- Email: [email protected]
Repair of Descemet's Membrane Detachment With the Assistance of Intraoperative Ultrasound Biomicroscopy
Fig. 1 (Zoric, Zoric, and Zoric). A 4Vi-year-old girl with an abscess with acute signs of inflammation on the left side of the face, and an abscess without inflammation on the right side of the face.
inflammation, and necrosis. The bacillus was found to be a human type of tuberculous mycobacterium. After a course of antituberculous therapy (rifampin, streptomycin, and isoniazid during the first month, then isoniazid and rifampin for the next 11 months), the eyelid process healed. Although tuberculosis is found worldwide, tubercu losis with facial abscess is rare.1'4 In our case, histopathologic and microbiologie examination established a human type of tuberculous mycobacterium as the cause of the bilateral facial lesions. Tuberculosis should therefore be considered as a possible cause of abscess with signs of acute inflammation, or a tumor like process without obvious signs of inflammation, even when the clinical features are not typical. REFERENCES 1. Albert DM, Jakobiec FA. Principles and practice of ophthal mology. Volume 3. Philadelphia: WB Saunders, 1994:1708. 2. Daniel TM. Tuberculosis. In: Harrison TR, editor. Harrison's principles of internal medicine, 11th edition. New York: McGraw Hill, 1987:625-33. 3. Duke-Elder S. System of ophthalmology. Volume 8. London: Henry Kimpton, 1964:103-10. 4. Fedukowicz HB. External infections of the eye. New York: Appleton-Century-Crofts, 1978:136-41.
Fig. 2 (Zoric, Zoric, and Zoric). Large, tumor-like abscess spreading over the right upper eyelid, eyebrow, and forehead.
Repair of Descemet's Membrane Detachment With the Assistance of Intraoperative Ultrasound Biomicroscopy
laboratory after inspection of native preparations,
Elisa N. Morinellï, M.D., Richard D. Najac, M.D., Mark G. Speaker, M.D., Celso Tello, M.D., Jeffrey M. Liebmann, M.D., and Robert Ritch, M.D.
Ziehl-Neelsen stain, inoculation of a guinea pig, and Löwenstein culture with material from each facial lesion produced the typical yellow, cauliflower-like colonies of Mycobacterium tuberculosis. The parents denied the existence of tuberculosis and other illnesses in their family, and x-ray of the child's lungs showed a calcified primary complex but no active change. The results of physical examination and laboratory analyses were normal, except for an increased erythrocyte sedimentation rate. A Mantoux reaction on the forearm (purified protein derivative RT23, 3 tuberculin units) was associated with pain,
PURPOSE: To evaluate the ability of ultrasound biomicroscopy to monitor the repair of large Des cemet's membrane detachments. METHODS: Intraoperative ultrasound biomicros copy was performed in two patients who had undergone previous unsuccessful surgical repair of large Descemet's membrane detachments. RESULTS: Ultrasound biomicroscopy visualized and located Descemet's membrane detachment and verified proper suture placement and mem brane repositioning.
718
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 19%
CONCLUSIONS: Ultrasound biomicroscopy is a useful tool to guide surgical repair of Descemet's membrane detachments, particularly when hazy media prevent satisfactory visualization.
L
ARGE DESCEMET'S MEMBRANE DETACHMENTS MAY result in persistent corneal edema and decreased visual acuity. Air, viscoelastic,1 and expansile gases2 have been reported as useful in repositioning Desce met's membrane to its proper position adjacent to the corneal stroma. Rarely, penetrating keratoplasty may become necessary.3 On occasion, visualization of the anterior chamber is difficult because of hazy or opaque media. We used an intraoperative, high-frequency (50 MHz), highresolution (50 μηι) ultrasound biomicroscope4 (Humphrey Instruments, Inc., San Leandro, Califor nia) in two cases with extensive detachment of Descemet's membrane and corneal haze to assist in the surgical repair. • CASE l: A 75-year-old woman underwent a planned extracapsular cataract extraction with pos terior chamber intraocular lens implantation. At the end of the procedure, a small superior Descemet's membrane detachment was noted and treated with an air-bubble tamponade. Visual acuity on postoperative day 1 was 20/200 with best correction in the treated eye. There was a small air bubble in the anterior chamber and trace corneal edema superiorly. On postoperative day 3, a large Descemet's detachment encompassed the superior two thirds of the cornea. Five days later, the patient underwent surgical repair, with injection of viscoelastic into the anterior cham ber and four 10-0 nylon sutures placed at the corneoscleral junction. Postoperatively, Descemet's mem brane remained detached, the corneal stroma became diffusely edematous, and visual acuity decreased to counting fingers. The patient was referred for treat ment. Accepted for publication Jan. 26, 1996. Department of Ophthalmology, New York Eye and Ear Infirmary (E.N.M., R.D.N., M.G.S., CT., J.M.L., R.R.); and New York Medical College (M.G.S., J.M.L., R.R.). Supported in part by an award in memory of Mary E. and Alexander Hirsch by the Fight for Sight research division of Prevent Blindness America, Schaumburg, Illinois (Dr. Tello), and by the Department of Ophthalmology Research Fund, New York Eye and Ear Infirmary, New York, New York. Inquiries to Robert Ritch, M.D., Glaucoma Service, New York Eye and Ear Infirmary, 310 E. 14th St., New York, NY 10003; fax: (212) 420-8743; E-mail: [email protected]
