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Descemet membrane detachment following viscoelastic injection for posttrabeculectomy hypotony
Correspondence cysts, cords, and Flexner–Wintersteiner rosettes was seen arising from the ciliary body with a neoplastic cyclitic membrane. The tumor extended posteriorly into the choroid and detached retina. There were no heteroplastic elements or extraocular spread. However, occasional mitotic figures were observed. Intraocular medulloepithelioma usually arises from the ciliary body, and rarely the optic nerve or the retina.1,2 Only 13 published cases of adult medulloepithelioma have been reported.2–5 The common clinical presentations are glaucoma, leukocoria, anterior chamber or iris mass, cataract, and rubeosis.1,2 The reason hypothesized for the late presentation of this embryonal tumor is that the embryonal anlage, although present, may delay in malignant transformation and growth.5 To the best of our knowledge, this is the 14th case in an adult and the first documented report of a medulloepithelioma with a large intravitreal hemorrhage. Vascular infiltration or erosion by the tumor is likely to be the cause. Various studies show that local resection is usually insufficient and enucleation is ultimately required because of tumor recurrence.1,2,5 Most of the tumor-related deaths are preceded by clinically obvious orbital spread.1,5 In conclusion, medulloepithelioma should be kept in the differential diagnosis of ciliary body or choroidal tumors presenting in adults.
REFERENCES
Descemet membrane detachment following viscoelastic injection for posttrabeculectomy hypotony
DMD is an infrequent, but potentially vision-threatening, complication of ocular surgery. Risk factors leading to DMD are glaucoma, soft globe, previous ocular surgery, corneal scarring, and an anatomical predisposition.1 Most commonly reported cases of DMD have been secondary to phacoemulsification, but it has also been reported following argon-neodymium:yttrium-aluminum-garnet (YAG) laser peripheral iridotomy, viscocanalostomy, trabeculectomy, deep sclerectomy, and other procedures involving the sclera.2–5 There are various treatment options for DMD. Conservative treatments have been utilized in smaller
A
65-year-old woman was referred to our clinic for the assessment of a large central Descemet membrane detachment (DMD) involving the left cornea. Her symptoms included decreased visual acuity of counting fingers at 1 meter and photosensitivity with no pain or injection. She had undergone previous trabeculectomy in this eye in 1996. One month prior to her presentation, she underwent a bleb revision to reduce the size of her overhanging bleb. She developed hypotony postoperatively and required several anterior chamber reformations with viscoelastic injection. The detachment of the Descemet membrane (DM) occurred during inadvertent injection of a viscoelastic device into the posterior corneal layers, with resulting dissection of the DM (Fig. 1).
Fig. 1—(A) Left eye, demonstrating the area where the corneal portion of the bleb was excised from encroaching onto the cornea. (B) Same eye, showing the detached Descemet membrane (arrow).
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1. Broughton WL, Zimmerman LE. A clinicopathologic study of 56 cases of intraocular medulloepitheliomas. Am J Ophthalmol 1978;85:407–18. 2. Shields JA, Eagle RC Jr, Shields CL, Potter PD. Congenital neoplasms of the non-pigmented ciliary epithelium (medulloepithelioma). Ophthalmology 1996;103:1998–2006. 3. Canning CR, McCartney AC, Hungerford J. Medulloepithelioma (diktyoma). Br J Ophthalmol 1988;72:764–7. 4. Font RL, Rishi K. Diffuse retinal involvement in malignant nonteratoid medulloepithelioma of ciliary body in an adult. Arch Ophthalmol 2005;123:1136–8. ´ 5. Sosinska-Mielcarek K, Senkus-Konefka E, Jaskiewicz K, Kordek R, Jassem J. Intraocular malignant teratoid medulloepithelioma in an adult: clinicopathological case report and review of literature. Acta Ophthalmol Scand 2006;84:259–62.
