Descemet membrane detachment caused by inadvertent introduction of an ophthalmic viscosurgical device (OVD) to the pre-Descemet space is a known complication of various intraocular surgeries. Specifically, Descemet membrane detachment resulting from OVD injection has been described after phacoemulsification,1 trabeculectomy,2 and viscocanalostomy.3 At present, there is no consensus on how to manage these cases. Documented management techniques range from observation to performing corneal transplantation and depend on the corneal endothelium status, the location and extent of the detachment, and the lack or presence of a Descemet tear.
We report a case of Descemet membrane detachment caused by accidental injection of an OVD with high viscosity and a high concentration of sodium hyaluronate (2.3%) (Healon5) into the pre-Descemet space. This was done in an attempt to reform the anterior chamber following hypotony after a mini glaucoma shunt (Ex-Press, Alcon Laboratories, Inc.) procedure.
A 74-year-old man with uncontrolled unilateral pseudoexfoliation glaucoma in the right eye was referred to our tertiary referral hospital for evaluation. The patient's ocular history included uneventful cataract extraction with posterior chamber intraocular lens (IOL) implantation in the right eye 6 years before his presentation. On examination, the corrected visual acuity (CDVA) was 6/9 in both eyes. Goldmann intraocular pressure (IOP) measured 26 mm Hg and cup-to-disc ratio was 0.8 in the right eye. The patient's left-eye examination was unremarkable except for a dense nuclear cataract. Despite topical and systemic medical treatment, the IOP remained high and the visual fields deteriorated. The patient had mini glaucoma shunt implantation without intraoperative complications.
On the third postoperative day, flattening of the anterior chamber was observed and the patient's IOP measured 14 mm Hg. On slitlamp examination, the bleb was normal and no leakage was detected. There was no iris–cornea touch. B-mode ultrasonography did not show choroidal detachment. An attempt was made to reform the anterior chamber with an intracameral injection of high-viscosity sodium hyaluronate 2.3% using the slitlamp. Immediately after injection, the anterior chamber deepened but a marked stromal opacity was observed, extending from the site of the injection to the center of the cornea. It was apparent that a substantial amount of OVD had been inadvertently injected to the corneal stroma and pre-Descemet space, resulting in Descemet membrane detachment. Direct contact between the IOL and the corneal endothelium was observed. As a result, the patient's CDVA dropped dramatically to counting fingers at 3 m. A careful slitlamp examination by a cornea specialist confirmed the findings.
The patient was taken promptly to the operating room in an attempt to drain the intracorneal OVD. An OVD was injected into the anterior chamber to keep the corneal endothelium away from the IOL and to create a compression effect on the Descemet membrane detachment site. Two paracenteses were also made in the pre-Descemet space at the site of the Descemet membrane detachment. A balanced salt solution maintainer was connected to 1 incision while the external corneal surface was gently tapped using a blunt spatula to drain the OVD from the opposite corneal incision. Next, stromal separation and suction of the OVD from the pre-Descemet space were performed with a 5 cc syringe connected to a 19-gauge cannula. Using these methods, the corneal endothelium could be separated from the IOL; however, the OVD could not be completely drained. At the end of the procedure, to protect the corneal endothelium, a large air bubble was injected into the anterior chamber.
On the following day, the patient's CDVA improved to 6/60 and the IOP was 9 mm Hg; however, a marked stromal opacity remained. Significant anterior chamber flattening was detected, with only a small air bubble separating the IOL from the corneal endothelium. An OVD was carefully injected into the anterior chamber without complications. Nine days postoperatively, the patient had anterior segment optical coherence tomography (AS-OCT) (HS-100, Canon, Inc.) that showed diffuse Descemet membrane detachment with a maximum height of 850 μm and without a tear of Descemet membrane (Figure 1, A). On ultrasound pachymetry, the central corneal thickness (CCT) in the injured right eye, excluding the detached Descemet membrane and endothelium, was 550 μm. This was not significantly different from the CCT in the undamaged left eye (560 μm). Because of the substantial intracorneal OVD residue and fear of corneal damage, another attempt was made to surgically remove some of the OVD 13 days postoperatively using the same methods described above. Once again, only a small amount was evacuated from the OVD pocket.
