Michael R. Banitt, MD, João Baptista Malta, MD, Roni M

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Presentation transcript:

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.