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Repair of late Descemet’s membrane detachment with perfluoropropane gas
Repair of late Descemet’s membrane detachment with perfluoropropane gas Manish Shah, MS, Jigar Bathia, MS, Kulin Kothari, MS We report 3 cases of Descemet’s membrane detachment detected 2 to 3 weeks after surgery that was treated by intracameral injection of perfluoropropane 14% (C3F8) isoexpansile mixture. We looked at the predisposing factors, the best method of treatment, and the final outcome in cases of Descemet’s membrane detachment following phacoemulsification. J Cataract Refract Surg 2003; 29:1242–1244 © 2003 ASCRS and ESCRS
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escemet’s membrane detachment was once a common occurrence during intraocular procedures such as cataract extraction,1 glaucoma surgery, and penetrating keratoplasty. However, with the availability of quality instruments, it now occurs less frequently. Localized or partial detachments may resolve on their own,2 but in cases of persistent or large detachments that cause visual impairment, surgical intervention is required. Descemet’s membrane detachment may go unrecognized at the time of surgery and be detected only postoperatively. It may present as decreased visual acuity (VA), corneal edema, and presence of Descemet’s membrane folds. This detachment can originate from the main or side-port incision. In this report, we describe 3 patients with Descemet’s membrane detachment managed over 6 months at our center. We also discuss the method of evaluation, management, and the possible predisposing factors.
Case Reports Three patients had uneventful clear corneal temporal phacoemulsification for cataract extraction with the implantation of a foldable intraocular lens (IOL). Postoperatively, topical flurbiprofen, betamethasone, and neomycin were pre-
Accepted for publication October 8, 2002. From Mumbai, Maharashtra, India. None of the authors has a financial interest in any product mentioned. Reprint requests to Dr. Manish Shah, 5, Victor Villa, Babulnath Road, Mumbai 400007, Maharashtra, India. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
scribed. All the patients had good vision immediately postoperatively but presented with complaints of dimness of vision 15 to 21 days after surgery. Examination revealed corneal haze, edema, and Descemet’s folds; a diagnosis of Descemet’s membrane detachment was made (Figure 1). The detachment was treated with topical hypertonic saline and steroids initially. However, there was no improvement in the clinical picture following medical therapy. In all cases, diagnosis of Descemet’s membrane detachment was made by slitlamp observation and the requisite photographs were taken. Data such as patient age, sex, VA, time of detachment after the primary surgery, and postoperative VA were recorded. Because of the poor response to medical therapy, surgical repair was made by injection of intracameral perfluoropropane 14% (C3F8) (isoexpansile concentration).
Technique Perfluoropropane gas 14% was used in an isoexpansile mixture diluted with air through a millipore filter. The patient was given topical proparacaine 0.5% eyedrops for anesthesia, and the eye was cleaned with povidone–iodine 5% solution. The eye was opened with an eye speculum, and the patient was instructed to look at the microscope light. The surgeon sat temporally, and a paracentesis was carried out with a 3.0 cc syringe and a 26-gauge needle. The paracentesis was from 5 to 7 o’clock (depending on the side). All the detached membranes originated from the phaco incisions in the superior and temporal quadrants, and the inferior quadrants were still attached; hence an inferior site was selected. About 1.0 cc of aqueous was aspirated. The gas mixture was then injected from the same paracentesis with a 26-gauge needle (Figure 2). To prevent the needle from entering the space between the cornea and the detached Descemet’s membrane, the needle was advanced parallel to the iris plane and introduced so the full bevel was seen in the anterior chamber. A single gas bubble 0886-3350/03/$–see front matter doi:10.1016/S0886-3350(02)01919-3
CASE REPORTS: SHAH
Figure 1. (Shah) External photograph showing Descemet’s de-
Figure 2. (Shah) Intraoperative photograph showing injection of
tachment 15 days after cataract surgery.
C3F8.
