CASE REPORT
Spontaneous Descemet Membrane Tear After Uneventful Big-Bubble Deep Anterior Lamellar Keratoplasty Vito Romano, MD,* Bernhard Steger, MD,* and Stephen B. Kaye, MD, FRCS, FRCOphth*†
Purpose: To report a case of delayed spontaneous Descemet membrane (DM) tear after big-bubble Deep Anterior Lamellar Keratoplasty (DALK).
Methods: Uneventful big-bubble DALK was performed on a 29-year-old patient with advanced keratoconus. No injury to DM was noted intraoperatively and in the first postoperative week. On examination after 1 month, the patient presented with tear and partial detachment of Descemet membrane (DMD). Results: Circumscribed eccentric stromal edema, but not DMD, partially resolved after a 3-month observational period. Conclusions: A tear to DM and consecutive DMD may occur spontaneously after big-bubble DALK. Sutural traction and regressing corneal stromal edema may be etiologic factors. Key Words: big-bubble technique, deep anterior lamellar keratoplasty, Descemet membrane tear (Cornea 2015;34:479–481)
T
earing of Descemet membrane (DM) is a known complication of intraocular surgery, most notably during cataract surgery,1 trabeculectomy,2 Descemet membrane endothelial keratoplasty,3 and deep anterior lamellar keratoplasty (DALK).4 Inadvertent rupture of DM during DALK occurs particularly in patients with keratoconus, where thinning is present with advanced cones.5 Descemet membrane rupture is detected either intraoperatively or during postoperative review by formation of a double anterior chamber due to DM detachment (DMD).5 We report the case of a 29-year-old patient with keratoconus who developed a presumably spontaneous DM tear 1 month after uneventful DALK.
Received for publication November 3, 2014; revision received December 11, 2014; accepted December 12, 2014. Published online ahead of print February 3, 2015. From the *Department of Corneal and External Eye Diseases, St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom; and †Department of Eye and Vision Science, University of Liverpool, Liverpool, United Kingdom. The authors have no funding or conflicts of interest to disclose. Reprints: Bernhard Steger, MD, St Paul’s Eye Unit, Royal Liverpool University Hospital, 8Z Link, Prescot St, Liverpool, L7 8XP, United Kingdom (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cornea Volume 34, Number 4, April 2015
CASE REPORT A 29-year-old man with advanced right keratoconus (steep meridian 63.4 D and flat meridian 54.9 D, thinnest point 413 mm) and best-corrected visual acuities (VA) of 20/200 in the right eye and 20/20 in the left eye underwent uneventful DALK in the right eye using the big-bubble technique.5 After performing 7.8-mm-diameter partial thickness trephination of the recipient cornea, a 30-gauge bent needle was introduced bevel down into the central cornea, and a big bubble was produced. A limbal paracentesis peripheral to the edge of the air bubble was performed. An excision of the cornea to the level of DM was performed. No ophthalmic viscosurgical device was used, and no visible perforation of DM under the bubble was noted. A 7.8-mm donor corneal button was stripped of the DM and sutured to the recipient with partial thickness combined interrupted 10-0 nylon sutures and continuous 11-0 prolene sutures. There was no air injection into the anterior chamber at the end of the procedure. A bandage contact lens of 22 mm in diameter was applied at the end of the procedure. Topical prednisolone acetate 1% eye drops (Pred Forte, Allergan) 6 times a day and chloramphenicol 0.5% eye drops (chloramphenicol) 4 times a day were used postoperatively. On the first postoperative day, the cornea was clear, the anterior chamber well formed, no double anterior chamber was noted, and the Seidel sign was negative. The bandage contact lens was replaced. No significant changes were noted on examination 1 week after surgery. One month after operation, the patient presented with a DM tear and localized corneal edema in the inferotemporal quadrant of the cornea (Fig. 1). The patient denied any ocular trauma or eye rubbing since the time of surgery. No intervention was performed. Two months after surgery, there was a reduction of corneal edema. Intraocular pressure remained within normal limits. No double anterior chamber was noted on optical coherence tomography. Endothelial specular microscopy of the central cornea was performed and showed normal endothelial cell density and morphology (endothelial cell density 2841 cells per square millimeter, coefficient of variation 28). In vivo confocal laser scanning microscopy of the affected peripheral corneal segment was performed and confirmed an intact monolayer of endothelial cells. Imaging quality was reduced because of residual corneal stromal edema (Fig. 2). The patient’s best-corrected visual acuity improved to 20/60, and the corneal edema in the temporal lower quadrant continued to improve.