Neelam Pushker, Noornika Khuraijam, Seema Sen, Mandeep Bajaj, Mridula Mehta Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to Noornika Khuraijam, MD: [email protected] Can J Ophthalmol 2008;43:253–4 doi:10.3129/i08-022
Fig. 2—Left eye, demonstrating the reattached Descemet membrane.
Correspondence detachments. However, for large detachments, the options include injection of air, expansile gas (such as SF6), or viscoelastic to hold the detached membrane against the stroma. With the presence of a functioning bleb, we used Healon to tamponade the detached DM. Three full-thickness 10-0 nylon sutures were placed to secure the DM to the stroma, and small stab incisions were made to drain any fluid collection between the DM and the stroma. Healon was then aspirated from the anterior chamber, and the wound was closed with a suture. At the 1-week follow-up, the DM was still detached superotemporally. The patient was taken back to the operating room for the same procedure as described above. At the 2-month follow-up, the DMD had resolved (Fig. 2), the sutures were removed, and the vision was measured to be hand motion, with a significant cataract present. The patient was asked to follow up with her referring ophthalmologist for management of her cataract. This was a unique case of DMD occurring after inadvertent injection of a viscoelastic device into the posterior cornea during anterior chamber reformation. In this case, viscoelastic and full-thickness sutures were employed to reapproximate the DM. In other instances, SF6 or air may also be used intracamerally instead of a viscoelastic device.
REFERENCES 1. Potter J, Zalatimo N. Descemet’s membrane detachment after cataract extraction. Optometry 2005;76:720–4. 2. Watson SL, Abiad G, Coroneo MT. Spontaneous resolution of corneal edema following Descemet’s detachment. Clin Experiment Ophthalmol 2006;34:797–9. 3. Liu DT, Lai JS, Lam DS. Descemet membrane detachment after sequential argon-neodymium:YAG laser peripheral iridotomy. Am J Ophthalmol 2002;134:621–2. 4. Feys J, Mohand-Said M, Nodarian M, Hollard P. [Spontaneous clearing of the cornea with detachment of Descemet’s membrane]. J Fr Ophtalmol 2002;25:502–4 [in French]. 5. Kozobolis VP, Christodoulakis EV, Siganos CS, Pallikaris IG. Hemorrhagic Descemet’s membrane detachment as a complication of deep sclerectomy: a case report. J Glaucoma 2001; 10:497–500.
Mahta Rasouli,* Rookaya Mather,† David Tingey† *Queen’s University, Kingston, Ont.; and of Western Ontario, London, Ont.
†University
Correspondence to Rookaya Mather, MD: [email protected] Can J Ophthalmol 2008;43:254–5 doi:10.3129/i08-018
CAN J OPHTHALMOL—VOL. 43, NO. 2, 2008
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REFERENCES
Descemet membrane detachment following viscoelastic injection for posttrabeculectomy hypotony
DMD is an infrequent, but potentially vision-threatening, complication of ocular surgery. Risk factors leading to DMD are glaucoma, soft globe, previous ocular surgery, corneal scarring, and an anatomical predisposition.1 Most commonly reported cases of DMD have been secondary to phacoemulsification, but it has also been reported following argon-neodymium:yttrium-aluminum-garnet (YAG) laser peripheral iridotomy, viscocanalostomy, trabeculectomy, deep sclerectomy, and other procedures involving the sclera.2–5 There are various treatment options for DMD. Conservative treatments have been utilized in smaller
A
65-year-old woman was referred to our clinic for the assessment of a large central Descemet membrane detachment (DMD) involving the left cornea. Her symptoms included decreased visual acuity of counting fingers at 1 meter and photosensitivity with no pain or injection. She had undergone previous trabeculectomy in this eye in 1996. One month prior to her presentation, she underwent a bleb revision to reduce the size of her overhanging bleb. She developed hypotony postoperatively and required several anterior chamber reformations with viscoelastic injection. The detachment of the Descemet membrane (DM) occurred during inadvertent injection of a viscoelastic device into the posterior corneal layers, with resulting dissection of the DM (Fig. 1).
