CASE SERIES
Descemet membrane stripping endothelial keratoplasty for Descemet membrane detachment following phacoemulsification Jong Jin Kim, MD, Hong Kyun Kim, MD, PhD ABSTRACT ● RÉSUMÉ Objective: To report successful vision restoration after Descemet membrane stripping endothelial keratoplasty (DSEK) for 3 cases with extensive Descemet membrane detachment (DMD) after phacoemulsification. Design: Retrospective case series. Participants: Three patients with extensive DMD after phacoemulsification. Methods: Three patients with DMD after phacoemulsification were reviewed. All patients developed DMD affecting more than 70% of the cornea and showed significant corneal edema, which did not resolve with air bubble tamponade. To resolve corneal edema, we performed DSEK. Results: Successful postoperative resolution of corneal edema was achieved for all 3 patients. Best corrected visual acuity improved from 2.20 ⫾ 0.72 (logMAR) to 0.24 ⫾ 0.06 (logMAR). No complications were noted during 24.7 ⫾ 3.2 months of follow-up (range 21–27 months). The change in spherical equivalent from pre-DSEK to 1 year postoperatively was þ0.87 D (range þ0.63 to þ1.25 D). Conclusions: DSEK may be a viable surgical option for treatment of patients with extensive DMD after phacoemulsification. However, when DSEK is contemplated, intraocular lens exchange for hyperopic shift after DSEK must be considered. Objet : Faire rapport de trois restaurations de la vision réussies après le recours à la kératoplastie endothéliale avec décapage de la membrane de Descemet (KEMD) pour traiter des cas de décollement majeur de la membrane de Descemet (DMD) après une phacoémulsification. Nature : Étude de cas rétrospective. Participants : Trois patients atteints d’un DMD important après une phacoémulsification. Méthodes : Trois cas de patients atteints d’un DMD important après une phacoémulsification ont été étudiés. Chez tous les patients, le DMD atteignait plus de 70 % de la cornée, et l’œdème cornéen important ne s’est pas résorbé malgré la tamponnade avec une bulle d’air. Pour réduire l’œdème cornéen, la KEMD a été pratiquée. Résultats : L’œdème cornéen a été éliminé après la chirurgie chez les trois patients. La meilleure acuité visuelle corrigée s’est améliorée, passant de 2,20 ± 0,72 (logMAR) à 0,24 ± 0,06 (logMAR). Aucune complication n’a été signalée pendant les 24,7 ± 3,2 mois de suivi (écart : 21-27 mois). La variation d’équivalent sphérique entre avant la chirurgie et un an après est de +0,87 D (écart : +0,63 à +1,25 D). Conclusions : La KEMD peut être une option chirurgicale viable pour le traitement de patients atteints d’un DMD après une phacoémulsification. Toutefois, si l’on opte pour la KEMD, il faut envisager un échange de lentilles intraoculaires pour corriger l’hypermétropie qui pourrait en résulter.
Descemet membrane detachment (DMD) is a rare but potentially sight-threatening complication of intraocular surgeries including phacoemulsification, extracapsular cataract surgery, glaucoma filtering surgery, and other minor surgical procedures. DMD may occur after intraocular lens (IOL) implantation or during irrigation and aspiration; it can also result from improper viscoelastic injection through a side-port incision.1–3 There is no gold standard for treating DMD.1,3–5 Although intracameral air bubble tamponade is effective for ameliorating DMD, the success rate of this procedure depends on the extent of detachment. When DMD is unresolved after repositioning, corneal transplantation may be needed.6 Since Descemet membrane stripping endothelial keratoplasty (DSEK) was first introduced, it has been reported to give better results than penetrating From the Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, South Korea Originally received May 21, 2014. Final revision Oct. 17, 2014. Accepted Oct. 28, 2014.
keratoplasty (PKP) in corneal endothelial dysfunction.7 In this article, we describe our experience with, and postoperative outcomes of, DSEK performed on 3 patients with DMD that developed after phacoemulsification.
