SUCCESSFUL MANAGEMENT OF DESCEMET DETACHMENT DUE TO HYDROSEPARATION DURING PHACOEMULSIFICATION

To describe a case of successful management of huge Descemet's Membrane Detachment (DMD) during hydration of phacoemulsification main port.

Case-report study from Instituto de Oftalmologia Dr. Gama Pinto

A 66 year-old male patient underwent cataract surgery using phacoemulsification on his right eye (RE) at Instituto de Oftalmologia Dr. Gama Pinto. There was no prior systemic or ophthalmic conditions. On preop evaluation, Best Corrected Visual Acuity (BCVA) was counting fingers on his RE and 20/1000 on his left eye (LE). Intraocular pressure (IOP) was 14 and 15 mmHg for the RE and LE, respectively. On slit lamp examination, there was an apparent corneal arcus senilis, formed anterior chamber, pseudoexfoliation and dense white cataracts on both eyes. No fundus examination was possible due to significant media opacities. Ultrasound imaging revealed no vitreoretinal abnormalities, namely retinal detachment. During examination, patient collaboration was very poor, hence a peribulbar anesthesia was planned.

Cataract surgery was performed uneventfully, the surgeon using triplanar corneal incision, viscoelastic soft-shell technique, direct chop, with good centration of the monofocal IOL. Upon phaco main port hydration, occured a sudden patient head movement, causing a BSS fluid wave to travel between the corneal stroma and Descemet's Membrane (DM), thereby resulting in a central rhegmatogenous DMD with 1/2 of corneal total area and subsequent loss of corneal transparency. Gentle hydration of the side borders of the main port and a transcorneal suture were then performed and an air bubble was injected in the anterior chamber, enough to encompass the whole DMD. After 5 minutes, the cornea regained its transparency, the eye was then patched, the patient was in supine position for 1 hour and instructed to do so at home in the first day of post op.

On post-op day one, patient had no complaints, BCVA was 20/100, IOP was 18 mmHg, the cornea was transparent and the DM was reattached, confirmed by Anterior Segment OCT (AS-OCT). One month after the surgery, BCVA was 20/30, with corneal transparency and apposition of DM.

DMD is a potentially vision-threatening complication of cataract surgery, rare in the intraoperative and common in the postoperative period. Major risk factors include advanced age, pre-existing corneal endothelial disease, hard cataract, prolonged surgical time, ragged clear corneal incisions and inadvertent trauma. Large, central DMD’s if not managed appropriately, may lead to corneal decompensation and opacification. AS-OCT can be useful for diagnosis, treatment planning and prognosis of such cases. Descemetopexy is the mainstay of treatment, with re-apposition in 71-87.5% of cases). Our case report highlights the importance of immediate recognition of intraoperative DMD and proper treatment, preventing surgical reintervention or irreversible corneal opacification.