DELAYED-ONSET ISOLATED CENTRAL DESCEMET

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DELAYED-ONSET ISOLATED CENTRAL DESCEMETS
MEMBRANE BLISTER DETACHMENT FOLLOWING
PHACOEMULSIFICATION

• Michael R. Banitt, MD, João Baptista Malta, MD,
  Roni M. Shtein, MD, and H. Kaz Soong, MD

DEPARTMENT OF OPHTHALMOLOGY AND VISUAL SCIENCES
W.K. KELLOGG EYE CENTER UNIVERSITY OF MICHICAN
Financial interest disclosure None for all
authors
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ABSTRACT AND PURPOSE

• We report 2 patients who developed delayed-onset
  isolated central Descemets membrane (DM)
  blister-like detachment following
  phacoemulsification.
• These were not associated with a tear in DM or
  inadvertent injection of fluid under DM, and no
  fluid tracks from the periphery were present.
• Although a small residual detachment (confirmed
  by optical coherence tomography) remained in both
  cases, the visual acuity improved to 20/25 in one
  patient and 20/30 in the other.
• We suspect that these unique focal detachments in
  DM may be associated with an underlying,
  pre-existing weakness in the attachment of DM to
  stroma.

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CASE ONE

• 68 yo F, with uncomplicated clear corneal
  phacoemulsification with minimal intraoperative
  iris prolapse
• POD1 - visual acuity (VA) 20/80 with corneal
  edema and folds, but no DM detachment
• Week 1 - VA improved to 20/25
• Week 2 VA dropped to 20/60, with focal,
  central, blister-like DM detachment
• Month 3 - Air injection into AC with no
  improvement
• Month 4 - 14 C3F8 injected into AC blister
  punctured with 25 ga. needle blister-like DM
  detachment improved, but not resolved and
  overlying stroma compact (pachymetry 547 µm)
• Month 6 - VA 20/25

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CASE TWO

• 58 yo F, with mild Fuchs dystrophy underwent
  uncomplicated phacoemulsification
• POD1 - VA 20/100, with corneal edema and folds,
  with no DM detachment
• Week 1 - VA improved to 20/30
• Week 3 - VA dropped to 20/80, with central,
  focal, blister-like DM detachment
• Month 2 - Air injected into AC, with partial
  resolution of DM detachment
• Month 7 - VA improved to 20/30 and overlying
  stroma compact (pachymetry 560 µm)

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DISCUSSION

• DM detachments after cataract surgery usually
  originate peripherally in the vicinity of the
  incision and are associated with shallowing or
  crowding of the anterior chamber during surgery,
  complicated or repeated operations, iatrogenic
  peeling of DM with surgical instruments or by
  intraocular lenses during insertion, excessively
  anterior or shelved incisions, and inadvertent
  injection of saline solution or viscoelastic
  under DM.
• Our cases are unique in that the detachment of DM
  was not associated with any of these known
  causative factors.
• Moreover, they were central, focal, not
  associated with breaks, remote from the cataract
  incision, and delayed in onset.

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DISCUSSION

• Both cases had marked central corneal stromal
  edema with folds of DM on the first postoperative
  day which cleared over several weeks in a
  centripetal fashion.
• The central stromal thickness returned to a
  compact 547 µm in the first patient and to 560 µm
  in the second patient. It is possible that the
  central endothelial cells in our patients may
  have undergone selectively greater loss than that
  in the periphery, triggering the delayed loss of
  focal DM attachment to stroma and the development
  of persistent central bullous DM detachment, in
  spite of the eventual complete resolution of
  stromal edema.
• At no time in either case was there obvious
  direct injury to the endothelium by instruments
  or the intraocular lens.

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DISCUSSION

• An abnormally weak anatomic attachment between
  corneal stroma and DM may predispose a cornea to
  DM detachment with no clear inciting event.
• It has been postulated that the ultrastructural
  fibrillary stromal attachments demonstrated in
  electron microscopic studies may indeed be
  abnormal in these some patients, rendering them
  susceptible to DM detachments.

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CONCLUSION

• We suspect that there may have been either a
  primary or secondary abnormal attachment of DM to
  the underlying corneal stroma.
• Such focal, isolated central DM blister
  detachments are unique, and to our best
  knowledge, have never been previously reported.

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REFERENCES

• Kansal S, Sugar J. Consecutive Descemet membrane
  detachment after successive phacoemulsification.
  Cornea 200120670-1.
• Binder PS, Rock ME, Schmidt KC, Anderson JA.
  High-voltage electron microscopy of normal human
  cornea. Invest Ophthalmol Vis Sci 1991322234-43.