Three Cases of Descemet's Membrane Detachment after Cataract Surgery

Descemet's membrane detachment (DMD) is an uncommon but serious complication of intraocular surgery. It was first reported in 1928 by Samuels, and since then it has been reported most often after cataract surgery. DMD has also been known to occur after other various ophthalmic procedures including: cyclodialysis, iridectomy, trabeculectomy, holmium laser sclerostomy, penetrating keratoplasty, full-thickness lamellar keratoplasty, pars plana vitrectomy and viscocanalostomy.1

The natural history of DMD has long been an area of controversy, and the appropriate timing for intervention remains unclear. Most DMDs remain small and localized to the wound, but some cases present with large, extensive detachments that result in severe corneal edema and a marked reduction in visual acuity. Traditional treatment regimens have included: observation, intracameral injections of air or viscoelastic, transcorneal suturing, and even corneal transplantation. During the past few years, intracameral injections with sulfur hexafluoride (SF6) or perfluoropropane (C3F8) gas have gained increasing acceptance as an efficient and effective treatment option for DMD.2

We report three cases of DMD that occurred after uncomplicated cataract surgery and describe their management and visual outcome.

In this article, we report three cases of DMD that were managed with different treatment methods. In the first case, the DMD was not located adjacent to the incision wound, while in the second patient, a typical large DMD following cataract surgery could be observed. The unusual superonasal location of the DMD in the first case leads us to suspect endothelial trauma during cataract surgery, although we do not recall touching the endothelium with surgical instruments in that area. Phacoemulsification energy also may have caused the unpredicted damage. In the second patient, any of the reported mechanisms of DMD listed below could have occurred, although we were not aware of any inadvertent event during surgery. The third patient had radial deep stromal opacities in the contralateral eye which were believed to be scars from previous DMD. Since this patient seemed to have a predisposition to Descemet's membrane separation and because the air injection performed in the other clinic was not successful, we carried out an intracameral C3F8 gas injection and a paracentesis of fluid. Both appeared to aid in the reattachment of the DMD.

DMDs are usually small and localized to the corneal wound, with minimal or no effect on corneal clarity and vision. However, larger detachments can cause severe corneal edema and visual disturbance, and they often require surgical intervention to prevent permanent corneal decomposition and a potential corneal transplant.2-4

Mackool and Holtz classified DMDs into a planar type, with the Descemet's membrane separated less than 1 mm from the corneal stroma, and a non-planar type, with a separation of greater than 1 mm. These two types can be further divided by whether the detachments are limited to the peripheral cornea, or if they involve both the peripheral and central cornea. They reported that planar detachments are more likely to resolve spontaneously, and non-planar detachments should be repaired early.5, 6 The first case in our report showed planar type DMD, and the second and third cases were non-planar type DMD. Assia et al divided DMDs into detachments with or without scrolling. Detachments without scrolling are more likely to resolve spontaneously.1, 5

Several mechanisms have been proposed as the possible causal mechanism for DMD: shallow chambers, complicated or repeated operations, inadvertent insertion of instruments between the corneal stroma and Descemet's membrane, anterior and shelved incisions, and the use of dull blades.5-7 Engaging the Descemet's membrane during intraocular lens implantation or with the irrigation/aspiration device (when mistaken as an anterior capsular remnant) can also lead to extensive DMD. Some have reported that inadvertent injection of viscoelastic material by inserting the cannula between Descemet's membrane and the corneal stroma may be the most common cause of Descemet's membrane detachment with the current surgical techniques.8

We understood that DMD could also be associated with the characteristics of the viscoelastic material used. We used Viscoat® in Cases 1 and 2. Cohesive viscoelastic material such as Healon® can be completely removed from the anterior chamber by aspiration. It takes a greater effort to remove dispersive substances such as Viscoat® from the anterior chamber, and complete removal is difficult to achieve. The inspiration/aspiration device may be closer to the corneal endothelium, causing the Descemet's membrane to separate from the stroma.9-11 Although this association is hardly conclusive due to the small number of cases in our experience, we believe that this is an interesting possibility that merits further investigation.

Bilateral cases of DMD have been reported during or after otherwise uneventful surgery.1 In our third case, the patient had endothelial scarring, presumed to be from old DMD in the right eye, which had undergone cataract surgery four years earlier. From this, we are led to suspect that some eyes may have a predisposition to DMD. The characteristics of patients who are at increased risk of DMD may be another topic that needs further study.

In summary, we reported three cases of DMD that received different treatments according to the severity of their conditions, and found favorable results. The time for intervention and the type of surgery used remain controversial. In addition, despite several recent reports in favor of early intracameral gas injection, it would be advisable to make intervention and treatment decisions on a case by case basis.