EyeWorld Asia-Pacific December 2020 Issue

SECONDARY FEATURE 26 EWAP DECEMBER 2020 Dr. Jacob’s solution was to do a relaxing descemetotomy by creating a clean keratome entry cut through the Descemet’s membrane and thus have an exit wound for the fluid to drain out from. The plan is to create an opening into the bullous base to allow a path for entrapped fluid to drain out, Dr. Jacob said. You can do this by creating a keratome entry through the bullous Descemet’s detachment. The patient did well postoperatively in this case. Dr. Jacob stressed the importance of realizing that instead of repeated air injections in an attempt to treat a case of bullous Descemet’s detachment, this entity should be recognized and treated immediately, effectively, and definitively during the primary surgery itself by following the strategy presented here. Strategies for handling Descemet’s detachments John Hovanesian, MD, shared a case of Descemet’s membrane detachment, offering pearls on how to handle this issue as a whole and also what he did for this particular patient. In his case, he assumed the detachment had occurred from the temporal incision, likely from hydration of the cornea at the end of the case. A Descemet’s detachment defines itself nicely when air is put inside the eye, Dr. Hovanesian said, adding that you can see the wrinkles and the area where normal appearing light reflex off the bubble occurs. He suggested several strategies for dealing with this issue, including stroking the cornea from the surface in hope of milking some aqueous from the cleft in the Descemet’s membrane. He also mentioned using a Q-tip, but instead of rubbing, which would disrupt the epithelium, he said to use a rolling motion to get broader pressure across the surface of the cornea. You could also do a cut-down from the surface, but the danger is perforating the tear in Descemet’s membrane and worsening the problem. Viscoelastic as a complicating factor “While limited Descemet’s detachments immediately anterior to a clear corneal incision are common and usually do not require any special treatment, large detachments can persist and require secondary intervention,” said Mark Packer, MD. In the case he shared, viscoelastic was inadvertently injected anterior to Descemet’s membrane, resulting in a complete detachment and corneal edema. The presence of viscoelastic was a complicating factor, however, gentle irrigation and instillation of air resulted in complete resolution. EWAP Editors’ note: Dr. Hovanesian practices at Harvard Eye Associates, Laguna Hills, California. Dr. Jacob practices at Dr. Agarwal’s Eye Hospital, Chennai, India. Dr. Packer practices at Packer Research Associates, Boulder, Colorado. None of the doctors declared any conflicting interests. Johan A. Hutauruk, MD JEC Eye Hospitals JEC @Kedoya, 8th Floor, Jl Terusan Arjuna Utara No. 1, Kedoya, West Jakarta, Indonesia, 11520 johan.hutauruk@jec.co.id ASIA-PACIFIC PERSPECTIVES D escemet’s membrane detachment (DMD) following cataract surgery is a complication that is quite common but rarely gets immediate attention from surgeons. This often happens because most patients with corneal edema or Descemet’s folds following cataract surgery on postoperative day 1 will recover with a clear cornea 1 week later. We only suspect DMD after corneal edema gets worse on the next follow-up and it has become increasingly difficult to see the corneal endothelial layer to determine whether the Descemet’s membrane was still attached. Fortunately, current technology with corneal OCT allows us to make the diagnosis and classification proposed by Dr. Jacob to be of great use in determining the next step. Prevention and early recognition By identifying the risk factors, we can prevent DMD from happening. Some of the risk factors that are thought to increase the incidence of DMD are the use of a blunt knife when making a corneal incision, very hard cataracts, the position of the injector when inserting the IOL, careless viscoelastic injection, and shallow anterior chambers. Most cases of DMD are related to intraoperative trauma from instrument insertion into a corneal wound, so if we are facing a case with the above risk factors, we should be more careful performing surgery. Early recognition is one of the factors that determine the success of DMD management. Although most DMD do not require any treatment, large DMD if not treated promptly will cause serious visual disturbances. The use of intraoperative OCT will greatly facilitate recognizing DMD and overcoming it during surgery, usually with air bubbles and making sure the DMD is attached to the stroma above it. During surgery, if I suspect DMD, I only use a simple classification system as to whether the DMD is peripheral or central to the cornea. DMD that occurs in the peripheral cornea is easier to manage using air bubbles; however, if DMD occurs in the central area, in my opinion it is better to use SF6 gas, then check with intraoperative OCT to make sure there is no gap between the Descemet’s layer and the stroma above it. Editors’ note: Dr. Hutauruk declared no conflicting interests. surgery. As the stromal hydration was done at the needle entry sideport, the fluid pushed the Descemet’s membrane down in a bullous configuration. Since the needle entry point was too small for the fluid to be pushed out, it did not respond to air injection, she said. The specific problems in this case, she said, were the needle prick entry wound and absence of exit wound for trapped fluid to egress. Despite pneumodescemetopexy, there was fluid collection within the detached bullous Descemet’s membrane.