DISCUSSION
DMD was first reported in the English literature by Samuels in 1928.6 DMD has been classified based on the extent of separation from the stroma. DMD often occurs after cataract surgery and mostly remains localized to the area of a corneal incision.1 More extensive detachments, however, can encroach on the visual axis. DMD is also a significant complication after DALK, which is usually caused by microor macro-perforations during surgery. It is recognized during the first postoperative week by formation of a double anterior www.corneajrnl.com |
479
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Romano et al
FIGURE 1. Color photograph at 1 month after surgery. The edges of DM tear are marked with arrows.
chamber. Depending on the extent or severity, management of DMD may be either medical or surgical. This report describes, to the best of our knowledge, the first definitive case of spontaneous DM tear after uncomplicated big-bubble DALK in a patient with a diagnosis of advanced keratoconus. The patient presented with a circumscribed and non–sight-threatening DMD due to a peripheral tear in DM 4 weeks after uneventful DALK and early postoperative follow-up. We chose to abstain from surgical intervention and only continued the topical steroid treatment regimen, based on several reports of spontaneous resolution of DMD. Assia et al7 reported 5 cases of subtotal detachment
Cornea Volume 34, Number 4, April 2015
with spontaneous resolution after 2 to 3 months. Minkowitz et al8 also published a case of spontaneous resolution of extensive detachment 1 month after cataract surgery. Mackool and Holtz9 suggested that multiple DMDs with less than 1-mm separation from the stroma will spontaneously resolve. In the present case, no spontaneous reattachment occurred, most likely because of the extent of the observed tear in DM. Corneal edema, however, continued to reduce 3 months after surgery. Repopulation of stroma with migrated endothelial cells is the most likely explanation of this finding.10 The presence of an intact endothelial cell layer in the affected corneal segment on in vivo confocal microscopy supports this conclusion. Given the absence of intraoperative perforation of DM or early postoperative DMD, etiology of the present DM tear remains to be explained. Kansal and Sugar11 suggested that the presence of inherent abnormalities of DM’s attachment to the stroma may be a predisposing factor for DMD, rather than mere mechanical forces during surgery. At the same time, Mahmood et al,12 after careful analysis, failed to identify any such further etiologic factors. We would speculate on possible reasons for the development of a late tear in Descemet membrane. Tractional forces created by deep and tight stromal sutures led to central flattening of the graft and stretching and distortion of Descemet membrane, particularly around and under the indent created by the sutures at the edge of the graft. This may have been exacerbated by the reduction of corneal stromal edema during the first postoperative month with further stretching of the posterior corneal surface and an increase in tension along Descemet membrane. Tractional forces can be expected to distribute to a lesser degree in a graft of relatively small diameter. It is also possible that there was a microtear in the peripheral part of Descemet from the pass of suture needle, which then extended in the ensuing weeks after surgery. Formation of a double anterior chamber in this scenario 1 to 4 weeks postoperatively would not be expected because of already present adherence of the graft to the underlying tissue membrane. It is not known whether there is a difference in elasticity, tensile strength, or thickness of the central compared with the peripheral part of Descemet membrane. Such differences might account for the presence of central as opposed to peripheral breaks in Descemet membrane in patients with buphthalmos (Haab Striae) or after birth trauma. REFERENCES
FIGURE 2. In vivo confocal microscopy of the edematous corneal segment. At the level of Descemet membrane, an intact monolayer of the corneal endothelium was found. Imaging quality was reduced because of residual corneal stromal edema. Scale bar: 40 mm.
480
| www.corneajrnl.com
1. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane detachment during phacoemulsification surgery. Br J Ophthalmol. 1996;80:185–186. 2. Wigginton SA, Jungschaffer DA, Lee DA. Postoperative Descemet membrane detachment with maintenance of corneal clarity after trabeculectomy. J Glaucoma. 2000;9:200–202. 3. Mittal V, Mittal R, Jain R, et al. Incidental central tear in Descemet membrane endothelial complex during Descemet membrane endothelial keratoplasty. BMJ Case Rep. 2014;20:29–30. 4. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol. 1997;81: 184–188. 5. Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2007;143:117–124. 6. Samuels B. Detachment of Descemet’s membrane. Trans Am Ophthalmol Soc. 1928;26:427–437.
Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 4, April 2015
7. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg. 1995;21:714–717. 8. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol. 1994;112:551–552. 9. Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol. 1977;95:459–463.
Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
DM Tear After DALK
10. Shah RD, Randleman JB, Grossniklaus HE. Spontaneous corneal clearing after Descemet’s stripping without endothelial replacement. Ophthalmology. 2012;119:256–260. 11. Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phacoemulsification. Cornea. 2001;20:670–671. 12. Mahmood MA, Teichmann KD, Tomey KF, et al. Detachment of Descemet’s membrane. J Cataract Refract Surg. 1998;24:827–833.
www.corneajrnl.com |
481
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Spontaneous Descemet Membrane Tear After Uneventful Big-Bubble Deep Anterior Lamellar Keratoplasty Vito Romano, MD,* Bernhard Steger, MD,* and Stephen B. Kaye, MD, FRCS, FRCOphth*†
Purpose: To report a case of delayed spontaneous Descemet membrane (DM) tear after big-bubble Deep Anterior Lamellar Keratoplasty (DALK).
