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 Table of Contents    
CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 46-49  

Hydrophilic intraocular lens opacification after repeated intracameral gas injection for Descemet membrane detachment


1 Department of Ophthalmology, Hospital Provincial De Castellón, Castellón De La Plana, Castellón, Spain
2 Department of Internal Medicine, Hospital General de Castellón, Castellón De La Plana, Castellón, Spain

Date of Web Publication30-Jan-2019

Correspondence Address:
Dr. Manuel Roca Sanz
C/Cataluña 33A 1° 4, Castellón de la Plana, Castellón, CP 12004
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_173_2017

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   Abstract 


Descemet membrane detachment (DMD) is a complication of a variety of eye procedures that can result in severe visual loss. We report a new case of the condition, in a highly myopic patient that had undergone cataract surgery, and presented a macular hemorrhage during the intervention. DMD was successfully treated with a combined technique of intracameral gas injection and transcorneal suturing. Following resolution of this complication, intraocular lens opacification was observed.

Keywords: Cataract surgery complication, Descemet membrane, Descemet membrane detachment, intraocular lens opacification, pathologic myopia, retinal hemorrhage


How to cite this article:
Sanz MR, Rallo MM, Gutierrez AG, Villanueva BR. Hydrophilic intraocular lens opacification after repeated intracameral gas injection for Descemet membrane detachment. Oman J Ophthalmol 2019;12:46-9

How to cite this URL:
Sanz MR, Rallo MM, Gutierrez AG, Villanueva BR. Hydrophilic intraocular lens opacification after repeated intracameral gas injection for Descemet membrane detachment. Oman J Ophthalmol [serial online] 2019 [cited 2019 May 20];12:46-9. Available from: http://www.ojoonline.org/text.asp?2019/12/1/46/251031




   Introduction Top


Descemet membrane detachment (DMD) is a rare complication of eye procedures such as cataract surgery, glaucoma surgery, and corneal transplants.[1] It can result in severe visual loss. We report a new case of DMD, after cataract surgery, successfully treated with a combined technique of intracameral gas injection and transcorneal suturing.[2]

Objectives

The objective of this study is to describe a case of persistent DMD following cataract surgery that was successfully treated with a combination of intracameral sulfur hexafluoride (SF6) injection and transcorneal suturing.


   Methods Top


A 69-year-old female who had 12 diopters of myopia underwent cataract surgery on her left eye. Retrobulbar block was used. During the procedure, a red reflex anomaly was noticed, and fundus examination revealed an inferior macular hemorrhage. No other incidents occurred during the technique, and the patient was prescribed topical steroids, antibiotics, and nonsteroidal anti-inflammatory drugs.

The next day, her left eye best-corrected visual acuity was light perception. Slit-lamp examination showed an intense diffuse corneal edema and a double anterior chamber image [Figure 1]a and [Figure 1]b. A nonplanar extensive DMD was diagnosed. Intraocular pressure was 17 mmHg. Opaque media impeded fundus assessment, and a B-scan ultrasonography was unrevealing. Examination of the fellow eye was normal. Nearly 22% SF6 was injected in the anterior chamber, and an inferior iridotomy was carried out. The patient was instructed to rest in supine position.
Figure 1: Slit-lamp examination shows generalized corneal edema with diffuse illumination (a), and a deep Descemet membrane detachment with slit-beam illumination (b)

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Two days later, corneal edema and DMD had improved [Figure 2]a. A cyclitic membrane was observed. She was prescribed cycloplegic agents and an increased dose of topical steroids. Optical coherence tomography (OCT) revealed a persistent, extensive, and planar DMD [Figure 2]b, with detachment deeper on the nasal and superior regions. Detailed fundus examination still was impossible, and posterior segment OCT showed a shallow neurosensory detachment of posterior pole [Figure 2]c.
Figure 2: Diffuse illumination reveals improvement of corneal edema following intracameral sulfur hexafl uoride injection (a). Optical coherence tomography shows a persistent shallow Descemet membrane detachment (b) and a neurosensory detachment of posterior pole (c)

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Eight days later, DMD was still present. SF6 was injected again, and two 10-0 nylon transcorneal sutures were placed in the nasal and superior zones [Figure 3]a.
Figure 3: Clinical images show a great improvement of edema and descemetopexy following sulfur hexafluoride and transcorneal sutures (a and b). Fundus image and angiography show diffuse chorioretinal atrophy where the hemorrhage was found (c and d)

