|Year : 2020 | Volume
| Issue : 3 | Page : 148-153
A prospective analysis on the outcomes of descemetopexy procedures for Descemet's membrane detachment post-cataract surgery
Anuraag Gandhi, Sabyasachi Chakrabarty, Anitha Venugopal, Shivkumar Chandrashekharan, Aditya Ghorpade
Department of General Ophthalmology, Aravind Eye Hospital & PG Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
|Date of Submission||25-Apr-2020|
|Date of Decision||14-May-2020|
|Date of Acceptance||29-May-2020|
|Date of Web Publication||14-Sep-2020|
Dr. Anuraag Gandhi
Aravind Eye Hospital and PG Institute of Ophthalmology, Tirunelveli, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aims: The aim of this study is to analyze the outcomes of air descemetopexy with/without suture augmentation (AD) for Descemet's membrane detachment (DMD) post-cataract surgery. Materials and Methods: This prospective study included 51 eyes that underwent AD at a tertiary hospital. The outcome measures were successful Descemet's membrane (DM) reattachment and improvement in visual acuity by at least two Snellen lines. Statistical Analysis: Mean, standard deviation, and percentage were used to summarize the data. Wilcoxon signed-rank test, Chi-square test, and Fischer's exact test were used to calculate statistical significance. P < 0.05 was considered statistically significant. Results: Out of 52,396 cataract surgeries, 51 patients required surgical intervention for DMD, postoperatively. The mean age of the participants was 66.67 ± 9.8 years with a male: female ratio of 6:11. A nonplanar DMD was found in 56.87% (n = 29). The most common surgery preceding DMD was small incision cataract surgery (68.6%; n = 35). The mean interval between cataract surgery and descemetopexy was 9.3 ± 7.9 days. The mean pre- and post-descemetopexy visual acuities were 1.01 ± 0.6 and 0.44 ± 0.49, respectively (P < 0.00001). After an air tamponade, an additional suture (s) had to be placed in 62.8% (n = 32) cases, out of which 23 required a single suture, seven needed two sutures, and two needed three sutures. A successful DM reattachment was seen in 92.2% (n = 47) with the first attempt. There was a statistically significant improvement in visual acuity post-descemetopexy irrespective of the timing of surgery (P < 0.001 for all surgeries performed within 2 weeks and P = 0.03 for surgeries performed later). Conclusion: AD is a safe and effective procedure for the treatment of post-cataract surgery DMD.
Keywords: Air descemetopexy, Descemet's membrane detachment, descemetopexy, nonplanar Descemet's membrane detachment, planar Descemet's membrane detachment
|How to cite this article:|
Gandhi A, Chakrabarty S, Venugopal A, Chandrashekharan S, Ghorpade A. A prospective analysis on the outcomes of descemetopexy procedures for Descemet's membrane detachment post-cataract surgery. TNOA J Ophthalmic Sci Res 2020;58:148-53
|How to cite this URL:|
Gandhi A, Chakrabarty S, Venugopal A, Chandrashekharan S, Ghorpade A. A prospective analysis on the outcomes of descemetopexy procedures for Descemet's membrane detachment post-cataract surgery. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2020 Sep 21];58:148-53. Available from: http://www.tnoajosr.com/text.asp?2020/58/3/148/294993
| Introduction|| |
Rehabilitation following cataract surgery occurs rapidly achieving good visual outcomes in most cases with relatively few complications. Descemet's membrane detachment (DMD) is a rare, but potentially serious complication of cataract surgery. Acute loss of vision from severe corneal edema can be the first sign and may also be the cause of delayed diagnosis. Apart from cataract surgery, a DMD may also occur during cyclodialysis, surgical iridectomy, trabeculectomy, holmium LASER sclerostomy, penetrating or lamellar keratoplasty, and viscocanalostomy.,,,
Small subclinical detachments go undetected because they resolve spontaneously within days after surgery. However, larger detachments of the Descemet's membrane (DM) can lead to more serious postoperative complications. Prompt recognition along with the management gives dramatic improvement of corneal edema and enhances the visual outcome.