VOL.121, No. 6
Preoperative ultrasound biomicroscopy in the operating room disclosed the full extent of the detached Descemet's membrane. Ultrasound biomi croscopy was performed after the initial injection of viscoelastic and after suture placement to verify the position of Descemet's membrane (Fig. 1). Postoper atively, Descemet's membrane was attached. One month postoperatively, the patient achieved bestcorrected visual acuity of 20/50 with a compact, clear cornea (Fig. 2). • CASE 2: A 66-year-old woman developed corneal edema after combined cataract and glaucoma surgery. Six weeks postoperatively, a detached Descemet's membrane was detected. Surgical repair was under taken, with injection of viscoelastic into the anterior chamber followed by placement of three interrupted 10-0 nylon sutures at the corneoscleral limbus. One week later, the cornea was diffusely edematous and Descemet's membrane was still detached. Visual acu ity was hand motions. The patient underwent repeat repair with preoperative ultrasound biomicroscopy to delineate the extent of the detachment. After the placement of the corneal sutures, repeat scanning showed Descemet's membrane to be in its correct position. Postoperatively, Descemet's membrane re mained attached and the corneal edema decreased. Final visual acuity was 20/150. Clinically marked Descemet's membrane detach ments are a rare complication of anterior segment surgery. Corneal edema may limit the examination of the anterior chamber and make the diagnosis difficult. Increased intraocular pressure or endothelial cell dysfunction may be mistakenly thought to be respon sible for the clinical appearance. Successful repair of a large Descemet's membrane detachment with corneoscleral sutures relies on the ability to visualize the whole extent of the detach ment before any procedure is performed. After the injection of viscoelastics, it is important to know whether Descemet's membrane has been pressed against the stroma with a minimal amount of folds so that it can reach the corneoscleral limbus to be included in each suture path. Ultrasound biomicroscopy, with its ability to image the anterior segment at high resolution, provides an excellent means for visualization of anterior chamber
BRIEF REPORTS
719
Fig. 1 (Morinelli and associates). Left, Ultrasound biomicroscopy shows the extent of Descemet's membrane detachment (arrow) before injection of viscoelastic. Right, Same area demonstrates the movement of Descemet's membrane toward the stroma after injection of viscoelastic.
surgical intervention of Descemet's membrane de tachments, particularly when corneal opacification is present. It also enables the surgeon to verify the reapposition of Descemet's membrane and the proper placement of the anchoring sutures. REFERENCES
Fig. 2 (Morinelli and associates). Ultrasound biomicros copy one month after repair shows compact cornea, attached Descemet's membrane, and proper placement of anchoring suture (arrow).
structures in the setting of a cloudy cornea.5 It can be used preoperatively to diagnose and delineate the extent of the detachment as well as to rule out the presence of any other abnormality of the anterior segment, such as iris incarceration in the wound or intraocular lens decentration, that might need con current treatment at the time of the repair. Ultrasound biomicroscopy is valuable in guiding 720
1. Donzis PB, Karcioglu AZ, Insler MS. Sodium hyaluronate (Healon) in the surgical repair of Descemet's membrane detachment. Ophthalmic Surg 1986;17:735-7. 2. Ellis DR, Cohen KL. Sulfur hexafluoride gas in the repair of Descemet's membrane detachment. Cornea 1994;14:436-7. 3. Merrick C. Descemet's membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg 1991;22:753-5. 4. Pavlin CJ, Sherar MD, Foster FS. Subsurface ultrasound biomicroscopy imaging of the intact eye. Ophthalmology 1990;97:244-50. 5. Milner MS, Liebmann JM, Tello C, Speaker MG, Ritch R. High resolution ultrasound biomicroscopy of the anterior segment in patients with dense corneal scars. Ophthalmic Surg 1994;25:284-7.
Ultrasound Biomicroscopic Analysis of Transient Shallow Anterior Chamber in Vogt-Koyanagi-Harada Syndrome Yoh-Ichi Kawano, M.D., Akihiko Tawara, M.D., Yuko Nishioka, M.D., Yayoi Suyama, M.D., Hidehisa Sakamoto, M.D., and Hajime Inomata, M.D.