The patient was followed regularly in our outpatient clinic. Gradually, the Descemet membrane detachment became smaller, the cornea became clearer (Figure 1), and the CDVA improved. The corneal endothelial cell count (ECC) in the left eye was 2278 cells/mm2; however, because of the significant Descemet membrane detachment in the damaged right eye, it was not possible to obtain reliable results during the first few visits. Four months after the accidental injection of OVD, the CDVA in the patient's right eye was 6/9, the same as measured at presentation. Examination of the right eye showed that all the sodium hyaluronate had absorbed and the cornea was clear except for a mild posterior stromal haze (Figure 1, E). Specular microscopy showed the ECC at 1374 cells/mm2 in the right eye. On the last follow-up examination 2 years after the surgery accidental injection of OVD, complete resolution of the deep corneal haze was observed on slitlamp examination. This was confirmed by AS-OCT, which showed a normal corneal appearance, including a regular posterior stroma (Figure 1, G). The ECC decreased to 1133 cells/mm2 in the injured right eye and remained stable in the left eye (2011 cells/mm2).
There have been few previous reports describing extensive Descemet membrane detachment without Descemet tear after intracameral OVD injection.4–7 In all cases, sodium hyaluronate 1.0% (Healon) was involved. In 2 of the previous cases,4,5 the surgical measures taken to remove the OVD were similar to our approach and the time to complete evacuation of the OVD from the cornea was nearly identical. Wigginton et al.6 presented their positive experience with conservative management, which resulted in spontaneous resolution of the Descemet membrane detachment after 6 months. In the case reported by Pieramici et al.,7 the OVD did not evacuate from the pre-Descemet space for 7 months and penetrating keratoplasty was performed. To our knowledge, our case is the first to report a central Descemet membrane detachment after intracameral injection of high-viscosity sodium hyaluronate 2.3%. Moreover, this is the first case in which contact between an IOL and corneal endothelium occurred in this setup.
Because of the close contact between the endothelium and the IOL, it was believed that all endothelial cells at this site had been compromised, thus necessitating immediate surgical intervention. In addition, because the viscosity of Healon5 is more than 20-fold greater than that of Healon and its hyaluronic acid concertation more than 2-fold higher, we believed that spontaneous resorption of the OVD was unlikely to occur. In 2 surgical interventions to aspirate the OVD, we were successful in separating the IOL–endothelium contact; however, some of the material unfortunately remained in the Descemet membrane detachment space. In retrospect, we realized that the OVD can be absorbed spontaneously without damaging the cornea while evacuating.
Similar to the cases noted above, our patient's cornea did not become clinically edematous and remained clear both during the Descemet membrane detachment and after Descemet membrane reattachment. This was evidenced by ultrasound pachymetry and AS-OCT (Figure 1). The normal CCT during the Descemet membrane detachment could be explained by the relative isoosmolarity of the OVD in the Descemet membrane detachment pocket.8 In this unique setup, stromal dehydration could theoretically be maintained, even if the corneal endothelium were compromised during the accidental injection of OVD, at least before significant hyaluronic acid degradation. The normal CCT after the resolution of the Descemet membrane detachment and the sufficient endothelial cell number and function indicate that the corneal endothelium was not completely compromised as a result of the accidental injection of OVD. We believe that a thin Healon5 layer separated the corneal endothelium from the anterior IOL surface, minimizing the expected endothelial cell damage at the time of the endothelial–IOL contact.
After resolution of the Descemet membrane detachment, the posterior cornea was slightly hazy on slitlamp biomicroscopic examination and hyperreflective on AS-OCT (Figure 1, E). This observation could represent an inflammatory process in the tissues bordering the Descemet membrane detachment interface. Alternatively, this hyperreflectivity might represent a localized corneal edema rarefaction of the tissues that are in contact with the fluid interface. The corneal haziness had minimal clinical significance, with the CDVA at 6/9, which represented the patient's baseline CDVA. At the last follow-up, 2 years after the accidental injection of OVD, the haze and hyperreflectivity were no longer visible (Figure 1, G).
Hoover et al.4 described a granulocytic response followed by macrophage invasion to the involved area when they examined enucleated rabbit corneas that were injected with sodium hyaluronate into the pre-Descemet space, thus producing Descemet membrane detachment. The granulocytic response was initiated as soon as 24 hours after the injection, and granulocytes were identified within the OVD bleb and the stromal fibers. Macrophage invasion was noted 5 days, 9 days, and 14 days after the injection and appeared in the OVD pocket as well as in the corneal stroma. These findings could explain our observation of the hyperreflective posterior stroma that, as stated above, could represent an inflammatory process. In addition, similar to our case, it has been shown that the AS-OCT hyperreflectivity of the interface found early after laser in situ keratomileusis disappears 6 months later.9 This observation might represent similar processes occurring in the stromal interface after Descemet membrane detachment.
Our case shows that aside from preventing corneal endothelium–IOL touch, surgical intervention might not be necessary in mild to moderate cases of sodium hyaluronate–associated Descemet membrane detachment and that a conservative approach could be considered.
None of the authors has a financial or proprietary interest in any material or method mentioned.
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