Figure 3. (Shah) Slitlamp photograph showing the postoperative appearance of the C3F8 gas bubble and complete reattachment of the Descemet’s detachment.
was formed, and care was taken so the entire anterior chamber was not filled. The needle was withdrawn with a Q-Tip威 pressing at the paracentesis site, and the intraocular pressure (IOP) was checked digitally. In case of high IOP, some gas was allowed to leak out by pressing the posterior lip of the paracentesis. Topical ciprofloxacin eye ointment was administered at the end of the procedure. Postoperatively, the patients were treated topically with antibiotics and steroids, along with topical -blockers and systemic acetazolamide. Intraocular pressure was recorded on days 1 and 3 and at the end of 1 week. The IOP was less than 21 mm Hg during the follow-up in all patients.
Results The median age of the 3 patients (1 man and 2 women) was 73 years (range 65 to 89 years). In all
cases, the diagnosis of Descemet’s detachment was made between 2 and 3 weeks postoperatively. All the detachments extended from the surgical wounds. In 1 case, the detachment appeared to extend from the side-port incision and in another, from the main incision. The origin of the detachment in the third case could not be firmly established. All patients developed central corneal haze, corneal edema, and Descemet’s folds, which gradually became dense, involving the central cornea. Successful reattachment of the detached membrane was achieved in all cases (Figure 3). Corneal clarity was reestablished within 15 days of gas injection. In 2 patients, the VA improved from 6/18 to 6/9 by the third week after the gas tamponade. In 1 patient, it improved from 6/60 to 6/6 in the first postoperative week. Follow-up ranged from 2 to 5 months. The period for reabsorption of the gas bubble ranged from 6 days to 2 weeks. Postoperatively, there was no increase in the IOP in any case. The VA stabilized after 4 weeks and did not deteriorate.
Discussion Localized detachments of Descemet’s membrane are uncommon and usually do not affect the postoperative visual outcome, as they tend to heal by spontaneous reattachment.2 In contrast, large detachments result in a considerable visual handicap and lead to permanent damage to the cornea. The cause of the detachment in these cases cannot be determined because no predisposing factors were found. A shallow anterior chamber may
J CATARACT REFRACT SURG—VOL 29, JUNE 2003
1243
CASE REPORTS: SHAH
make the entry difficult, and the use of blunt blades in this situation could be a predisposing factor.4 Detachment during the injection of viscoelastic agents and IOL insertion has been reported.1,5 In our study, 3 eyes were noted to have a Descemet’s detachment 2 weeks after phacoemulsification. The surgery was uneventful in all patients, and there was no obvious detachment intraoperatively. All patients had a clear corneal temporal tunnel incision and were left sutureless. The aim of the repair is to reposition Descemet’s membrane and keep it flat against the stroma until reattachment occurs.6 We used 14% C3F8 mixture as a tamponade7 because it stays in the anterior chamber for about 1 week. No corneal decompensation or fluctuation in the IOP was believed to be attributable to the isoexpansile gas exchange.7 Air may not be effective for reattachment because of early reabsorption. Viscoelastic agents such as sodium hyaluronate carry the risk for increasing the IOP and require constant monitoring. Full-thickness sutures cause stretch lines, making them a poor option. Gas can be injected from the original sideport incision or from a new incision, made near the site of the detached membrane. After the paracentesis, the gas is injected with the cannula facing posteriorly, flat-
1244
tening the detached membrane on the stroma and acting as a tamponade. All patients require constant IOP monitoring immediately postoperatively. However, we did not find a significant IOP increase in the patients.
