|Year : 2019 | Volume
| Issue : 2 | Page : 78-81
Inadvertent descemetorhexis and Descemet's membrane detachment after cataract surgery – Reendothelialization after C3F8 descemetopexy: A case report and review of literature
Abraham Kurian, Iodine Reghunadhan, Swapna Nair, Asha George
Cornea Services, Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, India
|Date of Submission||01-Mar-2018|
|Date of Acceptance||04-Sep-2018|
|Date of Web Publication||21-Aug-2019|
Medical Superintendent and Senior Consultant, Chaithanya Eye Hospital and Research Institute, Kesavadasapuram, Trivandrum - 695 004, Kerala
Source of Support: None, Conflict of Interest: None
We report a case of extracapsular cataract surgery, wherein inadvertent large central descemetorhexis and loss of Descemetís membrane (DM) were noted intraoperatively. Postoperatively, near total detachment of the remaining DM was noted. C3F8 descemetopexy at 2 weeks resulted in successful reattachment of the detached DM and reendothelialization in the area of lost DM. The corneal edema resolved with eventual good visual outcome and no complications. Although spontaneous reattachment of Descemetís detachment is described, early descemetopexy results in better visual outcome even in cases with extensive DM loss probably due to early resumption of the physiologic function following earlier anatomic reattachment.
Keywords: C3F8, descemetopexy, descemetorhexis
|How to cite this article:|
Kurian A, Reghunadhan I, Nair S, George A. Inadvertent descemetorhexis and Descemet's membrane detachment after cataract surgery – Reendothelialization after C3F8 descemetopexy: A case report and review of literature. J Clin Ophthalmol Res 2019;7:78-81
|How to cite this URL:|
Kurian A, Reghunadhan I, Nair S, George A. Inadvertent descemetorhexis and Descemet's membrane detachment after cataract surgery – Reendothelialization after C3F8 descemetopexy: A case report and review of literature. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Nov 20];7:78-81. Available from: http://www.jcor.in/text.asp?2019/7/2/78/264891
Descemet's membrane (DM) detachment is a rare but well-recognized complication of cataract surgery. Reports of iatrogenic descemetorhexis are few. Even cases with complicated DM detachments with large areas of central DM loss, when managed with early descemetopexy, can have successful reendothelialization and regain acceptable endothelial function and corneal clarity.
| Case Report|| |
A 73-year-old female patient, with mature cataract in her right eye and preoperative vision of hand movements, underwent extracapsular cataract surgery by a resident. After a superior section and dye-assisted capsulotomy, hydrodissection was attempted. The senior trained surgeon suspected an inadvertent descemetorhexis, took over and completed the rest of the surgery uneventfully. Intraoperatively, there was no overt evidence of detached DM and no active intervention was done.
During immediate postoperative period, the eye had full-thickness corneal edema and vision 1/60. A faint demarcation line inferiorly suggested a DM loss. Specular microscopy did not reveal any discernible endothelial cells (ECs). Hypertonic saline and lubricants were added to routine postoperative topical medications.
Anterior segment optical coherence tomography (ASOCT) 2 weeks postoperatively showed a central area of DM loss and the surrounding residual DM detached [Figure 1]a.
|Figure 1: (a) Anterior segment optical coherence tomography, 2 weeks after cataract surgery, showing corneal edema with central area of Descemet's membrane loss and the residual Descemet's membrane detached to varying extents along the surrounding periphery. (b) Anterior segment optical coherence tomography, 2 months postdescemetopexy, showing the residual Descemet's membrane attached. Superior cornea showing some residual edema with a thickened posterior corneal layer|
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The patient underwent descemetopexy with 14% C3F8 the same day. The corneal edema started clearing from the next day and by 5th day vision improved to 6/18.
