkranz MS, et al. The effects of silicone oil removal. Silicone Study Report 6. Arch Ophthalmol. 1994;112:778–785. 4. Choi WC, Choi SK, Lee JH. Silicone oil keratopathy. Korean J Ophthalmol. 1993;7:65–69. 5. Casswell AG, Gregor ZJ. Silicone oil removal. II. Operative and postoperative complications. Br J Ophthalmol. 1987;71:898–902. 6. Meng Q, Zhang S, Cheng H, et al. Long-term outcomes of Oxane Hd as intraocular tamponade in the treatment of complicated retinal detachment. Graefes Arch Clin Exp Ophthalmol. 2010;248:1091–1096. 7. Ti SE, Chee SP, Tan DT, et al. Descemet membrane detachment after phacoemulsification surgery: risk factors and success of air bubble tamponade. Cornea. 2013;32:454–459. 8. Marcon AS, Rapuano CJ, Jones MR, et al. Descemet’s membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109:2325–2330. 9. Li YH, Shi JM, Fan F, et al. Descemet membrane detachment after trabeculectomy. Int J Ophthalmol. 2012;5:527–529. 10. Stappler T, Williams R, Gibran SK, et al. A guide to the removal of heavy silicone oil. Br J Ophthalmol. 2008;92:844–847.
Ó 2014 Lippincott Williams & Wilkins
Descemet Membrane Detachment After Heavy Silicone Oil Removal From the Anterior Chamber George D. Kymionis, MD, PhD,*† Konstantinos I. Tsoulnaras, MD,* Niki A. Xanthopoulou, MD,* Nektarios E. Klados, MD,* and Miltiadis K. Tsilimbaris, MD, PhD*
Purpose: The aim of this study was to report a case of a central Descemet membrane detachment after heavy silicone oil removal from the anterior chamber.
Methods: This is a case report of a patient operated with scleral buckling and heavy silicone oil implantation for recurrent retinal detachment. In the patient’s follow-up examination, silicone oil was found to completely fill the anterior chamber. He underwent silicone extraction through a paracentesis from the anterior chamber. Immediately after the surgery, a central Descemet membrane detachment combined with corneal edema was identified on slit-lamp examination, and confirmed by anterior segment optical coherence tomography. The detached Descemet membrane was tamponaded successfully with the air bubble injection technique. Results: Four days later, the patient’s cornea appeared to be clear, and the Descemet membrane was found to be attached to the corneal stroma with no presence of silicone oil in the anterior chamber.
Conclusions: Descemet membrane detachment is a possible and rare complication that occurs after heavy silicone oil removal from the anterior chamber. Key Words: Descemet membrane detachment, heavy silicone oil, air bubble, retinal detachment, anterior segment, optical coherence tomography (Cornea 2014;33:317–318)
S
ilicone oil tamponade in surgery for complicated retinal detachment has become a very common technique that increases the postoperative success rate.1 However, silicone oil has been known to emulsify and/or migrate into various locations within the globe, and this property can lead to several complications, such as keratopathy, secondary cataract, and glaucoma.2 To reduce these complications, it is essential to
Received for publication October 29, 2013; revision received November 19, 2013; accepted November 19, 2013. Published online ahead of print January 21, 2014. From the *Department of Ophthalmology, Vardinoyiannion Eye Institute of Crete (VEIC), Faculty of Medicine, University of Crete, Heraklion, Crete, Greece; and †Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL. The authors have no funding or conflicts of interest to disclose. Reprints: George D. Kymionis, Faculty of Medicine, Vardinoyiannion Eye Institute of Crete (VEIC), University of Crete, Heraklion 71003, Crete, Greece (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
Cornea Volume 33, Number 3, March 2014
consider silicone oil removal from the vitreous cavity as soon as stable retinal reattachment has been accomplished.3 The necessity of removal becomes more mandatory with the presence of silicone oil in the anterior chamber and in contact with the corneal endothelium because it can lead to endothelial toxicity and corneal decompensation.4 The major complications of the removal of silicone oil are retinal redetachment (25%), hypotony (16%), and expulsive hemorrhage (1%).5 In recent years, the development of silicone oil with a specific gravity higher than that of water increased the spectrum of the clinical use of silicon oil in complicated retinal detachment surgery.6 Heavy silicone oil can effectively tamponade the inferior part of the retinal periphery, which is something technically very difficult to achieve with conventional silicone oil. In this article, we report Descemet membrane detachment as a new complication associated with heavy silicone oil removal from the anterior chamber and its treatment with intracameral air bubble injection.