There is a relative paucity in the literature regarding the guidelines for the management of DMD. Some of the questions that still remain unanswered are the need for an intervention in all cases and if required, its timing, the technique of re-attachment and the factors influencing the final outcome. There have been studies which have dealt with the outcomes of air descemetopexy post-cataract surgery, but they have all been of a retrospective nature.,,,, A recent review on the subject has shed light on many of these parameters but a fool proof algorithm is yet to be ascertained.
This prompted us to conduct a prospective study on the surgical repair of postcataract surgery DMD which would evaluate the outcomes of air descemetopexy with/without suture augmentation (AD).
| Materials and Methods|| |
This was a prospective study conducted on patients with post-cataract surgery DMD between December 2016 and December 2018 at a tertiary eye care center. All patients who developed DMD post-cataract surgery and were willing to undergo descemetopexy were included in the study. Patients who had a preexisting endothelial dystrophy and those in whom the DMD were managed conservatively were excluded. Patients in whom a descemetopexy was performed with the primary cataract surgery were excluded if the procedure was successful. Those who had undergone combined procedures (e.g., trabeculectomy with cataract surgery) or had a history of undergoing any intraocular procedure before the cataract extraction were also excluded.
Visual acuity with best correction was recorded using the Snellen's distance vision chart which was converted into a log MAR scale for statistical analysis. A slit-lamp biomicroscopy was done for both the eyes, and the presence of any exclusion criteria was ruled out. For all cases of DMD, a slit-lamp photograph and an anterior segment optical coherence tomography (AS-OCT) (Visante AS-OCT; Carl Zeiss Meditec, Dublin, California, USA) were taken thereafter for the confirmation of diagnosis [Figure 1]. The DMD was classified as planar when the DM separation was <1 mm and nonplanar when the separation was greater., Patients with involvement of more than 25% of the peripheral cornea were considered to have a visually significant DMD and were planned for a surgical intervention. The patients planned for a conservative approach were started on intensive topical steroids with sodium chloride 5% eye drops and 6% eye ointment for possible spontaneous resolution.
|Figure 1: Slit-lamp photograph and anterior segment optical coherence tomography of one of our patients with Descemet's membrane detachment (a) Descemet's membrane detachment in diffuse illumination. A distinct area of stromal edema is seen in the superotemporal quadrant (b) Slit image showing the presence of the detached Descemet's membrane beneath the area of stromal edema (c) Anterior segment optical coherence tomography from the same patient showing a hyperreflective wavy membrane beneath the stroma separated by a clear space|
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For our subjects, descemetopexy was done by air tamponading. If needed a suture was taken to help oppose the DM. All the procedures were done by a single, experienced surgeon. The procedures were performed either under a topical or peribulbar anesthesia.
A paracentesis was made at the limbus opposite to the site of the DMD. For fresh cases, if the side port was away from the site of DMD and was not involved, then the side port itself was used instead of making a new paracentesis. A 26-G viscoelastic cannula was introduced to reach beneath the plane of the DMD and sterile air, drawn up with the help of a microspore filter attached to a syringe, was slowly injected to tamponade the DM. The cannula was then gently withdrawn and the site of entry sealed with a surgical sponge for 1 min to prevent the air from escaping. In all the eyes, a complete air fill of the anterior chamber was targeted, and a supine position was maintained for 15–20 min. In case of inferior DMDs, a full chamber air-fill was maintained. A controlled release of air was attempted at 4 h postoperatively if the patient had the signs and symptoms of pupillary block. In the remaining cases, a partial, controlled release of air was performed intra-operatively to maintain an air fill of approximately two-thirds of the anterior chamber [Figure 2]. One drop of tropicamide (0.8%) and phenylephrine (2.5%) was instilled in all cases to prevent pupillary block in the immediate postoperative period. Patients with inferior DMDs and/or nonplanar DMDs underwent additional full-thickness suturing with 10-0 monofilament nylon. These mattress sutures were placed tangential to the limbus, in the mid-periphery, avoiding the visual axis, so that the detached DM would be opposed. The sutures were directed from the attached to the detached DM. The knots were buried and were removed after a month [Figure 3]. All patients were prescribed topical prednisolone acetate (1%) in tapering doses and Gatifloxacin (0.3%) q6h along with sodium chloride 5% eye drops and 6% eye ointment postoperatively. They were advised to lie in a supine position for 4 h postoperatively.