References 1. Aust W, Wernhard U. Defects of Descemet’s membrane as a complication in cataract extraction with lens implantation. Dev Ophthalmol 1987; 13:20 –29 2. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol 1994; 112:551–552 3. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg 1995; 21:714 –717 4. Payne T. Dull knives and Descemet’s membrane detachments [letter]. Arch Ophthalmol 1978; 96:542 5. Hoover DL, Giangiacomo J, Benson RL. Descemet’s membrane detachment by sodium hyaluronate. Arch Ophthalmol 1985; 103:805–808 6. Mahmood MA, Teichmann KD, Tomey KF, Al-Rashed D. Detachment of Descemet’s membrane. J Cataract Refract Surg 1998; 24:827–833 7. Macsai MS, Gainer KM, Chisholm C. Repair of Descemet’s membrane detachment with perfluoropropane (C3F8). Cornea 1998; 17:129 –134
J CATARACT REFRACT SURG—VOL 29, JUNE 2003
D
escemet’s membrane detachment was once a common occurrence during intraocular procedures such as cataract extraction,1 glaucoma surgery, and penetrating keratoplasty. However, with the availability of quality instruments, it now occurs less frequently. Localized or partial detachments may resolve on their own,2 but in cases of persistent or large detachments that cause visual impairment, surgical intervention is required. Descemet’s membrane detachment may go unrecognized at the time of surgery and be detected only postoperatively. It may present as decreased visual acuity (VA), corneal edema, and presence of Descemet’s membrane folds. This detachment can originate from the main or side-port incision. In this report, we describe 3 patients with Descemet’s membrane detachment managed over 6 months at our center. We also discuss the method of evaluation, management, and the possible predisposing factors.
Case Reports Three patients had uneventful clear corneal temporal phacoemulsification for cataract extraction with the implantation of a foldable intraocular lens (IOL). Postoperatively, topical flurbiprofen, betamethasone, and neomycin were pre-
Accepted for publication October 8, 2002. From Mumbai, Maharashtra, India. None of the authors has a financial interest in any product mentioned. Reprint requests to Dr. Manish Shah, 5, Victor Villa, Babulnath Road, Mumbai 400007, Maharashtra, India. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
scribed. All the patients had good vision immediately postoperatively but presented with complaints of dimness of vision 15 to 21 days after surgery. Examination revealed corneal haze, edema, and Descemet’s folds; a diagnosis of Descemet’s membrane detachment was made (Figure 1). The detachment was treated with topical hypertonic saline and steroids initially. However, there was no improvement in the clinical picture following medical therapy. In all cases, diagnosis of Descemet’s membrane detachment was made by slitlamp observation and the requisite photographs were taken. Data such as patient age, sex, VA, time of detachment after the primary surgery, and postoperative VA were recorded. Because of the poor response to medical therapy, surgical repair was made by injection of intracameral perfluoropropane 14% (C3F8) (isoexpansile concentration).
Technique Perfluoropropane gas 14% was used in an isoexpansile mixture diluted with air through a millipore filter. The patient was given topical proparacaine 0.5% eyedrops for anesthesia, and the eye was cleaned with povidone–iodine 5% solution. The eye was opened with an eye speculum, and the patient was instructed to look at the microscope light. The surgeon sat temporally, and a paracentesis was carried out with a 3.0 cc syringe and a 26-gauge needle. The paracentesis was from 5 to 7 o’clock (depending on the side). All the detached membranes originated from the phaco incisions in the superior and temporal quadrants, and the inferior quadrants were still attached; hence an inferior site was selected. About 1.0 cc of aqueous was aspirated. The gas mixture was then injected from the same paracentesis with a 26-gauge needle (Figure 2). To prevent the needle from entering the space between the cornea and the detached Descemet’s membrane, the needle was advanced parallel to the iris plane and introduced so the full bevel was seen in the anterior chamber. A single gas bubble 0886-3350/03/$–see front matter doi:10.1016/S0886-3350(02)01919-3
CASE REPORTS: SHAH
Figure 1. (Shah) External photograph showing Descemet’s de-
Figure 2. (Shah) Intraoperative photograph showing injection of
tachment 15 days after cataract surgery.
C3F8.
Figure 3. (Shah) Slitlamp photograph showing the postoperative appearance of the C3F8 gas bubble and complete reattachment of the Descemet’s detachment.
was formed, and care was taken so the entire anterior chamber was not filled. The needle was withdrawn with a Q-Tip威 pressing at the paracentesis site, and the intraocular pressure (IOP) was checked digitally. In case of high IOP, some gas was allowed to leak out by pressing the posterior lip of the paracentesis. Topical ciprofloxacin eye ointment was administered at the end of the procedure. Postoperatively, the patients were treated topically with antibiotics and steroids, along with topical -blockers and systemic acetazolamide. Intraocular pressure was recorded on days 1 and 3 and at the end of 1 week. The IOP was less than 21 mm Hg during the follow-up in all patients.