CASE REPORTS Case 1
An 84-year-old female was referred to our centre because of DMD in the right eye. She had undergone phacoemulsification and IOL implantation at a local clinic 1 week before the visit. One day after the original surgery, intracameral air injection to alleviate DMD was performed. However, severe corneal edema did not resolve. On the initial examination at our clinic, best corrected visual acuity Can J Ophthalmol 2015;50:73–76 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.10.017
Correspondence to Hong Kyun Kim, MD, Department of Ophthalmology, Kyungpook National University School of Medicine, 50 Samduk 2Ga, Jung-Gu, Daegu 700-721, South Korea; [email protected] CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
73
DSEK for Descemet membrane detachment—Kim and Kim
Fig. 1 — A, Preoperative slit-lamp biomicroscopic photograph of Case 1 showing a markedly edematous cornea. B, Optical coherence tomography image showing detachment and partial loss of Descemet membrane.
(BCVA) was finger counting in the right eye. Slit-lamp biomicroscopy revealed severe corneal edema and DMD that involved almost the entire area of the cornea (Fig. 1A). Optical coherence tomography with a Cirrus HD-OCT 5000 instrument (Carl Zeiss Meditec, Dublin, CA) showed a break-in Descemet membrane with detachment in the inferior midperipheral area (Fig. 1B). The axial length was 22.6 mm, and the central corneal thickness was 945 μm. The patient was diagnosed with DMD resulting from the cataract surgery, and DSEK was performed. For DSEK, the posterior lamellar disc was prepared with a femtosecond laser (IntraLase FS Laser; Abbott Medical Optics, Inc, Santa Ana, CA). The Descemet membrane in the central 8.0-mm area was scored with a reverse bent Price Sinskey hook (Asico, Inc, Westmont, Ill.). If there was a fluttering Descemet membrane flap over the central 8.0-mm area, we also finely scored the membrane and did not leave any remaining detached membrane. We found that a large area of the central Descemet membrane had been lost during the previous surgery. Two weeks after DSEK, corneal edema
Fig. 2 — Slit-lamp biomicroscopic photograph of Case 1 taken 21 months postoperatively showing a transparent, clear cornea.
74
CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
was reduced, and BCVA had improved to 20/200. One year later, the cornea remained clear, and the central corneal thickness was 725 μm. The change in spherical equivalent (SE) from target refraction of IOL implantation to 1 year postoperatively was þ0.65 D. At the 21-month follow-up visit, BCVA had increased to 20/40, and the cornea was still clear. No corneal haze or scar was noted (Fig. 2). Case 2
An 80-year-old male underwent phacoemulsification at a local clinic. During the procedure, posterior capsule rupture, lenticular fragment dislocation into the vitreous cavity, and DMD occurred in the left eye. The patient was referred to our centre 10 days postoperatively. On the initial examination at our clinic, BCVA was hand motion, and intraocular pressure was 4 mm Hg in the left eye. Slitlamp biomicroscopy revealed moderate corneal edema and DMD involving almost the entire area of the cornea. The central corneal thickness was 822 μm. The patient was diagnosed with lens dislocation and DMD resulting from the cataract surgery. The next day, 23-gauge pars plana vitrectomy to treat the dislocated lens fragment and IOL implantation in the ciliary sulcus were performed. In addition, intracameral air injection to alleviate DMD was performed. However, DMD did not resolve, and the patient underwent DSEK. During the surgery, we found that the midperipheral portion of the detached Descemet membrane had been lost and folded. Four days after DSEK, corneal edema was reduced, and BCVA had improved to 20/200. One year later, the cornea remained clear, and the central corneal thickness was 619 μm. The change in SE from target refraction of IOL implantation to 1 year postoperatively was þ0.71 D. At the 27-month follow-up visit, BCVA had improved to 20/32, and the cornea was still clear. No corneal haze or scar was noted. Case 3
A 79-year-old male was referred to our centre for DMD persisting for 3 weeks in the left eye. He had undergone
DSEK for Descemet membrane detachment—Kim and Kim phacoemulsification and IOL implantation at a local clinic 3 weeks before visiting our centre. One day after surgery, severe corneal edema and DMD were noted. Intracameral air injection was done at the local clinic. However, DMD had not resolved by the third postoperative week. On the initial examination at our clinic, BCVA was 20/800, and intraocular pressure was 7 mm Hg in the left eye. After 2 days, DSEK was performed. During the surgery, a wrinkled and folded detached Descemet membrane was found; an extensive area of the membrane had been lost. Three days after DSEK, corneal edema was reduced, and BCVA had improved to 20/50. After the corneal edema resolved, we found an anteriorly located clear corneal incision that had been performed during the phacoemulsification. One year later, the cornea remained clear, and the central corneal thickness was 650 μm. The change in SE from a target refraction of IOL implantation to 1 year postoperatively was þ1.25 D. At the 26-month follow-up visit, BCVA had improved to 20/32. The cornea was still clear. No corneal haze or scar was noted.