|Figure 2: Slit-lamp photograph of air descemetopexy without suture augmentation, 12 h post-procedure|
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|Figure 3: Slit-lamp photograph of air descemetopexy with suture augmentation, 12 h post-procedure|
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All patients were followed-up on days 1, 7, and 30 postdescemetopexy. The visual acuity was noted in each follow-up visit by Snellen's distance visual acuity chart. A slit-lamp examination was done to evaluate the status of the DMD at every visit. A slit-lamp photograph was taken, and an AS-OCT was done in each visit to confirm the clinical findings. If there was a detached DM at 1 week postdescemetopexy the patient was taken up for a repeat procedure.
In this study, success was defined as a complete reattachment of the DM as well as improvement in visual acuity by at least two Snellen lines and failure as a persistent DMD either partial or complete.
All patients were recruited after obtaining a proper informed consent. Clearance was obtained from the Institutional Review Board, and the study was carried out in accordance with the tenets of the declaration of Helsinki.
All statistical analyses were performed by STATA 11.1 (StataCorp, Texas, USA). Mean (standard deviation) or frequency (percentage) was used to describe the summary data. Wilcoxon signed-rank test was used to test the mean difference between logMAR visual acuity values pre- and post-operative. Other ocular parameters were compared using the Chi-square test and Fischer's exact test. P < 0.05 was considered as statistically significant.
| Results|| |
During the study period, 51 cases underwent postoperative DM reposition for visually significant DMD out of a total of 52,396 cataract surgeries (37,475 by consultants and 14,921 by trainees – postgraduate students and fellows). None of the patients refused a second surgical intervention.
A DMD had been noted intraoperatively in 19 cases. They were noted during the following steps - anterior chamber entry (n = 2), nucleus prolapse (n = 2), nucleus delivery (n = 10), epinucleus removal (n = 2), and cortex wash (n = 3). A successful primary descemetopexy was performed in all these cases in the same sitting. These cases have been excluded from our study and analyses.
The mean age of the participants was 66.67 ± 9.8 years (range = 45–85) with a male-to-female ratio of 6:11. The primary surgery preceding DMD was small incision cataract surgery (SICS) in 68.6% (n = 35), phacoemulsification in 29.4% (n = 15), and extracapsular cataract extraction (ECCE) in 1.9% (n = 1). The incidence of DMD for consultants was 0.08% (n = 29) and that for trainees was 0.15% (n = 22). This difference was statistically significant (P-value = 0.02). There was no correlation between the surgeon's experience and the final postdescemetopexy visual acuity (ρ = 0.073, P = 0.611).
[Figure 4] shows the site of origin of DMD in the various study participants. For both phacoemulsification and SICS, the most common site of DMD was the side port (n = 10 and 19 respectively). [Figure 5] shows the distribution and severity of DMDs in our study participants according to the Mackool classification. In case of both planar and nonplanar detachments, localized peripheral involvement was more commonly seen (n = 19 and n = 21, respectively). Extensive DMDs involving both the center and the periphery were rare, and these were frequently nonplanar (n = 8). In our study, descemetopexy was performed within a week in 41.2% (n = 21) cases and within 2 weeks in 86.3% (n = 44) cases. Only 13.7% (n = 7) of the cases underwent a descemetopexy after 2 weeks. The average time period between cataract surgery and descemetopexy was 9.3 ± 7.9 days (range 1–37 days). After an air tamponade, an additional suture (s) was placed in 62.8% (n = 32) cases out of which 23 cases needed a single suture (71.9%), seven cases needed two sutures (21.9%), and two cases needed three sutures (6.2%). None of the cases developed a secondary glaucoma post-descemetopexy.