Two weeks postinjection, the inferior border of the central DM loss could clearly be delineated, but the partially absorbed gas bubble and residual sectional edema obscured the superior border [Figure 2]a. Specular microscopy showed central EC density (ECD) of 580/mm2 with 0% hexagonality. Specular microscopy of the pseudophakic fellow eye showed ECD of 1860/mm2 and 40% hexagonality.
|Figure 2: (a) 2 weeks postdescemetopexy, the cornea showing significant clearing, the inferior border of the central area of Descemet's membrane loss clearly seen (superior border obscured by gas bubble and sectional edema). (b) 2 months postdescemetopexy, clear central cornea with clearly defined margins of the Descemet's loss seen extending to the superior limbus|
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Two months postoperatively, the gas bubble absorbed and the best-corrected vision improved to 6/6. The clear central cornea showed the well-delineated margins of the DM loss which measured 7.5 mm × 6 mm and extended to the superior limbus at the incision site [Figure 2]b. ASOCT now showed the remaining DM attached to the posterior stroma surrounding the areas of DM loss. However, the superior cornea near the section showed some residual edema with a thickened posterior corneal layer [Figure 1]b.
Repeat specular microscopy of the central cornea showed increase in ECD to 1668/mm2 with polymorphism and polymegathism but 0% hexagonality. However, specular microscopy done in the superior area corresponding to the thickened posterior corneal layer showed ECD of 811/mm2 and 0% hexagonality.
| Discussion|| |
Human corneal endothelium is characterized by a low regenerative capacity, attributed to low mitotic activity, and therefore, complete regeneration of the endothelial layer after injury is precluded. Interest in migration and enlargement capacities of ECs has been renewed due to recent breakthroughs in endothelial keratoplasty.
Study by Schwartzkopff et al. in a rat keratoplasty model concluded that reendothelialization following keratoplasty occursin vivo and restores graft clarity, following both immunological or surgical destruction of ECs. The study also provided evidence that peripheral recipient ECs are a sufficient source for graft reendothelialization.
Similar concepts have been speculated by Balachandran et al., who reported spontaneous recovery of corneal transparency in two cases with nearly complete graft detachment after Descemet membrane endothelial keratoplasty.
Although these dealt with EC loss in keratoplasty, the same concept holds true in descemetorhexis, and hence, these postulates on endothelial regeneration can be extrapolated to our case.
DM detachment is a rare but well-recognized complication of cataract surgery with a reported incidence of 0.5%–2.6%.
There is a relative paucity in literature regarding the guidelines for the management of DM detachment.
There are reports of resolution of prolonged corneal edema after spontaneous reattachment, but it takes several weeks to months. Meanwhile prolonged corneal edema may lead to visually significant corneal opacification. Waiting for spontaneous reattachment carries the risk of possible permanent corneal opacification and eventual keratoplasty for optimal vision.
Chow et al., in 2013, state that DM detachments may be treated either conservatively or surgically, with early surgical intervention favored for scrolled, extensive detachments. They conclude that optimal timing and treatment remain an unexplored area. Despite several reports of spontaneous DM reattachment, early intervention is advocated for speedy and best visual recovery. A study by Jain et al. on descemetopexy in postcataract surgery DM detachment concludes that early intervention by descemetopexy has a good final outcome.
There have been nine case reports published till date on iatrogenic descemetorhexis [Table 1]. Intracameral air injection was done in 2 eyes and 1 required intracameral air and SF6 injection along with transcorneal suturing. Of the rest which were managed conservatively, spontaneous resolution took several weeks to months and the final vision was much less compared to our case which regained a normal visual acuity in 2 months.
|Table 1: Case reports on inadvertent descemetorhexis published till date|
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Although the area of DM loss in those case reports was much smaller (about 5 mm × 5 mm) compared to 7.5 mm × 6 mm in our case, the final visual improvement was grossly subnormal compared to our case. Those cases with larger areas of DM loss had a grossly inadequate gain in vision.
To the best of our knowledge, ours is the first report of DM detachment complicated by descemetorhexis successfully managed by early C3F8 descemetopexy.
| Conclusion|| |
Supporting evidence from studies shows that migration and proliferation of the existing cells in the periphery can help in restoring the corneal clarity. To aid an earlier reattachment of DM detachment, the use of intracameral C3F8 is a safe and accepted procedure and should be tried as the first option even in cases complicated by loss of DM.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
All authors have completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest, and none were reported.
| References|| |
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Spontaneous corneal clearance despite graft detachment in descemet membrane endothelial keratoplasty. Am J Ophthalmol 2009;148:227-340.
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Corneal endothelium self-healing mathematical model after inadvertent descemetorhexis. J Cataract Refract Surg 2015;41:2313-8.
[Figure 1], [Figure 2]