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 1996
inflammation, and necrosis. The bacillus was found to be a human type of tuberculous mycobacterium. After a course of antituberculous therapy (rifampin, streptomycin, and isoniazid during the first month, then isoniazid and rifampin for the next 11 months), the eyelid process healed. Although tuberculosis is found worldwide, tubercu losis with facial abscess is rare.1'4 In our case, histopathologic and microbiologie examination established a human type of tuberculous mycobacterium as the cause of the bilateral facial lesions. Tuberculosis should therefore be considered as a possible cause of abscess with signs of acute inflammation, or a tumor like process without obvious signs of inflammation, even when the clinical features are not typical. REFERENCES 1. Albert DM, Jakobiec FA. Principles and practice of ophthal mology. Volume 3. Philadelphia: WB Saunders, 1994:1708. 2. Daniel TM. Tuberculosis. In: Harrison TR, editor. Harrison's principles of internal medicine, 11th edition. New York: McGraw Hill, 1987:625-33. 3. Duke-Elder S. System of ophthalmology. Volume 8. London: Henry Kimpton, 1964:103-10. 4. Fedukowicz HB. External infections of the eye. New York: Appleton-Century-Crofts, 1978:136-41.
Fig. 2 (Zoric, Zoric, and Zoric). Large, tumor-like abscess spreading over the right upper eyelid, eyebrow, and forehead.
Repair of Descemet's Membrane Detachment With the Assistance of Intraoperative Ultrasound Biomicroscopy
laboratory after inspection of native preparations,
Elisa N. Morinellï, M.D., Richard D. Najac, M.D., Mark G. Speaker, M.D., Celso Tello, M.D., Jeffrey M. Liebmann, M.D., and Robert Ritch, M.D.
Ziehl-Neelsen stain, inoculation of a guinea pig, and Löwenstein culture with material from each facial lesion produced the typical yellow, cauliflower-like colonies of Mycobacterium tuberculosis. The parents denied the existence of tuberculosis and other illnesses in their family, and x-ray of the child's lungs showed a calcified primary complex but no active change. The results of physical examination and laboratory analyses were normal, except for an increased erythrocyte sedimentation rate. A Mantoux reaction on the forearm (purified protein derivative RT23, 3 tuberculin units) was associated with pain,
PURPOSE: To evaluate the ability of ultrasound biomicroscopy to monitor the repair of large Des cemet's membrane detachments. METHODS: Intraoperative ultrasound biomicros copy was performed in two patients who had undergone previous unsuccessful surgical repair of large Descemet's membrane detachments. RESULTS: Ultrasound biomicroscopy visualized and located Descemet's membrane detachment and verified proper suture placement and mem brane repositioning.
718
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 19%
CONCLUSIONS: Ultrasound biomicroscopy is a useful tool to guide surgical repair of Descemet's membrane detachments, particularly when hazy media prevent satisfactory visualization.
L
ARGE DESCEMET'S MEMBRANE DETACHMENTS MAY result in persistent corneal edema and decreased visual acuity. Air, viscoelastic,1 and expansile gases2 have been reported as useful in repositioning Desce met's membrane to its proper position adjacent to the corneal stroma. Rarely, penetrating keratoplasty may become necessary.3 On occasion, visualization of the anterior chamber is difficult because of hazy or opaque media. We used an intraoperative, high-frequency (50 MHz), highresolution (50 μηι) ultrasound biomicroscope4 (Humphrey Instruments, Inc., San Leandro, Califor nia) in two cases with extensive detachment of Descemet's membrane and corneal haze to assist in the surgical repair. • CASE l: A 75-year-old woman underwent a planned extracapsular cataract extraction with pos terior chamber intraocular lens implantation. At the end of the procedure, a small superior Descemet's membrane detachment was noted and treated with an air-bubble tamponade. Visual acuity on postoperative day 1 was 20/200 with best correction in the treated eye. There was a small air bubble in the anterior chamber and trace corneal edema superiorly. On postoperative day 3, a large Descemet's detachment encompassed the superior two thirds of the cornea. Five days later, the patient underwent surgical repair, with injection of viscoelastic into the anterior cham ber and four 10-0 nylon sutures placed at the corneoscleral junction. Postoperatively, Descemet's mem brane remained detached, the corneal stroma became diffusely edematous, and visual acuity decreased to counting fingers. The patient was referred for treat ment. Accepted for publication Jan. 26, 1996. Department of Ophthalmology, New York Eye and Ear Infirmary (E.N.M., R.D.N., M.G.S., CT., J.M.L., R.R.); and New York Medical College (M.G.S., J.M.L., R.R.). Supported in part by an award in memory of Mary E. and Alexander Hirsch by the Fight for Sight research division of Prevent Blindness America, Schaumburg, Illinois (Dr. Tello), and by the Department of Ophthalmology Research Fund, New York Eye and Ear Infirmary, New York, New York. Inquiries to Robert Ritch, M.D., Glaucoma Service, New York Eye and Ear Infirmary, 310 E. 14th St., New York, NY 10003; fax: (212) 420-8743; E-mail: [email protected]