DISCUSSION DMD is a potentially serious complication of cataract surgery. Several predisposing factors are associated with the occurrence of DMD, including a shallow anterior chamber, anterior and shelved incisions, a high degree of surgical difficulty, and surgeon inexperience.8–10 Our case series, along with findings from previous reports, shows that cataract surgery performed on individuals with predisposing factors or surgical misadventures can lead to DMD. Case 1 had a shallow anterior chamber with a short axial length. Case 2 underwent a complicated cataract surgery, including posterior capsular rupture and vitreous loss. Case 3 showed an anteriorly located clear corneal incision. Reattachment of a detached Descemet membrane can be spontaneous, but it may require surgical intervention. Small lesions resolve with topical medical therapy within a few weeks to a few months. Corneal clarity can be maintained in most DMD cases, provided that the condition is recognized early and managed adequately. Although spontaneous reattachment of severe DMD has been reported, extensive separation of the membrane usually persists for a longer period and may require surgery for reattachment.11,12 Pneumodescemetopexy with intracameral gas has become the preferred treatment for DMD. Injections of sterile air, SF6 gas, or C3F8 gas have been suggested as appropriate treatment modalities.13,14 Marcon et al.15 reported a successful case series involving spontaneous reattachment or air tamponade reattachment of large nonscrolled DMDs. However, these researchers did not specify whether Descemet membrane had been lost. The decision regarding when to intervene in DMD should be made on a case-by-case basis after evaluation of the configuration of the detachment, accompanying
complications, and loss of Descemet membrane. In our case series, all the patients had DMD that affected more than 70% of the cornea, and all of the cases originated from the primary cataract surgery and were treated by means of pneumodescemetopexy with an intracameral air injection. However, DMD did not resolve after the injection. During DSEK, we saw loss of a large area of Descemet membrane in all 3 of our patients. When DMD is unresolved after repositioning by another procedure, PKP may be the final surgical option.6 However, DSEK is a better option than PKP for cases of DMD with regard to preservation of the recipient’s corneal stroma. DSEK involves the removal of the dysfunctional endothelium and Descemet membrane followed by replacement with healthy donor tissue composed of endothelium, Descemet membrane, and a thin layer of posterior stroma.16 All the patients in our study underwent DSEK for the treatment of DMD; stromal edema was quickly reduced, and visual acuity was rapidly recovered after the surgery. Even with long-term DMD and severe corneal edema (mean detachment period: 19.3 days), corneal clarity was achieved with DSEK. DSEK for treatment of extensive DMD offers many advantages over PKP, including reduced postoperative astigmatism, decreased risk for suture-related complications, and faster visual rehabilitation.17 Although the surgical results in our cases were excellent, we should have considered postoperative hyperopic shift (range þ0.63 to þ1.25 D). Previous studies found a mean postoperative hyperopic shift ranging from þ0.84 to þ1.26 D at 6 to 12 months in patients who underwent DSEK.18,19 A minus lens effect and a decrease in the radius of curvature upon addition of stromal tissue on the posterior curvature may have induced the hyperopic shift. Individuals who develop severe DMD during cataract surgery may need DSEK. When DSEK is chosen for treatment of DMD resulting from cataract surgery, IOL exchange should be considered for hyperopic shift. In conclusion, the results for this case series suggest that DSEK is a safe and viable option for managing extensive loss of Descemet membrane after cataract surgery. Even with a prolonged period of postoperative DMD and a large area of detachment, DMD was amenable to surgical repair by DSEK with good structural and functional outcomes.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.
