October 2020

IN FOCUS

My Worst Complication
Dealing with Descemet’s detachments


by Ellen Stodola Editorial Co-Director


Dr. Jacob’s patient had a bullous Descemet’s detachment following stromal hydration.
Source: Soosan Jacob, MD

Dr. Hovanesian noted that a Descemet’s detachment will define itself nicely when air is put into the eye.
Source: John Hovanesian, MD

Dr. Packer shared an OCT image from his case, noting that viscoelastic was the cause of complete detachment. However, the issue was resolved with irrigation and instillation of air.
Source: Mark Packer, MD

Descemet’s detachment is a potential complication that can arise in conjunction with cataract surgery. Experts share examples of when they encountered this problem, how they approached it, and how it might be avoided.

Bullous Descemet’s detachment

Soosan Jacob, MD, shared a case of bullous Descemet’s detachment. Dr. Jacob has developed a classification system for Descemet’s detachments and broken it down into different types: rhegmatogenous Descemet’s detachment, tractional Descemet’s detachment, bullous Descemet’s detachment, and complex Descemet’s detachment.
Rhegmatogenous is the most commonly seen type after phacoemulsification, according to Dr. Jacob’s classifications. It presents as detachment with a tear and can be treated easily by intracameral air or gas injection to achieve supra-Descemetic fluid drainage through the tear.
Those classified as bullous detachments are generally rarer, she said, and often show as a separation of the Descemet’s membrane into the anterior chamber, without a sufficiently large tear in the Descemet’s membrane. The problem in these bullous detachments is that air or gas injection that is supposed to push the supra-Descemetic fluid out does not work. The fluid is trapped as there’s no actual tear to serve as an egress route for the fluid, Dr. Jacob said.
Once you realize what the problem is, it’s easy to handle, she said, adding the surgeon can simply intentionally make a break in the Descemet’s membrane to create a route for the fluid to come out from. This can be done by a simple keratome entry into the supra-Descemetic fluid space. The most common instance in which bullous Descemet’s detachment occurs is when you’ve completed phaco and are doing stromal hydration, Dr. Jacob said. The fluid wave from a too posteriorly placed, misdirected cannula may separate the Descemet’s membrane from the stroma. This may be recognized as a fluid wave passing across the cornea. Simply putting in air from the opposite side as done for rhegmatogenous Descemet’s detachment does not cause the Descemet’s membrane to reattach in this case as the air bubble is not able to squeeze all the fluid out.
Dr. Jacob shared a case where the bullous detachment occurred secondary to stromal hydration at the end of phaco surgery. As the stromal hydration was done at the needle entry sideport, the fluid pushed the Descemet’s membrane down in a bullous configuration. Since the needle entry point was too small for the fluid to be pushed out, it did not respond to air injection, she said.
The specific problems in this case, she said, were the needle prick entry wound and absence of exit wound for trapped fluid to egress. Despite pneumodescemetopexy, there was fluid collection within the detached bullous Descemet’s membrane.
Dr. Jacob’s solution was to do a relaxing descemetotomy by creating a clean keratome entry cut through the Descemet’s membrane and thus have an exit wound for the fluid to drain out from.
The plan is to create an opening into the bullous base to allow a path for entrapped fluid to drain out, Dr. Jacob said. You can do this by creating a keratome entry through the bullous Descemet’s detachment.
The patient did well postoperatively in this case. Dr. Jacob stressed the importance of realizing that instead of repeated air injections in an attempt to treat a case of bullous Descemet’s detachment, this entity should be recognized and treated immediately, effectively, and definitively during the primary surgery itself by following the strategy presented here.

