INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY (OCT) GUIDED DESCEMETOPEXY WITH SF6 20% FOR DESCEMET’S MEMBRANE DETACHMENT (DMD) POST CATARACT SURGERY

Descemet’s membrane detachment (DMD) is a rare but potentially sight threatening complication after cataract surgery. The incidence of DMD is reported as 2.6% for extracapsular cataract extraction and 0.5% for phacoemulsification. Some recent studies showed that the incidence ranges from 0.044% to 0.81% after phacoemulsification surgery.

We describe a patient who had DMD following phacoemulsification cataract extraction with intraocular lens which was successfully managed by intracameral 20%SF6 injection with  real-time intraoperative OCT (iOCT) guidance.

A 79-year-old gentleman underwent an uneventful phacoemulsification surgery with a temporal clear cornea incision in his left eye with posterior chamber intraocular lens implantation at the referring hospital.

He was referred to our clinic a month later for a persistent corneal oedema. Presenting visual acuity was 1/60 compared to 0.2 decimal preoperatively, with an intraocular pressure of 12. Slit lamp examination showed significant central corneal oedema with descemet membrane folds. Anterior chamber view was blurred but was deep and quiet with no signs of infection or inflammation noted. A topical steroid (dexamethasone) and chloramphenicol were prescribed for the patient given six times a day, along with Sodium chloride 5% given four times a day. After one week of observation, the cornea oedema was stilll prominent. An anterior segment optical coherence tomography (AS-OCT) was performed which showed DMD extending centrally from the temporal surgical site.

Due to the significant DMD involving visual axis , we opted for surgical intervention. Intraoperative OCT guided descemetopexy with 20% SF6 was performed. An inferior paracentesis was made and 20% SF6 was injected into the anterior chamber under iOCT guidance with a full chamber for 15 minutes. Some gas was then released to about 70-80% filled, and intracameral cefuroxime was injected at the end of the surgery.  Patient was then instructed to lie supine for 2 hours post op and examined at slit lamp to ensure there was no pupillary block.

On post op day 1, DMD was attached fully and remained so at 1 month post-operatively, with cornea oedema completely resolved. Best corrected visual acuity improved from 1/60 preoperatively to 0.6 decimal.

In patients with corneal oedema after cataract surgery, careful examination has to be done to look for potential treatable causes. In case of poor anterior chamber view, if DMD is suspected, an AS-OCT can be performed to confirm the diagnosis and guide the management.  Intraoperative OCT can also be used successfully to assist the surgical treatment of DMD.