1. RELAXING DESCEMETOTOMY: A NEW SURGERY FOR TAUT DESCEMET’S MEMBRANE DETACHMENT & A NOVEL CLINICO-PATHOLOGICAL CLASSIFICATION OF DESCEMET'S MEMBRANE DETACHMENT
SOOSAN JACOB, MS, FCRS,DNB
ATHIYA AGARWAL, MD, DO;
AMAR AGARWAL, MS, FRCS, FRCO
GAURAV PRAKASH, MD
DR. AGARWAL’S GROUP OF EYE HOSPITALS
&
EYE RESEARCH CENTRE,
CHENNAI, INDIA
NONE OF THE AUTHORS HAVE ANY FINANCIAL DISCLOSURES

2. PURPOSE
BACKGROUND : Relaxing retinotomy is used when retinal foreshortening does not allow retina to settle down unless relaxing retinotomies are made. A similar situation can arise in the cornea when there is traction on the Descemet’s Membrane (DM) secondary to inflammation or fibrosis or if the DM gets incarcerated in a wound or suture. This can lead to a Taut Descemet’s Membrane Detachment (TDMD) as opposed to a DM which is torn and detached from the overlying stroma such as seen following phacoemulsification. Injecting air or long acting gas into the anterior chamber (AC) in an eye with TDMD does not allow the DM to appose against the corneal stroma because of the foreshortening . Relaxing Descemetotomy based on a principle similar to relaxing retinotomy would be the solution in this scenario.
PURPOSE : TO DESCRIBE A NEW SURGICAL TECHNIQUE FOR TAUT DMD (TDMD) AND TO PROPOSE A NEW ETIO-CLINICO-PATHOLOGICAL CLASSIFICATION SCHEME FOR DMD VIZ. STRIPPED DSCEMET’S MEMBRANE DETACHMENT (SDMD) AND TDMD

3. METHODS
INTRA-OPERATIVE EVALUATION:
TRYPAN BLUE DYE IS INJECTED
ANTERIOR CHAMBER IS IRRIGATED WITH BALANCED SALT SOLUTION (BSS) TO WASH AWAY EXCESS TRYPAN BLUE AND TO STUDY THE DYNAMICS OF THE DETACHED DM
PRE-OPERATIVE EVALUATION:
PATIENTS WITH CORNEAL EDEMA AND DESCEMET’S MEMBRANE DETACHMENT (DMD) WERE STUDIED.
THOROUGH PRE-OPERATIVE EVALUATION WAS DONE
ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY (ASOCT) WAS DONE
EXTENT OF DETACHMENT AND THE DEGREE OF TAUTNESS ASSESSED
IF THERE IS INADEQUATE APPOSITION AFTER AIR INJECTION, RELAXING DESCEMETOTOMY IS PROCEEDED WITH.
Taut Descemet’s Membrane Detachment

4. AC is filled with BSS/air. Air aids visualization of
SURGICAL TECHNIQUE .
AC is filled with BSS/air.
Air aids visualization of
edge of DM
26 gauge needle with tip bent in the reverse direction as capsulotomy needle
Bent needle is introduced into the AC and relaxing Descemetotomy incisions are made

5. SURGICAL TECHNIQUE Descmetotomy continued till DM is
fully apposed against stroma.
Extent of incision is determined
real time during surgery by assessing
degree of residual foreshortening
Non-expansile C3F8 (14%) or SF6 (12%)
for post-operative tamponade
Patient maintains a face up position
for 1 hour.

6. RESULTS
2 eyes of 2 patients underwent Relaxing Descemetotomy (RD) for TDMD.
The patients tolerated the procedure well and neither required a repeat surgery.
For both cases, the cornea became clearer post-operatively and the RDs could be seen on slit lamp imaging
ASOCT showed an attached DM

7. Long acting SF6 failed to
Case 1
Two Relaxing Descemetotomy incisions were made while AC was filled with BSS.
58 yo lady status post therapeutic PK (10 mm graft). Immediate post-op clear graft but at 2 months : corneal edema with TDMD in superior quadrant associated with graft-host junction synechiae.
Long acting SF6 failed to
appose DM.
Pre-op ASOCT
Iso-expansile concentration of SF6 (12%) injected into the AC with face up positioning for 1 hr.
Post op ASOCT
Post op day 1

8. Pre-op: Gas tamponade alone was
Case 2
Multiple small relaxing Descemetotomy incisions made superiorly under air.
Air then exchanged with long acting gas (C3F8, 14%) Face up positioning for 1 hour
27 yo female with peripheral corneal thinning and ectasia presented with traumatic rupture globe & inferior corneal tear. Underwent corneal tear suturing
Seven weeks later: corneal edema/ epithelial bedewing secondary to TDMD stretching upwards from the wound and iris adhered to wound
PRE-OP ASOCT
POST-OP ASOCT
Pre-op: Gas tamponade alone was
not successful.
Post-op day 1

9. DISCUSSION
DMD is occasionally faced by the ophthalmologist after surgery.
Various techniques have conventionally been proposed:
observation
viscoelastic injection
air injection and the use of long acting intra-cameral gas
trans-corneal mattress sutures
SDMD
DMD can be classified as SDMD and TDMD and management should be tailored according to the type of DMD.
TDMD

10. DISCUSSION
DMD previously classified as planar or nonplanar based on morphology
We propose new classification of DMD based on etio- pathogenesis
Stripped Descemet’s Membrane Detachment (SDMD)
Taut Descemet’s Membrane Detachment (TDMD)
This new classification helps in guiding management of DMD

11. SDMD TDMD Timing Intra-operative event
Intra-operative or post-operative event
Etiology
Pushing force on DM, eg. during viscoelastic injection or due to insertion of blunt instruments or intra-ocular lens
Due to inflammation and fibrosis of DM
Due to incarceration of DM within peripheral anterior synechiae/ graft-host junction/ wound/ suture
Due to adhesion and fibrosis of long standing SDMD to intra-ocular contents
Clinical features
Undulating/ scrolled/ crumpled membrane in AC
DM stretched out tight like a trampoline between points of attachment
Anterior Segment Optical Coherence Tomography
Undulating linear hyperreflective echo
Straight taut line between two points of attachment
Intra-operative features
Typical fluttering movement on irrigation with BSS
No fluttering movements on irrigation with BSS
Management
Air or long acting non-expansile gas injection/ suturing/
Relaxing Descemetotomy with long acting non-expansile gas injection
Rationale of surgery
Once apposed against overlying stroma, the endothelial pump makes the DM adhere permanently
Relaxing descemetotomy breaks stress forces acting on DM, relieving tautness of DM and allowing gas bubble to appose now lax DM against overlying stroma.

12. This classification helps in guiding the line of management
CONCLUSIONS
TDMD
SDMD
DMD can be classified based on etio-pathogenesis as either Stripped Descemet’s Membrane Detachment (SDMD) or a Taut Descemet’s Membrane Detachment (TDMD).
This classification helps in guiding the line of management
TDMD needs to be differentiated from SDMD as management differs.
Relaxing Descemetotomy is the treatment of choice for TDMD
Relaxing descemetotomy incisions act by breaking stress forces acting on the DM. The tautness of the DM is relieved and air or gas bubble is able to appose the now lax DM against the overlying corneal stroma.