|Year : 2023 | Volume
| Issue : 1 | Page : 19
Descemet's membrane detachment: Insights
Rahul Bhatia, Priyanka Gautam, Nitika Beri, Isha Sharma
Department of Ophthalmology, University College of Medical Science, Delhi, India
|Date of Submission||29-Dec-2022|
|Date of Decision||26-Jan-2023|
|Date of Acceptance||27-Jan-2023|
|Date of Web Publication||11-May-2023|
Department of Ophthalmology, University College of Medical Science, Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Descement's membrane detachment (DMD) is separation of Descemet's membrane (DM) from the overlying stroma. It is manifested as corneal oedema at the site of detachment. With the rising number of phacoemulsification in the world, the DMD becomes an important complication that may require additional surgical intervention leading to an increase in economic as well as a social burden on the patient and hospital. Descemet's membrane detachment(DMD) is an uncommon complication of cataract surgery that may lead to corneal scarring and poor post-op vision gain. Till now, there is no standardized protocol for the management of DMD. Various authors have tried to classify DMD. Newer techniques such as AS-OCT, Schiemflug imaging, etc have helped in the early detection of DMD chance improving the prognosis.
Keywords: Corneal edema, descemet's membrane detachment, Sf6
|How to cite this article:|
Bhatia R, Gautam P, Beri N, Sharma I. Descemet's membrane detachment: Insights. Pan Am J Ophthalmol 2023;5:19
| Introduction|| |
Descement's membrane detachment (DMD) is separation of Descemet's membrane (DM) from the overlying stroma. It is manifested as corneal edema at the site of detachment. This edema occurs due to the endothelial pump failure occurring due to DMD. On slit lamp, it is seen as a translucent membrane separated from the posterior stroma with an associated increase in stromal thickness due to fluid along with epithelial bullae. This condition was first described in the literature by Weve in 1927. DMD is an uncommon complication of cataract surgery occurring in about 0.044%–0.5% in phacoemulsification. With the rising number of phacoemulsification in the world, DMD becomes an important complication that may require additional surgical intervention leading to an increase in economic as well as a social burden on the patient and hospital. Furthermore, occult DMDs may occur mimicking pseudophakic bullous keratopathy.
| Epidemology and Etiology|| |
The main cause of DMD is surgical (cataract, lamellar keratoplasty, and trabeculectomy), whereas trauma and chemical burns also contribute to its epidemiology. DMD is usually diagnosed intraoperatively, but some authors have reported a rare occurrence of DMD in the late postoperative period (up to 3 weeks–6 months) also., Various factors have been implicated in the causation of DMD, including shallow anterior chambers, complicated/repeated procedures, blunt surgical instruments, and inadvertent injection of saline/air/viscoelastic material between the stroma and DM.
Most of the DMDs are small and found in the peripheral cornea along the site of corneal incisions. These peripheral DMDs are clinically insignificant, with no effect on the vision and usually do not require intervention. Only a small percentage (0.5%) of DMDs involve the central cornea, and up to 8% of these will subsequently require a corneal transplant.
Various authors have tried to classify and prognosticate DMDs. Mackool and Holtz classified DMD based on the size of separation of stroma with DM into planar (<1 mm separation) and nonplanar (more than 1 mm separation). It was suggested that the planar DMDs resolved spontaneously and did not require surgical intervention as needed in nonplanar DMDs. The location and extent of DMD were not included in the classification.
Based on the edges of the DMDs, these were divided into scrolled and nonscrolled DMD, with the nonscrolled having a better prognosis. In 2015, Jacob et al. proposed a new classification based on clinico-tomographically features of DMD that is rhegmatogenous, tractional, bullous, and complex. These classifications tried to predict the spontaneous reattachment of the DMD but did not provide insight into the timing of observation and surgical intervention.
Later, the DMDs were classified into central and peripheral in an attempt to provide indications for surgical intervention. Peripheral DMD is usually small, peripheral in location, and causes minimal central corneal edema. Central DMD causes central corneal edema and requires early surgical intervention. With the advances in anterior segment opticalcoherence tomography (AS-OCT) techniques, early detection of DMD is possible. AS-OCT can also be used to objectively measure the extent and height of the DMD and to monitor the progress of the treatment.