Fig. 1—(A) Left eye, demonstrating the area where the corneal portion of the bleb was excised from encroaching onto the cornea. (B) Same eye, showing the detached Descemet membrane (arrow).
254
CAN J OPHTHALMOL—VOL. 43, NO. 2, 2008
1. Broughton WL, Zimmerman LE. A clinicopathologic study of 56 cases of intraocular medulloepitheliomas. Am J Ophthalmol 1978;85:407–18. 2. Shields JA, Eagle RC Jr, Shields CL, Potter PD. Congenital neoplasms of the non-pigmented ciliary epithelium (medulloepithelioma). Ophthalmology 1996;103:1998–2006. 3. Canning CR, McCartney AC, Hungerford J. Medulloepithelioma (diktyoma). Br J Ophthalmol 1988;72:764–7. 4. Font RL, Rishi K. Diffuse retinal involvement in malignant nonteratoid medulloepithelioma of ciliary body in an adult. Arch Ophthalmol 2005;123:1136–8. ´ 5. Sosinska-Mielcarek K, Senkus-Konefka E, Jaskiewicz K, Kordek R, Jassem J. Intraocular malignant teratoid medulloepithelioma in an adult: clinicopathological case report and review of literature. Acta Ophthalmol Scand 2006;84:259–62.
Neelam Pushker, Noornika Khuraijam, Seema Sen, Mandeep Bajaj, Mridula Mehta Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to Noornika Khuraijam, MD: [email protected] Can J Ophthalmol 2008;43:253–4 doi:10.3129/i08-022
Fig. 2—Left eye, demonstrating the reattached Descemet membrane.
Correspondence detachments. However, for large detachments, the options include injection of air, expansile gas (such as SF6), or viscoelastic to hold the detached membrane against the stroma. With the presence of a functioning bleb, we used Healon to tamponade the detached DM. Three full-thickness 10-0 nylon sutures were placed to secure the DM to the stroma, and small stab incisions were made to drain any fluid collection between the DM and the stroma. Healon was then aspirated from the anterior chamber, and the wound was closed with a suture. At the 1-week follow-up, the DM was still detached superotemporally. The patient was taken back to the operating room for the same procedure as described above. At the 2-month follow-up, the DMD had resolved (Fig. 2), the sutures were removed, and the vision was measured to be hand motion, with a significant cataract present. The patient was asked to follow up with her referring ophthalmologist for management of her cataract. This was a unique case of DMD occurring after inadvertent injection of a viscoelastic device into the posterior cornea during anterior chamber reformation. In this case, viscoelastic and full-thickness sutures were employed to reapproximate the DM. In other instances, SF6 or air may also be used intracamerally instead of a viscoelastic device.
REFERENCES 1. Potter J, Zalatimo N. Descemet’s membrane detachment after cataract extraction. Optometry 2005;76:720–4. 2. Watson SL, Abiad G, Coroneo MT. Spontaneous resolution of corneal edema following Descemet’s detachment. Clin Experiment Ophthalmol 2006;34:797–9. 3. Liu DT, Lai JS, Lam DS. Descemet membrane detachment after sequential argon-neodymium:YAG laser peripheral iridotomy. Am J Ophthalmol 2002;134:621–2. 4. Feys J, Mohand-Said M, Nodarian M, Hollard P. [Spontaneous clearing of the cornea with detachment of Descemet’s membrane]. J Fr Ophtalmol 2002;25:502–4 [in French]. 5. Kozobolis VP, Christodoulakis EV, Siganos CS, Pallikaris IG. Hemorrhagic Descemet’s membrane detachment as a complication of deep sclerectomy: a case report. J Glaucoma 2001; 10:497–500.
Mahta Rasouli,* Rookaya Mather,† David Tingey† *Queen’s University, Kingston, Ont.; and of Western Ontario, London, Ont.
†University
Correspondence to Rookaya Mather, MD: [email protected] Can J Ophthalmol 2008;43:254–5 doi:10.3129/i08-018
CAN J OPHTHALMOL—VOL. 43, NO. 2, 2008
255