REFERENCES 1. Sukhija J, Ram J, Kaushik S, Gupta A. Descemet’s membrane detachment following phacoemulsification. Ophthalmic Surg Lasers Imaging. 2010;41:512-7. 2. Macsai MS. Total detachment of Descemet’s membrane after smallincision cataract extraction. Am J Ophthalmol. 1992;114:365-6. CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
75
DSEK for Descemet membrane detachment—Kim and Kim 3. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane detachment during phacoemulsification surgery. Br J Ophthalmol. 1996;80:185-6. 4. Shah M, Bathia J, Kothari K. Repair of late Descemet’s membrane detachment with perfluoropropane gas. J Cataract Refract Surg. 2003;29:1242-4. 5. Kim T, Hasan SA. A new technique for repairing Descemet membrane detachments using intracameral gas injection. Arch Ophthalmol. 2002;120:181-3. 6. Merrick C. Descemet’s membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg. 1991;22:753-5. 7. Price F, Price MO. Descemet’s stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant. J Refract Surg. 2005;21:339-45. 8. Samuels B. Detachment of Descemet’s membrane. Trans Am Ophthalmol Soc. 1928;26:427-37. 9. Zusman NB, Waring GO, Najarian LV, Wilson LA. Sulfur hexafluoride gas in the repair of intractable Descemet’s membrane detachment. Am J Ophthalmol. 1987;104:660-2. 10. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg. 1995;21:714-7. 11. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol. 1994;112:551-2.
76
CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
12. Vinekar A, Sukhija J, Brar GS, Ram J. “Late” functionally successful repair of Descemet’s membrane detachment following phacoemulsification. Eye (Lond). 2007;21:555-6. 13. Gault JA, Raber IM. Repair of Descemet’s membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;15:483-9. 14. Macsai MS, Gainer KM, Chisholm L. Repair of Descemet’s membrane detachment with perfluoropropane (C3F8). Cornea. 1998;17:129-34. 15. Marcon AS, Rapuano CJ, Jones MR, et al. Descemet’s membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109:2325-30. 16. Melles GR, Wijdh RH, Nieuwendaal CP. A technique to excise the Descemet membrane from a recipient cornea (descemetorhexis). Cornea. 2004;23:286-8. 17. Lee WB, Jacobs DS, Musch DC, et al. Descemet’s stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology. Ophthalmology. 2009;116:1818-30. 18. Koenig SB, Covert DJ, Dupps WJ Jr, Meisler DM. Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Cornea. 2007;26:670-4. 19. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;25:886-9.
Descemet membrane stripping endothelial keratoplasty for Descemet membrane detachment following phacoemulsification Jong Jin Kim, MD, Hong Kyun Kim, MD, PhD ABSTRACT ● RÉSUMÉ Objective: To report successful vision restoration after Descemet membrane stripping endothelial keratoplasty (DSEK) for 3 cases with extensive Descemet membrane detachment (DMD) after phacoemulsification. Design: Retrospective case series. Participants: Three patients with extensive DMD after phacoemulsification. Methods: Three patients with DMD after phacoemulsification were reviewed. All patients developed DMD affecting more than 70% of the cornea and showed significant corneal edema, which did not resolve with air bubble tamponade. To resolve corneal edema, we performed DSEK. Results: Successful postoperative resolution of corneal edema was achieved for all 3 patients. Best corrected visual acuity improved from 2.20 ⫾ 0.72 (logMAR) to 0.24 ⫾ 0.06 (logMAR). No complications were noted during 24.7 ⫾ 3.2 months of follow-up (range 21–27 months). The change in spherical equivalent from pre-DSEK to 1 year postoperatively was þ0.87 D (range þ0.63 to þ1.25 D). Conclusions: DSEK may be a viable surgical option for treatment of patients with extensive DMD after phacoemulsification. However, when DSEK is contemplated, intraocular lens exchange for hyperopic shift after DSEK must be considered. Objet : Faire rapport de trois restaurations de la vision réussies après le recours à la kératoplastie endothéliale avec décapage de la membrane de Descemet (KEMD) pour traiter des cas de décollement majeur de la membrane de Descemet (DMD) après une phacoémulsification. Nature : Étude de cas rétrospective. Participants : Trois patients atteints d’un DMD important après une phacoémulsification. Méthodes : Trois cas de patients atteints d’un DMD important après une phacoémulsification ont été étudiés. Chez tous les patients, le DMD atteignait plus de 70 % de la cornée, et l’œdème cornéen important ne s’est pas résorbé malgré la tamponnade avec une bulle d’air. Pour réduire l’œdème cornéen, la KEMD a été pratiquée. Résultats : L’œdème cornéen a été éliminé après la chirurgie chez les trois patients. La meilleure acuité visuelle corrigée s’est améliorée, passant de 2,20 ± 0,72 (logMAR) à 0,24 ± 0,06 (logMAR). Aucune complication n’a été signalée pendant les 24,7 ± 3,2 mois de suivi (écart : 21-27 mois). La variation d’équivalent sphérique entre avant la chirurgie et un an après est de +0,87 D (écart : +0,63 à +1,25 D). Conclusions : La KEMD peut être une option chirurgicale viable pour le traitement de patients atteints d’un DMD après une phacoémulsification. Toutefois, si l’on opte pour la KEMD, il faut envisager un échange de lentilles intraoculaires pour corriger l’hypermétropie qui pourrait en résulter.
