DMD was first described by Weve in 1927. Of all the procedures involving anterior chamber entry, it is reported most commonly after cataract surgery. The predisposing factors include hazy cornea, shallow anterior chamber and hypotony. Intra-operatively, use of blunt instruments for entry, oblique entry and anterior shelved corneal wounds, inadvertent injection of air, saline, antibiotics or viscoelastic between the stroma and descemet’s membrane, pinching of DM with aspiration cannula, hooking of IOL haptic into DM increase the chances of this complication [
8]. Marcon et al have attributed increased referrals of DMD to the increasing use of clear corneal incisions [
1]. Rarely, DMD can occur in the intermediate to late post-op period, after uncomplicated surgery [
3‐
6]. In the case discussed, DMD was noted 20 days (approximately 3 weeks) after uneventful cataract surgery. Although the entry wound was clear corneal, which in itself is a predisposing factor, the central location of detachment and clear cornea at previous visits ruled out the role of faulty wound location or construction and any kind of intra-op trauma to DM. Morkin et al have reported one such case of late DMD 11 months after cataract surgery and discussed the possibility of trauma as the triggering factor [
6]. In the case discussed, there was neither a history of eye rubbing nor any other trauma. The existence of underlying predisposing anatomical factors can be considered especially in cases with bilateral involvement [
4]. Pre-existing poor endothelial counts as a significant risk factor has been put forth by Ti et al. [
9] In our case, although specular microscopy was not done, the absence of corneal guttae pre-operatively gave an impression of healthy endothelium. Similarly, Kansal et al have suggested abnormal fibrillary stromal adhesion to Descemet’s membrane as the possible cause [
10]. Genetic predisposition in the form of dysfunctional anchoring protein BIGH3 (due to mutation of TGFBI gene) has been postulated by Hirano et al. [
11] Although literature suggests various theories, the exact pathophysiology of delayed onset DMD still remains poorly understood due to lack of concrete evidence.
Management is largely dependent on intracameral injections of expansile gases like C
3F
8 or SF
6 given the ease and good success rate of the procedure [
1,
2,
4,
6]. We attempted pneumatic descemetopexy twice with SF
6 without a positive result. Anticipating a similar outcome, air was injected at third place and as expected detached DM failed to settle. Finally, corneal venting incision with air tamponade was done resulting in DM attachment. These corneal venting incisions have variable applications in DMD cases. Menezo et al reported one of the earliest cases suggesting the role of corneal paracentesis with air tamponade for DMD after cataract surgery [
12]. Ghaffariyeh et al successfully attempted supra-descemet fluid drainage with corneal venting incisions for DMD after phacoemulsification without the use of any air/gas tamponade [
7]. Looking at the success of this technique we tried it in our case and achieved complete descemet’s re-attachment with good visual outcome. Literature also describes the role of these incisions for drainage of interface fluid following Descemet’s stripping endothelial keratoplasty (DSEK) [
13]. The underlying principle of this technique is to drain the fluid entrapped in the supra-descemet’s space that otherwise prevents the apposition of DM to stroma even after pneumatic tamponade.