|Figure 4: Bar diagram summarizing the site of Descemet's membrane detachment in the different surgical procedures included in our study. SICS: Small incision cataract surgery; ECCE: Extracapsular cataract extraction|
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|Figure 5: Bar diagram summarizing the extent and severity of Descemet's membrane detachment according to the Mackool classification. Planar Descemet's membrane detachment = Descemet's membrane separation <1 mm; Nonplanar Descemet's membrane detachment = Descemet's membrane separation >1 mm|
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The mean predescemetopexy visual acuity was 1.01 ± 0.6 which improved to 0.44 ± 0.49 at 1 month post-descemetopexy, the difference being statistically significant (P-value < 0.00001). The mean pre-descemetopexy visual acuity for patients who did not need a suture AD was 1.01 ± 0.48 while those that needed a suture AD was 1.07 ± 0.77 (P = 0.45). At 1 month post-descemetopexy, the visual acuities in the two groups were 0.36 ± 0.31 and 0.46 ± 0.63, respectively. There was no statistically significant difference in the visual outcomes between the two procedures (P = 0.97).
The improvement in visual acuity was ≥2 Snellen lines in 92.2% cases (n = 47). For participants who underwent descemetopexy within 1 week of the primary procedure, the mean pre- and post-descemetopexy logMAR visual acuities were 1.31 ± 0.79 and 0.54 ± 0.73, respectively. For those who underwent descemetopexy between 1 and 2 weeks of their initial cataract surgeries, the mean pre-descemetopexy visual acuity was 0.92 ± 0.56 logMAR which improved to 0.31 ± 0.29 logMAR after descemetopexy. In case of patients who underwent descemetopexy after 2 weeks of the initial procedure, the mean pre-descemetopexy acuity was 0.69 ± 0.38 logMAR and the mean postprocedure acuity was 0.43 ± 0.38. The improvement in visual acuity post-descemetopexy was statistically significant irrespective of the timing of surgery (P < 0.001 for all surgeries performed within 2 weeks and P = 0.03 for surgeries performed later).
A successful descemetopexy was achieved in 92.2% (n = 47) in the first attempt. In four cases (7.8%), the initial procedure was unsuccessful and a repeat descemetopexy had to be performed. Two of them had a mature cataract, and the remaining had brown cataracts. In all these cases, SICS with posterior chamber intraocular lens implantation had been done as the initial surgery. In one of the mature cataract cases, the pre-descemetopexy visual acuity was 2.3 logMAR which stayed the same even after the intervention. He had already received two primary mattress sutures, but this had failed to reattach the DM completely. The old sutures were supplemented with an additional transcorneal suture. After the second attempt, the DM attached, but the visual acuity improved only to 1.3 logMAR because of a preexisting glaucomatous optic atrophy.
In the other three cases, the pre-descemetopexy visual acuities were 1.78, 1 and 0.6 logMAR which became 1.78, 0.78, and 1 logMAR, respectively after the failed descemetopexy. In these cases, only an air descemetopexy had been done initially and during the repeat procedure transcorneal sutures were placed. However, they ended up with persistent corneal edema due to endothelial decompensation after the repeat procedure. Out of these three cases, one underwent a Descemet stripping endothelial keratoplasty. The other two patients were unwilling to undergo the same due to senility with a satisfactory vision in the fellow eye and were lost to follow-up.
| Discussion|| |
An iatrogenic DMD is a rare complication and may occur in a cataract surgery during intraocular lens implantation, irrigation/aspiration or by an improper viscoelastic cannula placement through the side-port incision.
In the presence of corneal edema, it is often impossible to make a diagnosis of DMD on slit-lamp biomicroscopy. In addition, it is difficult to determine its configuration (planar or scrolled) and location, which are vital for planning the surgical technique. Hence, in all cases, an AS-OCT should be done to confirm the diagnosis.,,
Waiting for spontaneous reattachment of a DMD has its own advantages., With watchful waiting, there is a lesser risk of infection or further damage to an already compromised corneal endothelium. Moreover, because of poor visualization of the DMD through the edematous cornea, it can be technically difficult to repair. However, in patients with DMD involving the visual axis, surgical intervention to promote reattachment is the preferred approach. An early intervention is perhaps better as a prolonged DMD can result in corneal opacification with fibrosis and wrinkling of the DM, thereby affecting visual recovery., The strategies for the management of a DMD include manual unscrolling, suturing, or gas tamponade.
