Small peripheral detachments of the Descemet membrane commonly occur during intraocular surgery. However, extensive clinically significant stripping of the membrane is rare, and the exact pathogenesis is unclear. Bilateral detachments have been described leading to speculation that there may be an anatomic predisposition for this infrequent complication. We report a case of bilateral Descemet membrane detachment with documented preoperative abnormalities of the corneal endothelium.
On postoperative day 2 after phacoemulsification froma superior approach with intraocular lens (IOL) insertion, an 83-year-old woman was referred to the Mayo Clinic (Rochester, Minn) for evaluation of corneal edema due to a Descemet membrane detachment that was noticed intraoperatively. She was treated with 20% sulfur hexafluoride gas tamponade in the anterior chamber on postoperative day 11 and was instructed to remain in an upright position. The detachment resolved, and her visual acuity returned to 20/25 in the affected eye. Endothelial specular photomicrographs were obtained of the contralateral eye. Five years later, we performed phacoemulsification on the left eye from a superior approach with IOL insertion. Intraoperatively, extreme care was used to avoid stripping the Descemet membrane. On postoperative day 1, the patient had a large detachment that did not resolve with observation. Three days later, the left eye was treated with gas tamponade and postural positioning. The detachment resolved, and her visual acuity improved to 20/40 OS.
Preoperatively, the biomicroscopic examination of the left eye revealed the subjective appearance of an irregular endothelial surface similar to, but more coarse than, the beaten-metal appearance of the endothelium in iridocorneal endothelial syndrome (Figure 1). In comparison with 10 age-matched controls from a previous study of healthy patients (mean age, 73 years; range, 70-79 years), our patient had a higher mean cell area (mean, 473 µm2 compared with mean ± SD, 348.8 ± 36.1 µm2), a higher coefficient of variation(34% compared with 27%), and a lower percentage of hexagonal cells (mean, 60% compared with mean ± SD, 65.5% ± 3.1%). The endothelial morphologic characteristics were not consistent with iridocorneal endothelial syndrome or Fuchs dystrophy.
A, Endothelial specular photomicrograph of the left eye preoperatively. B, Endothelial specular photomicrograph of the eye of a healthy patient.
In 1964, the idea of an intrinsic abnormality was first proposed in an article on Descemet membrane detachments by Scheie, 1 as discussed by John McLean, MD. Since then, additional cases of bilateral detachments have been reported with further speculation on an anatomic predisposition but without supporting evidence.2- 4 In our patient, we noted abnormalities in the results of both the biomicroscopic examination and the morphometric analysis of her endothelium that may have contributed to her subsequent membrane detachment. Given the paucity of data available for this rare complication, our 1 case suggests an underlying defect leading to its occurrence, although this idea may not be generalizable to the population as a whole.
In light of this information, we recommend additional preoperative counseling and careful examination of the contralateral eye in patients with Descemet membrane detachment prior to undertaking additional surgery. For cataract surgery, we recommend considering incision into the anterior chamber superiorly, rather than temporally, to facilitate gas tamponade of the endothelial break should a detachment occur.
This study was supported in part by Research to Prevent Blindness, New York, NY.
Corresponding author: Keith H. Baratz, MD, Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: firstname.lastname@example.org).
Fang JP, Amesur KB, Baratz KH. Preexisting Endothelial Abnormalities in Bilateral Postoperative Descemet Membrane Detachment. Arch Ophthalmol. 2003;121(6):903-904. doi:10.1001/archopht.121.6.903