EyeWorld India December 2020 Issue

SECONDARY FEATURE EWAP DECEMBER 2020 25 D escemet’s detachment is a potential complication that can arise in conjunction with cataract surgery. Experts share examples of when they encountered this problem, how they approached it, and how it might be avoided. Bullous Descemet’s detachment Soosan Jacob, MD, shared a case of bullous Descemet’s detachment. Dr. Jacob has developed a classification system for Descemet’s detachments and broken it down into different types: rhegmatogenous Descemet’s detachment, tractional Descemet’s detachment, bullous Descemet’s detachment, and complex Descemet’s detachment. Rhegmatogenous is the most commonly seen type after phacoemulsification, according to Dr. Jacob’s classifications. It presents as detachment with a tear and can be treated easily by intracameral air or gas injection to achieve supra-Descemetic fluid drainage through the tear. Those classified as bullous detachments are generally rarer, she said, and often show as a separation of the Descemet’s membrane into the anterior chamber, without a sufficiently large tear in the Descemet’s membrane. The problem in these bullous detachments is that air or gas injection that is supposed to push the supra- Descemetic fluid out does not work. The fluid is trapped as there’s no actual tear to serve as an egress route for the fluid, Dr. Jacob said. Once you realize what the problem is, it’s easy to handle, she said, adding the surgeon can simply intentionally make a break in the Descemet’s membrane to create a route for the fluid to come out from. This can be done by a simple keratome entry into the supra- Descemetic fluid space. The most common instance in which bullous Descemet’s detachment occurs is when you’ve completed phaco and are doing stromal hydration, Dr. Jacob said. The fluid wave from a too posteriorly placed, misdirected cannula may separate the Descemet’s membrane from the stroma. This may be recognized as a fluid wave passing across the cornea. Simply putting in air from the opposite side as done for rhegmatogenous Descemet’s detachment does not cause the Descemet’s membrane to reattach in this case as the air bubble is not able to squeeze all the fluid out. Dr. Jacob shared a case where the bullous detachment occurred secondary to stromal hydration at the end of phaco Dealing with Descemet’s detachments by Ellen Stodola Editorial Co-Director This article originally appeared in the October 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Hovanesian: jhovanesian@harvardeye.com Jacob: dr_soosanj@hotmail.com Packer: mark@markpackerconsulting.com Bullous Descemet’s detachment following stromal hydration. Source: Soosan Jacob, MD A Descemet’s detachment defines nicely when air is injected into the eye. Source: John Hovanesian, MD