Partial Descemet's membrane detachment with clear cornea after 3 Years post uneventful phacoemulsification

Amr Mounir; Engy Mohamed Mostafa

doi:10.4103/sjopthal.sjopthal_11_19

CASE REPORT

Year : 2019 | Volume : 11 | Issue : 1 | Page : 31-33

Partial Descemet's membrane detachment with clear cornea after 3 Years post uneventful phacoemulsification

Amr Mounir, Engy Mohamed Mostafa
Department of Ophthalmology, Sohag Faculty of Medicine, Sohag University Hospital, Sohag, Egypt

Date of Submission	25-May-2019
Date of Decision	24-Jun-2019
Date of Acceptance	26-Jun-2019
Date of Web Publication	10-Oct-2019

Correspondence Address:
Dr. Amr Mounir
Department of Ophthalmology, Sohag Faculty of Medicine, Sohag
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sjopthal.sjopthal_11_19

Abstract

In this report, we presented a 67-year-old male patient complaining of discomfort and slight eye redness for 1 week in the right eye. His surgical history was notable for uneventful phacoemulsification with a posterior chamber intraocular lens implantation in this eye 3 years earlier. Slit-lamp examination of the same eye revealed an area of localized partial Descemet's membrane detachment (DMD) in the right eye. The detached membrane was rolled and wrinkled with no associated stromal edema with clear corneal stroma. Anterior segment optical coherence tomography showed incomplete detachment with no associated increase in the corneal thickness in areas overlying detached and attached DM. The decision was to proceed with conservative treatment with monthly follow-up. After 6 months, the condition remained stable with no change in size of the DMD or in the corneal clarity.

Keywords: Clear cornea, Descemet's membrane detachment, uneventful phacoemulsification

How to cite this article:
Mounir A, Mostafa EM. Partial Descemet's membrane detachment with clear cornea after 3 Years post uneventful phacoemulsification. Sudanese J Ophthalmol 2019;11:31-3

How to cite this URL:
Mounir A, Mostafa EM. Partial Descemet's membrane detachment with clear cornea after 3 Years post uneventful phacoemulsification. Sudanese J Ophthalmol [serial online] 2019 [cited 2023 Mar 29];11:31-3. Available from: https://www.sjopthal.net/text.asp?2019/11/1/31/268792

Introduction

Descemet's membrane detachment (DMD) is unusual yet serious complication of intraocular surgery with different causes.^[1] It usually arises from traumatic clear corneal incision tears that progress to the central cornea as aqueous humor enters the predescemetic space.^[2] DMD presents as a detached translucent membrane in the anterior chamber, and extensive cases may create a “double-anterior-chamber” appearance.^[3] The majority of cases of DMD are subclinical and only detected with gonioscopic examination.^[4] In most cases, DMD resolves spontaneously, while larger detachments requiring surgical intervention only account for 0.5% of all cases.^[5] We report a case of a partial DMD which was discovered 3 years after phacoemulsification without subsequent corneal decompensation.

Case Report

A 67-year-old male patient presented to the outpatient clinic of the Ophthalmology Department, Sohag University Hospital, Egypt, with a vague complaint of discomfort in the right eye and slight eye redness for 1 week with no photophobia or blepharospasm. His systemic medical history was unremarkable. His surgical history was notable for uneventful phacoemulsification with a posterior chamber intraocular lens implantation in this eye 3 years earlier. There was no history of trauma.

His best-corrected visual acuity (BCVA) was 0.6 in the right eye, which is consistent with the presence of posterior capsule opacification. The left eye has BCVA of 0.3 due to the presence of early cortical cataract (Lens Opacities Classification System, version II C2). The intraocular pressure was 12.5 and 13.5 mmHg in the right and left eyes, respectively. Slit-lamp examination (Topcon SL-2 D, Japan) of the right eye revealed an area of localized partial DMD in the right eye, extending from the temporal aspect of the cornea from 7 to 12 clock position, which correlates to the site of the main incision and the side port incision of the phacoemulsification surgery [Figure 1]a and [Figure 1]b.

Figure 1: (a) An area of localized partial Descemet's membrane detachment in the right eye, (b) Rolled and wrinkled detached membrane with no associated stromal edema with clear corneal stroma

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The detached membrane was rolled and wrinkled with no associated stromal edema with clear corneal stroma. The detached membrane approached the temporal edge of the pupil. There were no signs of cell or flare in the right eye. Fundus examination was unremarkable in both the eyes.

The diagnosis of DMD was confirmed with anterior segment optical coherence tomography (AS-OCT) (RTVue-OCT, Model RT100, Optovue Inc., Fremont, CA, USA); it showed incomplete detachment with no associated increase in the corneal thickness in areas overlying detached and attached DM [Figure 2]a and [Figure 2]b and no fluid entrapped.

Figure 2: (a) Anterior segment optical coherence tomography showing incomplete detachment (b) Thickness map showing no associated increase in the corneal thickness in areas overlying detached and attached Descemet's membrane

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The decision was to proceed with conservative treatment in the form of topical combination of steroids and antibiotics eye drops (Tobradex) for 1 week for relieve of the ocular irritation symptoms (which is seasonal allergy). Monthly follow-up for the patient was the decision as the condition seemed to be of relatively long duration with no signs of corneal decompensation. After 6 months, the condition remained stable with no change in the size of the DMD or in the corneal clarity.