This study was done to analyze the outcomes of DMD postcataract surgery managed by air descemetopexy with or without a suture augmentation. Among all the causes of postcataract surgery DMD, SICS was the most important contributor in our study. This is similar to the reports of Chaurasia et al., Jain et al., Odayappan et al. and Das et al. Odayappan et al., found that ECCE was the most common contributor for a DMD (0.26%) followed by SICS (0.11%). This disparity can be attributed to the difference in the sheer number of surgeries performed in each group (ECCE = 1559, SICS = 85,311). They performed a Fisher's exact test between the two groups and found that the difference was not statistically significant (P = 0.106). In the treatise by Garg et al., phacoemulsification was found to be the most common cause for postcataract surgery DMD. This is perhaps because phacoemulsification was the most commonly performed mode of cataract surgery in the study population described by Garg et al.
There was a statistically larger incidence of DMD among trainees (0.15%) when compared to consultants (0.08%) (P = 0.02 by Chi-square test). This corresponds to the findings of Odayappan et al., who found a similar disparity. (0.17% for trainees versus 0.07% for consultants).
In our study, irrespective of the timing of surgery, descemetopexy was associated with a statistically significant improvement of visual acuity in 92.2% cases. This corresponds to the report by Odayappan et al. where 92.3% cases achieved an improvement one Snellen line after a successful primary descemetopexy. Similarly, in the study by Das et al., a successful functional outcome was achieved in 85% cases. In contrast, Garg et al. reported an improvement of 2 lines or more (Snellen's chart) in only 74.63% cases. This glaring disparity is perhaps because they had to perform a descemetopexy after a month of the primary procedure in 19 cases, while in our study, only two cases underwent a descemetopexy after a month. A review of literature revealed that a shorter interval between the primary procedure and the reattachment procedure is associated with a significantly greater likelihood of reattachment and in turn a significant improvement of visual acuity.
All our patients were treated by air descemetopexy. Some of our patients had to receive a suture augmentation, but this did not affect the final visual outcome. Four cases did not show an improvement in visual acuity. This was due to the persistence of corneal edema in three of our cases and glaucomatous optic atrophy in one. In other contemporary studies, failure of improvement of visual acuity postprocedure has been attributed to persistent corneal edema, visually significant corneal scarring, posterior capsular plaques, cystoid macular edema, and spheroidal degeneration.
Four cases required a repeat descemetopexy procedure. Air descemetopexy with suture may be associated with DM tenting and worsening of a DMD as the leading edge is not fixed. This was perhaps the cause for failure in at least one of our cases. Patient-specific predisposition and poor endothelial counts could have been the other important factors for the failure of primary descemetopexy.,, This might be a major contributor in the remaining three of our study subjects, all of whom went into corneal decompensation after the repeat procedure.
The major limitations of our study were a short follow-up period and a lack of pachymetric and specular microscopic data. A specular microscopy, before and after the intervention, would have given us a fair idea about the effect of DMD and its repair on the endothelium. It would also have helped us validate the theory that poor endothelial cell counts are associated with an increased risk of DMD and a failure of descemetopexy. Pachymetry in each case would have given us a clue about the relationship between corneal thickness and resolution of DMD. Finally, a follow-up period of 1 month is insufficient to determine the long-term success of the procedure.
| Conclusion|| |
To conclude, air descemetopexy with or without suture augmentation for DMD postcataract surgery led to a successful DM reposition and improvement in visual acuity in a majority of our cases. There was a greater risk of undergoing multiple attempts of DM reposition post-descemetopexy if the DMD was nonplanar. In our study, we could not find a correlation between the interim period of waiting after cataract surgery and the success of air descemetopexy.
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Conflicts of interest
There are no conflicts of interest.
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