Bilateral Spontaneous Descemet Membrane Detachment Following Uncomplicated Bilateral Simultaneous Phaco-Emulsification.

We report the case of a 66-year-old diabetic female with Chronic Obstructive Pulmonary Disease (COPD) and obstructive sleep apnoea (OSA) on home oxygen who developed spontaneous bilateral Descemet membrane detachment (DMD) after uncomplicated Simultaneous Immediate Bilateral Cataract Surgery (SIBCS).  Though spontaneous DMD after uncomplicated phaco-emulsification have been reported before, it has not been reported after SIBCS. The success rates with air pneumatic descemetopexy is excellent, with ranges between 90% - 95%. In this case, surgical intervention with gas injection in the anterior chamber (AC) and surgical peripheral iridotomies (PI) resulted in excellent visual acuity restoration in the patient.

DMD following phacoemulsification has the potential to cause irreversible corneal decompensation. This rare complication has a documented incidence of between 0.044 and 0.5%. Whilst modern cataract surgical techniques have led to greater post-operative outcomes, a higher incidence of clinically significant DMD after phacoemulsification has been reported with modern cataract extraction techniques. DMD generally occurs in early-postoperative period,with late-onset DMDs reported less frequently.

A 66-year-old diabetic with COPD presented with a 6-month history of worsening vision in both eyes (BE). BCVA was HM in her RE and 6/24 in her left eye. She had no documented corneal pathology and was found to have bilateral nuclear sclerotic cataracts. She underwent uneventful same-day SIBCS following international guidelines by different surgeons in either eye. No DMD was noted in either eye.

Four weeks after uncomplicated cataract surgery, the patient presented with Counting Fingers vision in BE. Extensive corneal oedema was observed in BE. No other pathology was noted. Her VA never improved postoperatively.Anterior segment optical coherence tomography (AS-OCT) confirmed the presence of DMD from the temporal and central cornea. To provide reattachment of DMD, bilateral air descemetopexies were performed under local anaesthesia in the operating room. 100% air was injected with a 26-guage cannula into the AC through the temporal incision (3 o’clock) under aseptic conditions and a surgical PI was made inferiorly in BE to reduce the risk of pupil block. A stat dose of subconjunctival cefuroxime and dexamethasone was given at the end of the procedure. No intra-operative complications was observed. Postoperatively, the patient postured supine for 24 hours. 

A week post descemetopexy, DMD was completely reattached in the right eye and partially re-attached in the left eye. One month post descemetopexy, BCVA in the RE was 6/6 and 6/9 in the LE with completely reattached DMD in BE.

Though it has been suggested that pre-existing corneal pathology and dense cataracts may be a cause for spontaneous DMD, other factors may contribute. This case highlights that some patients may be anatomically predisposed to DMD due to weak adhesions between the stroma and Descemet’s membrane. With SIBCS being on the rise, spontaneous bilateral DMDs may also be seen increasingly in those eyes with unrecognized risk factors for spontaneous DMD.  There are reports of spontaneous reattachment after few weeks. With unilateral DMD, 'watch and wait' is a viable option. But in bilateral DMD cases, early air or gas descemetopexy may be needed. This might be a point for discussion at the consenting stage for SIBCS.