Descemet membrane detachment (DMD) is a rare but potentially sight-threatening complication of intraocular surgeries including phacoemulsification, extracapsular cataract surgery, glaucoma filtering surgery, and other minor surgical procedures. DMD may occur after intraocular lens (IOL) implantation or during irrigation and aspiration; it can also result from improper viscoelastic injection through a side-port incision.1–3 There is no gold standard for treating DMD.1,3–5 Although intracameral air bubble tamponade is effective for ameliorating DMD, the success rate of this procedure depends on the extent of detachment. When DMD is unresolved after repositioning, corneal transplantation may be needed.6 Since Descemet membrane stripping endothelial keratoplasty (DSEK) was first introduced, it has been reported to give better results than penetrating From the Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, South Korea Originally received May 21, 2014. Final revision Oct. 17, 2014. Accepted Oct. 28, 2014.
keratoplasty (PKP) in corneal endothelial dysfunction.7 In this article, we describe our experience with, and postoperative outcomes of, DSEK performed on 3 patients with DMD that developed after phacoemulsification.
CASE REPORTS Case 1
An 84-year-old female was referred to our centre because of DMD in the right eye. She had undergone phacoemulsification and IOL implantation at a local clinic 1 week before the visit. One day after the original surgery, intracameral air injection to alleviate DMD was performed. However, severe corneal edema did not resolve. On the initial examination at our clinic, best corrected visual acuity Can J Ophthalmol 2015;50:73–76 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2014.10.017
Correspondence to Hong Kyun Kim, MD, Department of Ophthalmology, Kyungpook National University School of Medicine, 50 Samduk 2Ga, Jung-Gu, Daegu 700-721, South Korea; [email protected] CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
73
DSEK for Descemet membrane detachment—Kim and Kim
Fig. 1 — A, Preoperative slit-lamp biomicroscopic photograph of Case 1 showing a markedly edematous cornea. B, Optical coherence tomography image showing detachment and partial loss of Descemet membrane.
(BCVA) was finger counting in the right eye. Slit-lamp biomicroscopy revealed severe corneal edema and DMD that involved almost the entire area of the cornea (Fig. 1A). Optical coherence tomography with a Cirrus HD-OCT 5000 instrument (Carl Zeiss Meditec, Dublin, CA) showed a break-in Descemet membrane with detachment in the inferior midperipheral area (Fig. 1B). The axial length was 22.6 mm, and the central corneal thickness was 945 μm. The patient was diagnosed with DMD resulting from the cataract surgery, and DSEK was performed. For DSEK, the posterior lamellar disc was prepared with a femtosecond laser (IntraLase FS Laser; Abbott Medical Optics, Inc, Santa Ana, CA). The Descemet membrane in the central 8.0-mm area was scored with a reverse bent Price Sinskey hook (Asico, Inc, Westmont, Ill.). If there was a fluttering Descemet membrane flap over the central 8.0-mm area, we also finely scored the membrane and did not leave any remaining detached membrane. We found that a large area of the central Descemet membrane had been lost during the previous surgery. Two weeks after DSEK, corneal edema
Fig. 2 — Slit-lamp biomicroscopic photograph of Case 1 taken 21 months postoperatively showing a transparent, clear cornea.
