| Background:Descemet’s membrane detachment(DMD)is a potentially sight-threatening complication,which occurs most often after cataract surgery.DMD has also been reported in several other eye surgeries,such as glaucoma surgeries like trabeculectomy and canaloplasty,iridectomy,corneal transplant,vitrectomy,laser sclerotomy,and alkaline burns.The main risk factors are old age,pre-existing endothelial diseases,such as Fuchs’ dystrophy,abnormal Desmetet’s membrane,prolonged surgery,asymmetrical corneal incision,Complicated or repeated operations,suboptimal quality of surgical equipment,Shallow anterior chamber,hard nuclear cataracts,and inadvertent injection of saline or viscoelastic material in the space between Descemet’s membrane the posterior stroma,and unintentional trauma caused by blunt probes and phacoemulsification its self.DM detachment is an ophthalmic emergency condition that can lead to significant visual impairment from persisting corneal edema which can be reversed with early intervention.Amongst other causes of DM detachment,cataract surgery has been reported to cause in almost 43% of the cases and 0.5% after phacoemulsification.Managing of DM detachment depends on the size and location of the detachment.Management choices include observation with symptomatic treatment,anterior chamber air bubble injections,corneal suturing,viscoelastic or expansible gases,and corneal transplantation.Most DMDs are peripheral and spontaneously resolve without intervention.Simple DMD detachment can also be treated successfully by improving corneal nutrition and implementing symptomatic treatment of edema.However,in cases which the DM detachment is Extensive or central and combined with DM folds,curls,or there is complete detachment of the DM,surgery is highly recommended as soon as possible to avoid unnecessary loss of endothelial cells and the development of bullous keratopathy,and if not managed timely and properly,it may lead to corneal decompensation and opacification.Phacoemulsification has been the preferred procedure in the western world and china but that accounted for only less than 10% of all the surgeries in developing countries.Descemetopexy is an innovative procedure described by sparks in 1967.After withdrawing aqueous in the pre-descematic space and injecting air into the anterior chamber of three eyes with extensive DMDs.Since then descemetopexy has shown good anatomic attachment rates and visual outcomes and has become the standard surgical treatment of DMD.Objective:The objective of this study is to evaluate the effectiveness of descemetopexy procedure as a management of DM detachment,to prevent vision loss and to stop the need of invasive surgeries like keratoplasty for the management of DMD.Methods:We carried out a retrospective study on cases following phacoemulsification surgery which was diagnosed to have Descemet’s Membrane Detachment and was managed by injecting a sterile air bubble into the anterior chamber to reposition the DM,in the Department of Ophthalmology of First Hospital of Jilin University,Changchun,China.Based on the computer database registry search of First Hospital of Jilin University,between 2016 January to 2019 December.A total of 6 patients(6 eyes)were managed using air bubble injection for DM detachment secondary to previous cataract surgeries and all of the cases were referrals.The patient’s age,sex,the status of the cornea,diagnosis,localization of the defect,preoperative visual acuity,and postoperative visual acuity was recorded.Visual acuity was also recorded based on Snellen’s Chart decibel system.The diagnosis and localization of DM detachment were based on anterior segment optical coherence tomography(Zeiss.Germany)and slitlamp examination(Zeiss.Germany).All 6 cases were taken in to the operating room,anterior chamber was injected sterile air bubble under the guidance of a surgical microscope.A 15-degree side incisor(Mani.Japan)is used to make corneal incision preferably in a transparent and nondetached area of the cornea.Some aqueous humor was released through this incision,and then air was injected using 30-gauge hydro dissection cannula attached to a 5 mm syringe.Sufficient air bubble injection was maintained to fill the anterior chamber as possible.After the operation,the intraocular pressure was maintained at T + 1,and patients were instructed to keep a supine position for at least 4 hours.Postoperative observation was conducted to ensure the detached descemet’s membrane,bubble position,size,absorption time,corneal recovery time,visual prognosis,high intraocular pressure or other complications.During observation of the next day of the surgery,if the DM is not well reset,air bubble was injected again using same procedure.If the intraocular pressure exceeds 30mmHg(1mmHg = 0.113kPa),then intravenous infusion of mannitol and oral acetazolamide are used to reduce intraocular pressure and avoid high intraocular pressure for better corneal endothelial function.Eyes were checked after 1 day of the surgery,Topical steroids and antibiotics in tapering doses were advised daily till the complete resolution of the DMD.Results:Considering the epidemic data of the 6 cases of our study 3 were males and 3 were females.The age of the patient was 67-89 years.On clinical analysis,the diseased eye was left in all 6 patients and the predisposing disease leading to DMD was cataract surgery.No any other surgical complications were detected such as,posterior capsular tears or vitreous loss.In all 5 cases,the IOL was placed in the capsular bag.In regards to the status of cornea,all patients presented with mild to moderate corneal edema and conjunctival injection which mostly subsided three days after surgery.However,there was significant difference in the size and location of the defects.The detachment was in infratemporal region in 4 patients,supranasal in 1 patient and,supratemporal region in 1 patient.All 6 cases underwent descemetopexy procedure,and after the operation,postoperative VA remained poor in 1 patient while other 5 patients showed improved VA on follow up.Results suggested that the size,time after the cataract surgery,and the shape of the detachment were the influence factors.The procedure was successful in the first attempt in four patients,while other two patients,1 case required rebubbling while the other was a failure.The case which required rebubling was an 82-year-old female with previous both eyes pterygium resection 10 years ago who underwent cataract surgery.During the operation,DM detachment was detected and a sterile air bubble was injected.However,the procedure was unsuccessful and the next day AS-OCT detected DM detachment,this was because of an incorrect site of air bubble injection led to the folding of the DM,and incorrectly folding of the DM caused DM to form like a scar which prevented successful reattachment of the DM.Thus it is very important that the surgeon to carefully choose and locate the appropriate site for the air bubble injection.Many authors also suggested that,to inject the air bubble away from any edematous and detached area of the DM.The patient underwent the 2nd reparative air bubble injection.However,on the next day after the 2nd time air bubble injection,part of the endothelium was peeled off again,corneal edema worsened and sterile air bubble injection was repeated.Fortunately,the DMD resolved and reattached after 1 week.With BCVA of 20/30.The failure case was also a 67-year-old male,the,patient had developed ophthalmitis after cataract surgery and vitrectomy has been done previously.However,2 months after the cataract surgery patient developed DM detachment,which was unresolved and not responsive to air bubble injection.We hypothesize that this due to,the patient was aphakic and there was no barrier between the anterior and posterior segment,the air bubble may escape into the posterior segment.Moreover,the anterior chamber was shallow and unstable,while the pupil was also distorted.Thus,efficient tamponade cannot be established.Furthermore,AS-OCT showed that the detached Descemet’s membrane was thick and adherent to the iris.This is because an inflammatory fibrin exudates trap and gravitate down into the inferior anterior chamber leading to contraction of the iris and adhesion between iris and Descemet’s membrane which further prevented Descemet’s membrane to reattach due to traction of the iris.Conclusion:We found that cataract surgery is a major contributing factor to Descemet’s membrane detachment.The procedure was uneventful.Visual acuity outcomes of the patients were restored in most of the patients who underwent the procedure and reached complete reattachment after 1 week.No adverse effects were detected during the follow?up period.There was no infection and fallen detachment or pupillary block.We found that descemetopexy is a relatively safe,effective procedure for the treatment of DM detachment to save the visual acuity of the patients after cataract surgery complications.Furthermore,it is not a costly procedure,does not need special techniques and it can be used by both developed and developing nations. |
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