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One month later, Descemet membrane was completely attached and corneal edema had disappeared [Figure 3]b. Posterior capsule and anterior surface of intraocular lens (IOL) were opaque. Neodymium-doped yttrium aluminum garnet (Nd: YAG) capsulotomy was performed to improve fundus visibility. Subretinal fluid had completely disappeared, and chorioretinal atrophy was noticed at the site of previous hemorrhage [Figure 3]c and [Figure 3]d. Four months later, sutures were removed. Anterior surface of the lens showed opacification in the central zone [Figure 4] and [Figure 5].
Figure 4: Clinical image shows a demarcation line that surrounds the previously detached Descemet membrane and the intraocular lens opacification

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Figure 5: Anterior lens opacification was best seen using broad-beam illumination at 45°

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   Discussion Top


If persistent bullous corneal edema is found after cataract surgery, DMD must be considered. In those cases, corneal opacity can mask the detachment, particularly when it is small and planar. In that situation, ancillary tests such as anterior segment OCT, ultrasound biomicroscopy, or Scheimpflug imaging can be helpful.[1],[3]

Endothelial abnormalities such as low cell count or anomalous anchoring proteins may predispose to DMD.[3] The condition may complicate intracameral injection of substances, insertion of the IOL, or hydration of surgical wounds, particularly when dull surgical knives for incisions have been used previously, long and tight corneal tunnels have been constructed, or entry with instruments has been excessively oblique.[3] In our case, recording of surgery was reviewed, and none of those possible causes of DMD was noticed.

When DMD complicates cataract surgery, an increased risk seems to exist for the same complication, if the fellow eye is operated on.[3] In our patient, cataract surgery had been performed on her right eye 6 months earlier, without complications.

Clinically, the condition is classified into planar, when the distance between Descemet membrane and stroma is less than 1 mm, or nonplanar, when such distance is 1 mm or more. DMD depth, extension, and location are decisive features to tailor the treatment.

Surgical treatment would be necessary in almost all nonplanar DMDs, especially those affecting central zone.

Many techniques have been described to achieve descemetopexy. Nowadays, the most commonly used is intracameral injection of air or inert gasses such as octafluoropropane (C3F8) or SF6.[4] After injection, the patient is usually recommended to be in supine position. Air tamponade, due to its quick absorption, is usually not enough for big detachments.[1] In those cases, inert gasses are more appropriate because they stay longer in anterior chamber. When injecting gas in anterior chamber, it is generally recommended to perform an inferior iridotomy to prevent acute ocular hypertension due to pupillary block.[5]

Combination of intracameral gas and transcorneal sutures has also been described to treat this condition. Treatment algorithms have been proposed for this pathology, but they do not specify which surgical approach is more appropriate depending on features of the detachment. At the moment, we consider that this technique may be appropriate when gas alone has proved to be ineffective. Further research about this entity is needed to test this hypothesis and to elaborate an accurate surgical treatment algorithm.[6]

The use of viscoelastic solutions, Nd: YAG laser, corneal venting incisions, and mechanical repositioning with spatulas, has also been described for DMD treatment, in cases similar to ours.[6],[7]

Resolution of DMD has also been reported with the use of topical steroids and hyperosmotic agents only. Nevertheless, failure rates are high and time to resolution is usually prolonged. Such therapeutic approach could be appropriate with nonplanar, small, and noncenter involving DMDs. If Descemet membrane is not reattached promptly, adhesion to other intraocular structures and fibrotic changes can occur.[8]

When coincident fundus pathology is suspected and ocular media are not clear enough, ultrasonography can be useful to assess retina and vitreous cavity status.

If a new hemorrhage is seen after retrobulbar block, accidental scleral perforation must be considered first of all, although other possible causes include neovascular membrane or subretinal hemorrhage related to pathologic myopia.[9] In our case, no other suggestive signs of scleral perforation were found. No relationship could be established between hemorrhage and DMD.

IOL opacification has been described following intracameral gas use in pseudophakic patients. Case series have been reported following DSAEK in patients with hydrophilic IOLs. Analysis of IOLs reported granular calcification.[10]

It seems that repeated exposure to gas increases the risk of this complication. Other possible risk factor is prolonged breakdown of the blood-aqueous barrier. In our case, important anterior chamber inflammation and rebubbling could play an important role in the haze development.