Methods: Uneventful big-bubble DALK was performed on a 29-year-old patient with advanced keratoconus. No injury to DM was noted intraoperatively and in the first postoperative week. On examination after 1 month, the patient presented with tear and partial detachment of Descemet membrane (DMD). Results: Circumscribed eccentric stromal edema, but not DMD, partially resolved after a 3-month observational period. Conclusions: A tear to DM and consecutive DMD may occur spontaneously after big-bubble DALK. Sutural traction and regressing corneal stromal edema may be etiologic factors. Key Words: big-bubble technique, deep anterior lamellar keratoplasty, Descemet membrane tear (Cornea 2015;34:479–481)
T
earing of Descemet membrane (DM) is a known complication of intraocular surgery, most notably during cataract surgery,1 trabeculectomy,2 Descemet membrane endothelial keratoplasty,3 and deep anterior lamellar keratoplasty (DALK).4 Inadvertent rupture of DM during DALK occurs particularly in patients with keratoconus, where thinning is present with advanced cones.5 Descemet membrane rupture is detected either intraoperatively or during postoperative review by formation of a double anterior chamber due to DM detachment (DMD).5 We report the case of a 29-year-old patient with keratoconus who developed a presumably spontaneous DM tear 1 month after uneventful DALK.
Received for publication November 3, 2014; revision received December 11, 2014; accepted December 12, 2014. Published online ahead of print February 3, 2015. From the *Department of Corneal and External Eye Diseases, St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom; and †Department of Eye and Vision Science, University of Liverpool, Liverpool, United Kingdom. The authors have no funding or conflicts of interest to disclose. Reprints: Bernhard Steger, MD, St Paul’s Eye Unit, Royal Liverpool University Hospital, 8Z Link, Prescot St, Liverpool, L7 8XP, United Kingdom (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cornea Volume 34, Number 4, April 2015
CASE REPORT A 29-year-old man with advanced right keratoconus (steep meridian 63.4 D and flat meridian 54.9 D, thinnest point 413 mm) and best-corrected visual acuities (VA) of 20/200 in the right eye and 20/20 in the left eye underwent uneventful DALK in the right eye using the big-bubble technique.5 After performing 7.8-mm-diameter partial thickness trephination of the recipient cornea, a 30-gauge bent needle was introduced bevel down into the central cornea, and a big bubble was produced. A limbal paracentesis peripheral to the edge of the air bubble was performed. An excision of the cornea to the level of DM was performed. No ophthalmic viscosurgical device was used, and no visible perforation of DM under the bubble was noted. A 7.8-mm donor corneal button was stripped of the DM and sutured to the recipient with partial thickness combined interrupted 10-0 nylon sutures and continuous 11-0 prolene sutures. There was no air injection into the anterior chamber at the end of the procedure. A bandage contact lens of 22 mm in diameter was applied at the end of the procedure. Topical prednisolone acetate 1% eye drops (Pred Forte, Allergan) 6 times a day and chloramphenicol 0.5% eye drops (chloramphenicol) 4 times a day were used postoperatively. On the first postoperative day, the cornea was clear, the anterior chamber well formed, no double anterior chamber was noted, and the Seidel sign was negative. The bandage contact lens was replaced. No significant changes were noted on examination 1 week after surgery. One month after operation, the patient presented with a DM tear and localized corneal edema in the inferotemporal quadrant of the cornea (Fig. 1). The patient denied any ocular trauma or eye rubbing since the time of surgery. No intervention was performed. Two months after surgery, there was a reduction of corneal edema. Intraocular pressure remained within normal limits. No double anterior chamber was noted on optical coherence tomography. Endothelial specular microscopy of the central cornea was performed and showed normal endothelial cell density and morphology (endothelial cell density 2841 cells per square millimeter, coefficient of variation 28). In vivo confocal laser scanning microscopy of the affected peripheral corneal segment was performed and confirmed an intact monolayer of endothelial cells. Imaging quality was reduced because of residual corneal stromal edema (Fig. 2). The patient’s best-corrected visual acuity improved to 20/60, and the corneal edema in the temporal lower quadrant continued to improve.