Strategies for handling Descemet’s detachments

John Hovanesian, MD, shared a case of Descemet’s membrane detachment, offering pearls on how to handle this issue as a whole and also what he did for this particular patient. In his case, he assumed the detachment had occurred from the temporal incision, likely from hydration of the cornea at the end of the case.
A Descemet’s detachment defines itself nicely when air is put inside the eye, Dr. Hovanesian said, adding that you can see
the wrinkles and the area where normal appearing light reflex off the bubble occurs. 
He suggested several strategies for dealing with this issue, including stroking the cornea from the surface in hope of milking some aqueous from the cleft in the Descemet’s membrane. 
He also mentioned using a Q-tip, but instead of rubbing , which would disrupt the epithelium, he said to use a rolling motion to get broader pressure across the surface of the cornea.
You could also do a cut-down from the surface, but the danger is perforating the tear in Descemet’s membrane and worsening the problem.

Viscoelastic as a complicating factor

“While limited Descemet’s detachments immediately anterior to a clear corneal incision are common and usually do not require any special treatment, large detachments can persist and require secondary intervention,” said Mark Packer, MD. In the case he shared, viscoelastic was inadvertently injected anterior to Descemet’s membrane, resulting in a complete detachment and corneal edema. The presence of viscoelastic was a complicating factor, however, gentle irrigation and instillation of air resulted in complete resolution.

About the doctors

John Hovanesian, MD

Harvard Eye Associates
Laguna Hills, California

Soosan Jacob, MD
Dr. Agarwal’s Eye Hospital
Chennai, India

Mark Packer, MD
Packer Research Associates
Boulder, Colorado

Relevant disclosures

Hovanesian
: None
Jacob: None
Packer: None

Contact

Hovanesian
: jhovanesian@harvardeye.com
Jacob: dr_soosanj@hotmail.com
Packer: mark@markpackerconsulting.com


OCT image of Descemet’s detachment
Source: Chandrashekhar Wavikar, MD

During the 2020 ASCRS Virtual Annual Meeting, an on-demand film by Chandrashekhar Wavikar, MD, Wavikar Eye Institute, Thane, India, and colleagues titled “A Killer Wave Surviving Descemet’s Detachment” explored the complication of a Descemet’s detachment in a cataract surgery case.
Dr. Wavikar detailed cataract surgery on a 65-year-old male patient who had a well-dilated pupil and no other risk factors.
During surgery, Dr. Wavikar had completed his rhexis when he noticed a Descemet’s detachment.
He immediately did a sideport incision on the opposite side and started injecting viscoelastic under the Descemet’s membrane, flattening it against the cornea. He proceeded with gradual hydrodissection, trying not to disturb the anterior chamber too much. He kept injecting viscoelastic to ensure that the Descemet’s membrane did not fall down.
When beginning phaco, Dr. Wavikar was cautious and used low parameters, starting with a direct chop. But since the vacuum was low, direct chop wasn’t possible, so he shifted to a four-quadrant technique. He noted that he was doing phaco inside the capsular bag as much as possible to be away from the Descemet’s membrane.
While implanting the lens, the tip of the cartridge was inserted into the anterior chamber, and the lens was implanted in two steps. The trailing haptic was introduced into the bag, and air was introduced into the anterior chamber (far from the detachment).
Dr. Wavikar noticed his sideports were leaking, so he had to use several stiches. Air was then introduced to hyperinflate the anterior chamber to raise IOP to a significant level. The patient rested in that same position for some time.
Dr. Wavikar noted several instances that may cause increased chance of Descemet’s membrane detachment. This could occur because of a difficult surgery, for example, deep set eyes or a shallow anterior chamber. Specific factors that could increase the incidence include blunt instruments, improper direction during insertion, and viscodissection. Viscodissection was to blame in this case, Dr. Wavikar said.
The lesson learned is to insert the cannula well into the anterior chamber before injecting viscoelastic. He also noted that with careful, slow surgery, you can complete the surgery successfully, even with the complication of Descemet’s detachment.
Attendees of the 2020 ASCRS Virtual Annual Meeting can find the film from Dr. Wavikar on demand.

Relevant disclosures

Wavikar
: None

Contact

Wavikar: drcmwavikar@wavikareye.com

Dealing with Descemet’s detachments Dealing with Descemet’s detachments
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