Results The median age of the 3 patients (1 man and 2 women) was 73 years (range 65 to 89 years). In all
cases, the diagnosis of Descemet’s detachment was made between 2 and 3 weeks postoperatively. All the detachments extended from the surgical wounds. In 1 case, the detachment appeared to extend from the side-port incision and in another, from the main incision. The origin of the detachment in the third case could not be firmly established. All patients developed central corneal haze, corneal edema, and Descemet’s folds, which gradually became dense, involving the central cornea. Successful reattachment of the detached membrane was achieved in all cases (Figure 3). Corneal clarity was reestablished within 15 days of gas injection. In 2 patients, the VA improved from 6/18 to 6/9 by the third week after the gas tamponade. In 1 patient, it improved from 6/60 to 6/6 in the first postoperative week. Follow-up ranged from 2 to 5 months. The period for reabsorption of the gas bubble ranged from 6 days to 2 weeks. Postoperatively, there was no increase in the IOP in any case. The VA stabilized after 4 weeks and did not deteriorate.
Discussion Localized detachments of Descemet’s membrane are uncommon and usually do not affect the postoperative visual outcome, as they tend to heal by spontaneous reattachment.2 In contrast, large detachments result in a considerable visual handicap and lead to permanent damage to the cornea. The cause of the detachment in these cases cannot be determined because no predisposing factors were found. A shallow anterior chamber may
J CATARACT REFRACT SURG—VOL 29, JUNE 2003
1243
CASE REPORTS: SHAH
make the entry difficult, and the use of blunt blades in this situation could be a predisposing factor.4 Detachment during the injection of viscoelastic agents and IOL insertion has been reported.1,5 In our study, 3 eyes were noted to have a Descemet’s detachment 2 weeks after phacoemulsification. The surgery was uneventful in all patients, and there was no obvious detachment intraoperatively. All patients had a clear corneal temporal tunnel incision and were left sutureless. The aim of the repair is to reposition Descemet’s membrane and keep it flat against the stroma until reattachment occurs.6 We used 14% C3F8 mixture as a tamponade7 because it stays in the anterior chamber for about 1 week. No corneal decompensation or fluctuation in the IOP was believed to be attributable to the isoexpansile gas exchange.7 Air may not be effective for reattachment because of early reabsorption. Viscoelastic agents such as sodium hyaluronate carry the risk for increasing the IOP and require constant monitoring. Full-thickness sutures cause stretch lines, making them a poor option. Gas can be injected from the original sideport incision or from a new incision, made near the site of the detached membrane. After the paracentesis, the gas is injected with the cannula facing posteriorly, flat-
1244
tening the detached membrane on the stroma and acting as a tamponade. All patients require constant IOP monitoring immediately postoperatively. However, we did not find a significant IOP increase in the patients.
References 1. Aust W, Wernhard U. Defects of Descemet’s membrane as a complication in cataract extraction with lens implantation. Dev Ophthalmol 1987; 13:20 –29 2. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol 1994; 112:551–552 3. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg 1995; 21:714 –717 4. Payne T. Dull knives and Descemet’s membrane detachments [letter]. Arch Ophthalmol 1978; 96:542 5. Hoover DL, Giangiacomo J, Benson RL. Descemet’s membrane detachment by sodium hyaluronate. Arch Ophthalmol 1985; 103:805–808 6. Mahmood MA, Teichmann KD, Tomey KF, Al-Rashed D. Detachment of Descemet’s membrane. J Cataract Refract Surg 1998; 24:827–833 7. Macsai MS, Gainer KM, Chisholm C. Repair of Descemet’s membrane detachment with perfluoropropane (C3F8). Cornea 1998; 17:129 –134
J CATARACT REFRACT SURG—VOL 29, JUNE 2003