Transcript Delayed-Onset Isolated Central Descemet’s Membrane Blister

DELAYED-ONSET ISOLATED CENTRAL DESCEMET’S
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
ABSTRACT AND PURPOSE
• We report 2 patients who developed delayed-onset isolated central
Descemet’s 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.
CASE ONE
• 68 yo F, with uncomplicated clear corneal phacoemulsification with
minimal intraoperative iris prolapse
• POD#1 - 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
CASE TWO
• 58 yo F, with mild Fuchs’ dystrophy underwent uncomplicated
phacoemulsification
• POD#1 - 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)
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.
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.
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.
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.
REFERENCES
• Kansal S, Sugar J. Consecutive Descemet
membrane detachment after successive
phacoemulsification. Cornea 2001;20:670-1.
• Binder PS, Rock ME, Schmidt KC, Anderson
JA. High-voltage electron microscopy of
normal human cornea. Invest Ophthalmol Vis
Sci 1991;32:2234-43.