DISCUSSION
DMD was first reported in the English literature by Samuels in 1928.6 DMD has been classified based on the extent of separation from the stroma. DMD often occurs after cataract surgery and mostly remains localized to the area of a corneal incision.1 More extensive detachments, however, can encroach on the visual axis. DMD is also a significant complication after DALK, which is usually caused by microor macro-perforations during surgery. It is recognized during the first postoperative week by formation of a double anterior www.corneajrnl.com |
479
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Romano et al
FIGURE 1. Color photograph at 1 month after surgery. The edges of DM tear are marked with arrows.
chamber. Depending on the extent or severity, management of DMD may be either medical or surgical. This report describes, to the best of our knowledge, the first definitive case of spontaneous DM tear after uncomplicated big-bubble DALK in a patient with a diagnosis of advanced keratoconus. The patient presented with a circumscribed and non–sight-threatening DMD due to a peripheral tear in DM 4 weeks after uneventful DALK and early postoperative follow-up. We chose to abstain from surgical intervention and only continued the topical steroid treatment regimen, based on several reports of spontaneous resolution of DMD. Assia et al7 reported 5 cases of subtotal detachment
Cornea Volume 34, Number 4, April 2015
with spontaneous resolution after 2 to 3 months. Minkowitz et al8 also published a case of spontaneous resolution of extensive detachment 1 month after cataract surgery. Mackool and Holtz9 suggested that multiple DMDs with less than 1-mm separation from the stroma will spontaneously resolve. In the present case, no spontaneous reattachment occurred, most likely because of the extent of the observed tear in DM. Corneal edema, however, continued to reduce 3 months after surgery. Repopulation of stroma with migrated endothelial cells is the most likely explanation of this finding.10 The presence of an intact endothelial cell layer in the affected corneal segment on in vivo confocal microscopy supports this conclusion. Given the absence of intraoperative perforation of DM or early postoperative DMD, etiology of the present DM tear remains to be explained. Kansal and Sugar11 suggested that the presence of inherent abnormalities of DM’s attachment to the stroma may be a predisposing factor for DMD, rather than mere mechanical forces during surgery. At the same time, Mahmood et al,12 after careful analysis, failed to identify any such further etiologic factors. We would speculate on possible reasons for the development of a late tear in Descemet membrane. Tractional forces created by deep and tight stromal sutures led to central flattening of the graft and stretching and distortion of Descemet membrane, particularly around and under the indent created by the sutures at the edge of the graft. This may have been exacerbated by the reduction of corneal stromal edema during the first postoperative month with further stretching of the posterior corneal surface and an increase in tension along Descemet membrane. Tractional forces can be expected to distribute to a lesser degree in a graft of relatively small diameter. It is also possible that there was a microtear in the peripheral part of Descemet from the pass of suture needle, which then extended in the ensuing weeks after surgery. Formation of a double anterior chamber in this scenario 1 to 4 weeks postoperatively would not be expected because of already present adherence of the graft to the underlying tissue membrane. It is not known whether there is a difference in elasticity, tensile strength, or thickness of the central compared with the peripheral part of Descemet membrane. Such differences might account for the presence of central as opposed to peripheral breaks in Descemet membrane in patients with buphthalmos (Haab Striae) or after birth trauma. REFERENCES
FIGURE 2. In vivo confocal microscopy of the edematous corneal segment. At the level of Descemet membrane, an intact monolayer of the corneal endothelium was found. Imaging quality was reduced because of residual corneal stromal edema. Scale bar: 40 mm.
480
| www.corneajrnl.com
1. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane detachment during phacoemulsification surgery. Br J Ophthalmol. 1996;80:185–186. 2. Wigginton SA, Jungschaffer DA, Lee DA. Postoperative Descemet membrane detachment with maintenance of corneal clarity after trabeculectomy. J Glaucoma. 2000;9:200–202. 3. Mittal V, Mittal R, Jain R, et al. Incidental central tear in Descemet membrane endothelial complex during Descemet membrane endothelial keratoplasty. BMJ Case Rep. 2014;20:29–30. 4. Sugita J, Kondo J. Deep lamellar keratoplasty with complete removal of pathological stroma for vision improvement. Br J Ophthalmol. 1997;81: 184–188. 5. Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2007;143:117–124. 6. Samuels B. Detachment of Descemet’s membrane. Trans Am Ophthalmol Soc. 1928;26:427–437.
Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 4, April 2015
7. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg. 1995;21:714–717. 8. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol. 1994;112:551–552. 9. Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol. 1977;95:459–463.
Copyright Ó 2015 Wolters Kluwer Health, Inc. All rights reserved.
DM Tear After DALK
10. Shah RD, Randleman JB, Grossniklaus HE. Spontaneous corneal clearing after Descemet’s stripping without endothelial replacement. Ophthalmology. 2012;119:256–260. 11. Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phacoemulsification. Cornea. 2001;20:670–671. 12. Mahmood MA, Teichmann KD, Tomey KF, et al. Detachment of Descemet’s membrane. J Cataract Refract Surg. 1998;24:827–833.
www.corneajrnl.com |
481
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