74
CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
was reduced, and BCVA had improved to 20/200. One year later, the cornea remained clear, and the central corneal thickness was 725 μm. The change in spherical equivalent (SE) from target refraction of IOL implantation to 1 year postoperatively was þ0.65 D. At the 21-month follow-up visit, BCVA had increased to 20/40, and the cornea was still clear. No corneal haze or scar was noted (Fig. 2). Case 2
An 80-year-old male underwent phacoemulsification at a local clinic. During the procedure, posterior capsule rupture, lenticular fragment dislocation into the vitreous cavity, and DMD occurred in the left eye. The patient was referred to our centre 10 days postoperatively. On the initial examination at our clinic, BCVA was hand motion, and intraocular pressure was 4 mm Hg in the left eye. Slitlamp biomicroscopy revealed moderate corneal edema and DMD involving almost the entire area of the cornea. The central corneal thickness was 822 μm. The patient was diagnosed with lens dislocation and DMD resulting from the cataract surgery. The next day, 23-gauge pars plana vitrectomy to treat the dislocated lens fragment and IOL implantation in the ciliary sulcus were performed. In addition, intracameral air injection to alleviate DMD was performed. However, DMD did not resolve, and the patient underwent DSEK. During the surgery, we found that the midperipheral portion of the detached Descemet membrane had been lost and folded. Four days after DSEK, corneal edema was reduced, and BCVA had improved to 20/200. One year later, the cornea remained clear, and the central corneal thickness was 619 μm. The change in SE from target refraction of IOL implantation to 1 year postoperatively was þ0.71 D. At the 27-month follow-up visit, BCVA had improved to 20/32, and the cornea was still clear. No corneal haze or scar was noted. Case 3
A 79-year-old male was referred to our centre for DMD persisting for 3 weeks in the left eye. He had undergone
DSEK for Descemet membrane detachment—Kim and Kim phacoemulsification and IOL implantation at a local clinic 3 weeks before visiting our centre. One day after surgery, severe corneal edema and DMD were noted. Intracameral air injection was done at the local clinic. However, DMD had not resolved by the third postoperative week. On the initial examination at our clinic, BCVA was 20/800, and intraocular pressure was 7 mm Hg in the left eye. After 2 days, DSEK was performed. During the surgery, a wrinkled and folded detached Descemet membrane was found; an extensive area of the membrane had been lost. Three days after DSEK, corneal edema was reduced, and BCVA had improved to 20/50. After the corneal edema resolved, we found an anteriorly located clear corneal incision that had been performed during the phacoemulsification. One year later, the cornea remained clear, and the central corneal thickness was 650 μm. The change in SE from a target refraction of IOL implantation to 1 year postoperatively was þ1.25 D. At the 26-month follow-up visit, BCVA had improved to 20/32. The cornea was still clear. No corneal haze or scar was noted.
DISCUSSION DMD is a potentially serious complication of cataract surgery. Several predisposing factors are associated with the occurrence of DMD, including a shallow anterior chamber, anterior and shelved incisions, a high degree of surgical difficulty, and surgeon inexperience.8–10 Our case series, along with findings from previous reports, shows that cataract surgery performed on individuals with predisposing factors or surgical misadventures can lead to DMD. Case 1 had a shallow anterior chamber with a short axial length. Case 2 underwent a complicated cataract surgery, including posterior capsular rupture and vitreous loss. Case 3 showed an anteriorly located clear corneal incision. Reattachment of a detached Descemet membrane can be spontaneous, but it may require surgical intervention. Small lesions resolve with topical medical therapy within a few weeks to a few months. Corneal clarity can be maintained in most DMD cases, provided that the condition is recognized early and managed adequately. Although spontaneous reattachment of severe DMD has been reported, extensive separation of the membrane usually persists for a longer period and may require surgery for reattachment.11,12 Pneumodescemetopexy with intracameral gas has become the preferred treatment for DMD. Injections of sterile air, SF6 gas, or C3F8 gas have been suggested as appropriate treatment modalities.13,14 Marcon et al.15 reported a successful case series involving spontaneous reattachment or air tamponade reattachment of large nonscrolled DMDs. However, these researchers did not specify whether Descemet membrane had been lost. The decision regarding when to intervene in DMD should be made on a case-by-case basis after evaluation of the configuration of the detachment, accompanying