Discussion

DMD is a potentially serious, sight-threatening complication of cataract surgery.^[6] Due to the increasing popularity of cataract surgery, postoperative reports of DMD after phacoemulsification surgery become common.^[5] In our case, DMD was accidentally discovered after 3 years of uneventful phacoemulsification with no visual manifestations (BCVA: 0.6).

Because DMD usually occurs following heavy manipulation of cataract surgery, its occurrence after uneventful procedure is considered a rare condition.^[7] On slit-lamp examination, the detached membrane was found to extend from the previous phacoemulsification incision site which can be explained by that DMD resulted from old minute injury to the DM during fashioning the side wound incision during phacoemulsification and passed unnoticed during surgery. With time, DMD had started to increase in a gradual slow manner. This type of DMD is considered a simple DMD involving <1/4 of the cornea and fits into the classification presented by Guo et al.^[8] However, our reported DMD forms a type of rhegmatogenous DMD with free undulating edge and a peripheral tear according to the classification by Jacob et al.^[9]

Extensive DMD leads to severe corneal edema, which can be due to fluid influx to the space between corneal stroma and DM.^[10]

In our case, the interesting finding was the absence of signs of corneal decompensation. The clear cornea in our case is not consistent with the current concept of attached DM and consecutively the endothelial membrane in maintaining corneal dehydration. The endothelial cells are responsible for regulating cellular pump function to achieve sufficient corneal dehydration, resulting in maintained corneal transparency.^[11] The clear cornea might be attributed to a pattern of endothelial cell migration over the area of detached cornea, which is similar to the mechanism of corneal clearing after DM endothelial keratoplasty reported in several studies.^{[11],[12],[13]} There was uniform corneal thickness with no change in corneal thickness in the area of attached membrane versus the area of and detached membrane, which was confirmed by AS-OCT.

Different regiments were reported to treat DMD including medical treatment and air tamponade with air or SF6 in large DM detachment and may require penetrating keratoplasty or endothelial keratoplasty in severe cases.^[14],[15]

In our case, the decision was conservative management with no interference as the long follow-up period showed stationary course with no worsening of visual acuity. Another cause was that the AS-OCT showed that the detached membrane was markedly thin, wrinkled, and rolled, which gave an idea that detachment was of long duration. Thus, the trial for unfolding the detached part would have been a hazardous maneuver with unexpected results.

Conclusions

Despite the fact that DMD is a potentially serious complication, it can be managed conservatively if there was no progress and no effect on corneal clarity.

Declaration of patient consent

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Benatti CA, Tsao JZ, Afshari NA. Descemet membrane detachment during cataract surgery: Etiology and management. Curr Opin Ophthalmol 2017;28:35-41.
2.	Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet's membrane detachment after cataract surgery: Management and outcome. Ophthalmology 2002;109:2325-30.
3.	Chow VW, Agarwal T, Vajpayee RB, Jhanji V. Update on diagnosis and management of descemet's membrane detachment. Curr Opin Ophthalmol 2013;24:356-61.
4.	Monroe WM. Gonioscopy after cataract extraction. South Med J 1971;64:1122-4.
5.	Khng CY, Voon LW, Yeo KT. Causes and management of descemet's membrane detachment associated with cataract surgery – Not always a benign problem. Ann Acad Med Singapore 2001;30:532-5.
6.	Potter J, Zalatimo N. Descemet's membrane detachment after cataract extraction. Optometry 2005;76:720-4.
7.	Ti SE, Chee SP, Tan DT, Yang YN, Shuang SL. Descemet membrane detachment after phacoemulsification surgery: Risk factors and success of air bubble tamponade. Cornea 2013;32:454-9.
8.	Guo P, Pan Y, Zhang Y, Tighe S, Zhu Y, Li M, et al. Study on the classification of descemet membrane detachment after cataract surgery with AS-OCT. Int J Med Sci 2018;15:1092-7.
9.	Jacob S, Agarwal A, Chaudhry P, Narasimhan S, Chaudhry VN. A new clinico-tomographic classification and management algorithm for descemet's membrane detachment. Cont Lens Anterior Eye 2015;38:327-33.
10.	Xie W, Xu Y, Yao YF. Descemet's membrane detachment with schisis induced by phacoemulsification. Optom Vis Sci 2016;93:1562-6.
11.	Balachandran C, Ham L, Verschoor CA, Ong TS, van der Wees J, Melles GR, et al. Spontaneous corneal clearance despite graft detachment in descemet membrane endothelial keratoplasty. Am J Ophthalmol 2009;148:227-340.e1.
12.	Dirisamer M, Dapena I, Ham L, van Dijk K, Oganes O, Frank LE, et al. Patterns of corneal endothelialization and corneal clearance after descemet membrane endothelial keratoplasty for fuchs endothelial dystrophy. Am J Ophthalmol 2011;152:543-50.e1.
13.	Jacobi C, Zhivov A, Korbmacher J, Falke K, Guthoff R, Schlötzer-Schrehardt U, et al. Evidence of endothelial cell migration after descemet membrane endothelial keratoplasty. Am J Ophthalmol 2011;152:537-42.e2.
14.	Gatzioufas Z, Schirra F, Löw U, Walter S, Lang M, Seitz B, et al. Spontaneous bilateral late-onset descemet membrane detachment after successful cataract surgery. J Cataract Refract Surg 2009;35:778-81.
15.	Couch SM, Baratz KH. Delayed, bilateral descemet's membrane detachments with spontaneous resolution: Implications for nonsurgical treatment. Cornea 2009;28:1160-3.