CASE REPORT A 63-year-old male patient presented with retinal detachment in his left eye. The patient’s ocular history in the left eye includes complicated cataract operation with a break of the posterior lens capsule and the implantation of the lens in the sulcus. He had been operated twice for recurrent retinal detachments; the first was treated 9 months ago and included vitrectomy, cryotherapy, and intraocular injection of silicone oil (polydimethylsiloxane, Oxane 1300; Bausch and Lomb), whereas the second one was treated 5 months later and included vitrectomy, silicone oil removal, endolaser coagulation, and injection of heavy silicone oil (Silicone Oil 5.700 mPas–RMN3 mixture, Oxane Hd, Bausch and Lomb). Because of recurrent retinal detachment in his left eye, the patient underwent scleral buckling with the placement of a hard silicone buckling element 12 mm from the scleral limbus inferiorly. The operation was completed uneventfully. On the first postoperative day, an ophthalmic examination revealed a clear cornea, whereas the anterior chamber was completely filled with silicone oil, probably because of the diffusion of silicone oil through the ruptured posterior capsular bag, while the intraocular lens was placed in the sulcus. The endothelial cell density was 1727 cells per square millimeter, and the intraocular pressure was 45 mm Hg. Because of the increased intraocular pressure, the patient was operated for silicone removal from the anterior chamber. On the third postoperative day, an anterior chamber maintainer was placed inferior temporally, and an incision was made in the sclerocorneal limbus with a 19-G surgical blade in the 12-o’clock position. The exit of silicone oil from the anterior chamber was observed with the passive exchange of the oil with balanced salt solution. The process was completed uneventfully. www.corneajrnl.com |
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FIGURE 1. High-resolution anterior segment corneal optical coherence tomography scan in the horizontal meridian, visualizing the patient’s corneal edema and the large central Descemet membrane detachment. Immediately after the operation, slit-lamp examination revealed a hazy cornea with severe corneal edema and a large central Descemet membrane detachment. The detached area was starting to develop centrally and extended to the periphery of the cornea. Anterior segment optical coherence tomography confirmed these findings (Fig. 1). To reattach and tamponade the membrane to the corneal stroma, an intracameral air bubble was injected with a 27-G needle (Shandong Zibo Shanchuan Medical Instrument Co, China) posteriorly to the detached Descemet membrane, and the patient was advised to keep his head facing up for the rest of the day. Despite the posterior capsule bag being ruptured, injected air was maintained at the anterior chamber, probably because of the barrier of the vitreous cavity that was completely filled by heavy silicone oil. At the fourth follow-up day, slit-lamp examination showed that Descemet membrane was attached to the corneal stroma while edema was resolved. The endothelial cell density was 1698 cells per square millimeter, and the intraocular pressure was 8 mm Hg. No silicone oil could be detected in the anterior chamber. Posterior segment biomicroscopy revealed an attached retina.
DISCUSSION Descemet membrane detachment occurs as a rare complication of ocular trauma or intraocular surgery such as cataract surgery and trabeculectomy.7–9 Although the cause is not clear, several probable reasons are as follows: shallow anterior chamber, accidental insertion of the instruments between stroma and Descemet membrane, use of blunt microkeratomes, shelved incisions, inadvertent injection of saline or viscoelastic into the space between the deep stroma and Descemet membrane, or weak adhesions between these layers that may be caused by a genetic disorder.7–9
318
| www.corneajrnl.com
In our case report, none of the previously described causative factors was present. It seems that the patient’s Descemet membrane detachment was directly related to the silicone oil removal because it was detected right after the surgery. Descemet membrane detachment related to the incision and accidental insertion of the instruments between the deep corneal stroma and the Descemet membrane layer would detach Descemet membrane in the periphery; in our case, the detachment was central. Therefore, a possibly strong adhesion of the silicone oil to the endothelium layer caused Descemet membrane detachment during the operation when silicone oil was removed from the anterior chamber. Heavy silicone oil is known to have a very high affinity for ocular tissues such as the retinal surface. This can result in difficulties encountered during heavy silicone oil removal from the vitreous cavity leading to the inability to remove the silicone from the retinal surface.10 It is possible that such a high affinity for the corneal endothelium led to the complication described here. To the best of our knowledge, our case report presents a new complication of heavy silicone oil removal from the anterior chamber, Descemet membrane detachment. It is of great importance for both corneal and retinal specialists to be aware of this complication, and additional considerations should be made about injecting heavy silicone oil for retinal detachment in aphakia or in eyes with no capsular barrier. However, Descemet membrane detachment could be successfully treated with the intracameral air bubble injection technique. REFERENCES 1. Norman BC, Oliver J, Cheeks L, et al. Corneal endothelium permeability after anterior chamber silicone oil. Ophthalmology. 1990;97:1671–1677. 2. Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology. 1988;95:870–876. 3. Hutton WL, Azen SP, Blumenkranz MS, et al. The effects of silicone oil removal. Silicone Study Report 6. Arch Ophthalmol. 1994;112:778–785. 4. Choi WC, Choi SK, Lee JH. Silicone oil keratopathy. Korean J Ophthalmol. 1993;7:65–69. 5. Casswell AG, Gregor ZJ. Silicone oil removal. II. Operative and postoperative complications. Br J Ophthalmol. 1987;71:898–902. 6. Meng Q, Zhang S, Cheng H, et al. Long-term outcomes of Oxane Hd as intraocular tamponade in the treatment of complicated retinal detachment. Graefes Arch Clin Exp Ophthalmol. 2010;248:1091–1096. 7. Ti SE, Chee SP, Tan DT, et al. Descemet membrane detachment after phacoemulsification surgery: risk factors and success of air bubble tamponade. Cornea. 2013;32:454–459. 8. Marcon AS, Rapuano CJ, Jones MR, et al. Descemet’s membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109:2325–2330. 9. Li YH, Shi JM, Fan F, et al. Descemet membrane detachment after trabeculectomy. Int J Ophthalmol. 2012;5:527–529. 10. Stappler T, Williams R, Gibran SK, et al. A guide to the removal of heavy silicone oil. Br J Ophthalmol. 2008;92:844–847.
Ó 2014 Lippincott Williams & Wilkins