The mechanism of IOL opacification remains unclear. Direct contact between IOL and gas can induce microstructural changes, increasing permeability to aqueous components and subsequent crystallization. It has also been suggested that metabolic changes in aqueous humor could play a key role in this pathology since protein and calcium levels, among others, are higher than normal. Maybe these two factors have a synergistic effect. In all the cases previously described, only anterior lens surface was affected.[11]

In our case, both important anterior chamber inflammation and rebubbling could play an important role in the haze development. Only the anterior lens surface presented haze.

Differential diagnosis with proliferation of low-virulence microorganisms over the IOL should be considered. These patients normally develop a chronical, low-grade uveitis, being the early postoperative normal. The eye did not show inflammatory signs during the next year after the procedure, being this cause less suitable.

The iris can be a protective factor for opacification. One case in a patient with iris atrophy has been previously reported, and the underlying zone of the IOL was also affected. Hydrophobic lenses seem less prone to develop haze.

Nowadays, the only treatment that improves visual function is IOL exchange. When posterior capsulotomy is present, the safeness of the procedure can be compromised. The choice of IOL model and technique depends on capsular bag integrity. Due to low expectancy of visual improvement, we decided not to explant the IOL.


   Conclusion Top


DMD is an unusual entity that can appear following many ocular procedures. Many techniques have been described to achieve descemetopexy, but nowadays, there are not standardized therapeutic algorithms.

Hydrophilic IOLs seem to be prone to opacification following intracameral gas injections. Increased permeability and aqueous composition changes could explain this phenomenon. This complication may require IOL exchange.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Orucoglu F, Aksu A. Complex descemet's membrane tears and detachment during phacoemulsification. J Ophthalmic Vis Res 2015;10:81-3.  Back to cited text no. 1
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2.
Mackool RJ, Holtz SJ. Descemet membrane detachment. Arch Ophthalmol 1977;95:459-63.  Back to cited text no. 2
    
3.
Bhatia HK, Gupta R. Delayed-onset descemet membrane detachment after uneventful cataract surgery treated by corneal venting incision with air tamponade: A case report. BMC Ophthalmol 2016;16:35.  Back to cited text no. 3
    
4.
Datar S, Kelkar A, Jain AK, Kelkar J, Kelkar S, Gandhi P, et al. Repeat descemetopexy after descemet's membrane detachment following phacoemulsification. Case Rep Ophthalmol 2014;5:203-6.  Back to cited text no. 4
    
5.
Sáles CS, Mayko ZM, Terry MA, Straiko MD. Preventing and managing postoperative complications in DMEK surgery. In: Jacob S, editor. Mastering Endothelial Keratoplasty. Ch. 7. India: Springer; 2016. p. 115-6.  Back to cited text no. 5
    
6.
Jeng BH, Meisler DM. A combined technique for surgical repair of descemet's membrane detachments. Ophthalmic Surg Lasers Imaging 2006;37:291-7.  Back to cited text no. 6
    
7.
Menezo V, Choong YF, Hawksworth NR. Reattachment of extensive descemet's membrane detachment following uneventful phaco-emulsification surgery. Eye (Lond) 2002;16:786-8.  Back to cited text no. 7
    
8.
Kumar DA, Agarwal A, Sivanganam S, Chandrasekar R. Height-, extent-, length-, and pupil-based (HELP) algorithm to manage post-phacoemulsification descemet membrane detachment. J Cataract Refract Surg 2015;41:1945-53.  Back to cited text no. 8
    
9.
Gadkari SS. Evaluation of 19 cases of inadvertent globe perforation due to periocular injections. Indian J Ophthalmol 2007;55:103-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Morgan-Warren PJ, Andreatta W, Patel AK. Opacification of hydrophilic intraocular lenses after descemet stripping automated endothelial keratoplasty. Clin Ophthalmol 2015;9:277-83.  Back to cited text no. 10
    
11.
Norouzpour A, Zarei-Ghanavati S. Hydrophilic acrylic intraocular lens opacification after descemet stripping automated endothelial keratoplasty. J Ophthalmic Vis Res 2016;11:225-7.  Back to cited text no. 11
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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