complications, and loss of Descemet membrane. In our case series, all the patients had DMD that affected more than 70% of the cornea, and all of the cases originated from the primary cataract surgery and were treated by means of pneumodescemetopexy with an intracameral air injection. However, DMD did not resolve after the injection. During DSEK, we saw loss of a large area of Descemet membrane in all 3 of our patients. When DMD is unresolved after repositioning by another procedure, PKP may be the final surgical option.6 However, DSEK is a better option than PKP for cases of DMD with regard to preservation of the recipient’s corneal stroma. DSEK involves the removal of the dysfunctional endothelium and Descemet membrane followed by replacement with healthy donor tissue composed of endothelium, Descemet membrane, and a thin layer of posterior stroma.16 All the patients in our study underwent DSEK for the treatment of DMD; stromal edema was quickly reduced, and visual acuity was rapidly recovered after the surgery. Even with long-term DMD and severe corneal edema (mean detachment period: 19.3 days), corneal clarity was achieved with DSEK. DSEK for treatment of extensive DMD offers many advantages over PKP, including reduced postoperative astigmatism, decreased risk for suture-related complications, and faster visual rehabilitation.17 Although the surgical results in our cases were excellent, we should have considered postoperative hyperopic shift (range þ0.63 to þ1.25 D). Previous studies found a mean postoperative hyperopic shift ranging from þ0.84 to þ1.26 D at 6 to 12 months in patients who underwent DSEK.18,19 A minus lens effect and a decrease in the radius of curvature upon addition of stromal tissue on the posterior curvature may have induced the hyperopic shift. Individuals who develop severe DMD during cataract surgery may need DSEK. When DSEK is chosen for treatment of DMD resulting from cataract surgery, IOL exchange should be considered for hyperopic shift. In conclusion, the results for this case series suggest that DSEK is a safe and viable option for managing extensive loss of Descemet membrane after cataract surgery. Even with a prolonged period of postoperative DMD and a large area of detachment, DMD was amenable to surgical repair by DSEK with good structural and functional outcomes.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.
REFERENCES 1. Sukhija J, Ram J, Kaushik S, Gupta A. Descemet’s membrane detachment following phacoemulsification. Ophthalmic Surg Lasers Imaging. 2010;41:512-7. 2. Macsai MS. Total detachment of Descemet’s membrane after smallincision cataract extraction. Am J Ophthalmol. 1992;114:365-6. CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
75
DSEK for Descemet membrane detachment—Kim and Kim 3. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane detachment during phacoemulsification surgery. Br J Ophthalmol. 1996;80:185-6. 4. Shah M, Bathia J, Kothari K. Repair of late Descemet’s membrane detachment with perfluoropropane gas. J Cataract Refract Surg. 2003;29:1242-4. 5. Kim T, Hasan SA. A new technique for repairing Descemet membrane detachments using intracameral gas injection. Arch Ophthalmol. 2002;120:181-3. 6. Merrick C. Descemet’s membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg. 1991;22:753-5. 7. Price F, Price MO. Descemet’s stripping with endothelial keratoplasty in 50 eyes: a refractive neutral corneal transplant. J Refract Surg. 2005;21:339-45. 8. Samuels B. Detachment of Descemet’s membrane. Trans Am Ophthalmol Soc. 1928;26:427-37. 9. Zusman NB, Waring GO, Najarian LV, Wilson LA. Sulfur hexafluoride gas in the repair of intractable Descemet’s membrane detachment. Am J Ophthalmol. 1987;104:660-2. 10. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg. 1995;21:714-7. 11. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol. 1994;112:551-2.
76
CAN J OPHTHALMOL — VOL. 50, NO. 1, FEBRUARY 2015
12. Vinekar A, Sukhija J, Brar GS, Ram J. “Late” functionally successful repair of Descemet’s membrane detachment following phacoemulsification. Eye (Lond). 2007;21:555-6. 13. Gault JA, Raber IM. Repair of Descemet’s membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;15:483-9. 14. Macsai MS, Gainer KM, Chisholm L. Repair of Descemet’s membrane detachment with perfluoropropane (C3F8). Cornea. 1998;17:129-34. 15. Marcon AS, Rapuano CJ, Jones MR, et al. Descemet’s membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109:2325-30. 16. Melles GR, Wijdh RH, Nieuwendaal CP. A technique to excise the Descemet membrane from a recipient cornea (descemetorhexis). Cornea. 2004;23:286-8. 17. Lee WB, Jacobs DS, Musch DC, et al. Descemet’s stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology. Ophthalmology. 2009;116:1818-30. 18. Koenig SB, Covert DJ, Dupps WJ Jr, Meisler DM. Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Cornea. 2007;26:670-4. 19. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006;25:886-9.