An AS-OCT-based algorithm was used in the identification and prognostication of postoperative DMD. DMDs were managed surgically or medically based on the detachment's height, extent, length (chord), and relation to the pupil (HELP protocol). The measurements were made using AS-OCT. This was the first AS-OCT-based objective protocol that helped in the early detection and standardized management of DMDs.
| Management|| |
The majority of the DMDs, being in the peripheral cornea, rarely cause central corneal edema. The localized corneal edema may be asymptomatic and resolve spontaneously. These DMDs may be managed conservatively with topical corticosteroids and hyperosmotic agents with a spontaneous reattachment rate of around 60%.
The main aim of management is to prevent permanent corneal decompensation by stromal scarring and induced astigmatism. Various treatment methods have been used in the management for central DMD or nonspontaneously resolving peripheral DMDs.
These include manual repositioning using a cyclodialysis spatula, ophthalmic viscosurgical device solutions, or air. The folded flap of Descemet's membrane may be mechanically unfolded and manipulated using these agents. This is useful in cases of DMD along the incisions in the peripheral cornea.
Various authors have also used descemetopexy using 100% air or isoexpansile gases such as 15%–20% SF6 or 12%–14% C3F8.,,, These gases have a tamponading effect on the DMD, reaching a success rate of 90%–95%. The advantages of using 100% air are lower cost, shorter time of absorption, and less risk of endothelial toxicity or pupillary block than with other long-standing gases. As shown in [Figure 1], these gases provide mechanical tamponade and help in the adhesion of the DMD. These may be combined with mechanical manipulation of the DMD flap in cases of scrolled edges [Figure 2].
|Figure 1: Slit-lamp photo showing DMD in the paracentral area postcataract surgery with AS-OCT image. DMD: Descement's membrane detachment, AS-OCT: Anterior segment optical coherence tomography, white arrow showing DMD on slit lamp examination|
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|Figure 2: Image showing SF6 gas in anterior chamber for tamponade of DMD. DMD: Descement's membrane detachment|
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These intracameral gases may also be combined with transcorneal suturing in redetachment cases. This is particularly useful in cases of peripheral DMD at or near the site of the main port/side port.
Bhatia and Gupta, in 2016, used a 20G microvitreoretinal blade to drain the fluid pockets using an AS-OCT and Scheimpflug imaging with air tamponade in a case with persistent DMD. Similar technique with multiple stab incisions with intracameral C3F8 gas was used by the author. This technique is particularly useful in failed attempts of tamponade. The use of AS-OCT has helped in exact localizing the highest point of descemet's detachment and planning the site and the depth of the incisions [Figure 3].
|Figure 3: Image showing external drainage using MVR incision with SF6 gas for tamponade. MVR: Microvitreoretinal|
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Weng et al., in 2017, used a 23-gauge needle to puncture the peripheral cornea to drain the preDescemet fluid with intracameral air tamponade, with an AS-OCT as a guide to plan the site of puncture.
Merrick proposed penetrating keratoplasty for persistent DMD. Keratoplasty is the last resort for visual rehabilitation with limitations of the nonavailability of the corneal tissue, risk of rejection or infection, the requirement of good postoperative care, and regular follow-up. [Table 1] and [Figure 4] summarize all the management options for Descemet's membrane detachment.
|Figure 4: Summary of all the management options for descemet's membrane detachment|
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| Conclusion|| |
DMD is an uncommon vision-threatening complication of cataract surgery. The prognosis depends on early detection and prompt management. Newer modalities such as AS-OCT, Schiemflug imaging, and pachymetry help in early diagnosis and management. The majority of DMD is small and spontaneously resolves requiring only medical management. For persistent large DMD, descemetopexy using expansile gases has been used to tamponade the DM and cause attachment of DM. The use of the AS-OCT-based HELP algorithm has led to an objective assessment of DMD and thinning of the gray line between either going for observation or intervention with various modalities available. If descemetopexy fails, a corneal venting incision can be used as a last treatment option before going for keratoplasty. Keratoplasty remains the treatment of choice for long-standing and persistent DMD.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]