VOL.121, No. 6
Preoperative ultrasound biomicroscopy in the operating room disclosed the full extent of the detached Descemet's membrane. Ultrasound biomi croscopy was performed after the initial injection of viscoelastic and after suture placement to verify the position of Descemet's membrane (Fig. 1). Postoper atively, Descemet's membrane was attached. One month postoperatively, the patient achieved bestcorrected visual acuity of 20/50 with a compact, clear cornea (Fig. 2). • CASE 2: A 66-year-old woman developed corneal edema after combined cataract and glaucoma surgery. Six weeks postoperatively, a detached Descemet's membrane was detected. Surgical repair was under taken, with injection of viscoelastic into the anterior chamber followed by placement of three interrupted 10-0 nylon sutures at the corneoscleral limbus. One week later, the cornea was diffusely edematous and Descemet's membrane was still detached. Visual acu ity was hand motions. The patient underwent repeat repair with preoperative ultrasound biomicroscopy to delineate the extent of the detachment. After the placement of the corneal sutures, repeat scanning showed Descemet's membrane to be in its correct position. Postoperatively, Descemet's membrane re mained attached and the corneal edema decreased. Final visual acuity was 20/150. Clinically marked Descemet's membrane detach ments are a rare complication of anterior segment surgery. Corneal edema may limit the examination of the anterior chamber and make the diagnosis difficult. Increased intraocular pressure or endothelial cell dysfunction may be mistakenly thought to be respon sible for the clinical appearance. Successful repair of a large Descemet's membrane detachment with corneoscleral sutures relies on the ability to visualize the whole extent of the detach ment before any procedure is performed. After the injection of viscoelastics, it is important to know whether Descemet's membrane has been pressed against the stroma with a minimal amount of folds so that it can reach the corneoscleral limbus to be included in each suture path. Ultrasound biomicroscopy, with its ability to image the anterior segment at high resolution, provides an excellent means for visualization of anterior chamber
BRIEF REPORTS
719
Fig. 1 (Morinelli and associates). Left, Ultrasound biomicroscopy shows the extent of Descemet's membrane detachment (arrow) before injection of viscoelastic. Right, Same area demonstrates the movement of Descemet's membrane toward the stroma after injection of viscoelastic.
surgical intervention of Descemet's membrane de tachments, particularly when corneal opacification is present. It also enables the surgeon to verify the reapposition of Descemet's membrane and the proper placement of the anchoring sutures. REFERENCES
Fig. 2 (Morinelli and associates). Ultrasound biomicros copy one month after repair shows compact cornea, attached Descemet's membrane, and proper placement of anchoring suture (arrow).
structures in the setting of a cloudy cornea.5 It can be used preoperatively to diagnose and delineate the extent of the detachment as well as to rule out the presence of any other abnormality of the anterior segment, such as iris incarceration in the wound or intraocular lens decentration, that might need con current treatment at the time of the repair. Ultrasound biomicroscopy is valuable in guiding 720
1. Donzis PB, Karcioglu AZ, Insler MS. Sodium hyaluronate (Healon) in the surgical repair of Descemet's membrane detachment. Ophthalmic Surg 1986;17:735-7. 2. Ellis DR, Cohen KL. Sulfur hexafluoride gas in the repair of Descemet's membrane detachment. Cornea 1994;14:436-7. 3. Merrick C. Descemet's membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg 1991;22:753-5. 4. Pavlin CJ, Sherar MD, Foster FS. Subsurface ultrasound biomicroscopy imaging of the intact eye. Ophthalmology 1990;97:244-50. 5. Milner MS, Liebmann JM, Tello C, Speaker MG, Ritch R. High resolution ultrasound biomicroscopy of the anterior segment in patients with dense corneal scars. Ophthalmic Surg 1994;25:284-7.
Ultrasound Biomicroscopic Analysis of Transient Shallow Anterior Chamber in Vogt-Koyanagi-Harada Syndrome Yoh-Ichi Kawano, M.D., Akihiko Tawara, M.D., Yuko Nishioka, M.D., Yayoi Suyama, M.D., Hidehisa Sakamoto, M.D., and Hajime Inomata, M.D.
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE 1996