Journal of Pediatric Ophthalmology and Strabismus

Images in Pediatric Ophthalmology 

A Membrane in the Eye

Shikha Gupta, MD; Kishan Azmira, MD; Viney Gupta, MD

Abstract

A 40-year-old woman, who underwent surgery for glaucoma in both eyes at age 1 year, presented with a membrane in her right eye. Her left eye was prosthetic following phthisis. Her right eye had a visual acuity of 6/24 and an intraocular pressure of 16 mm Hg. The overlying cornea was clear and the crystalline lens appeared normal. The pupil was 9 mm in diameter with atrophic iris stroma. She also had evidence of hypertelorism, flat midfacies, and oligodentia. Based on those characteristics and her ocular features, she was diagnosed as having Axenfield-Reiger syndrome. On slit-lamp biomicroscopy, a glassy membrane partially folded on itself arising from the corneal endothelium between the 10- and 2-o'clock positions, aligned vertically, and could be seen floating in the anterior chamber (Figure 1A). On high-definition anterior segment optical coherence tomography, the membrane was found to be attached to corneal endothelium centrally and superotemporally (Figure 1B). The intervening corneal endothelium between the two points of attachment showed mild irregularities and focal excrescences (arrowhead). The nature of this membrane was difficult to ascertain because the left eye was not available to provide diagnostic clues. Iridocorneal adhesions, as seen in Peter's anomaly, seemed unlikely because there was no overlying corneal opacity. The surgery for congenital glaucoma was a combined trabeculectomy with trabeculotomy, during which the detachment of Descemets's membrane may have occurred accidentally when rotating Harm's trabeculotome anterior to Schlemm's canal. Milder forms of descemetolysis are known to occur in approximately 8% of eyes undergoing trabeculotomy with a metallic probe.1 In an adult cornea, the detachment of Descemet's membrane to such a large extent would result in corneal decompensation.2 However, overlying corneal clarity despite the large Descemet's membrane detachment could possibly be due to the regeneration of endothelium in young individuals.3 No intervention was planned because stripping off the membrane could have led to further disinsertion of Descemet's membrane and possible corneal decompensation.4

A 40-year-old woman, who underwent surgery for glaucoma in both eyes at age 1 year, presented with a membrane in her right eye. Her left eye was prosthetic following phthisis. Her right eye had a visual acuity of 6/24 and an intraocular pressure of 16 mm Hg. The overlying cornea was clear and the crystalline lens appeared normal. The pupil was 9 mm in diameter with atrophic iris stroma. She also had evidence of hypertelorism, flat midfacies, and oligodentia. Based on those characteristics and her ocular features, she was diagnosed as having Axenfield-Reiger syndrome. On slit-lamp biomicroscopy, a glassy membrane partially folded on itself arising from the corneal endothelium between the 10- and 2-o'clock positions, aligned vertically, and could be seen floating in the anterior chamber (Figure 1A). On high-definition anterior segment optical coherence tomography, the membrane was found to be attached to corneal endothelium centrally and superotemporally (Figure 1B). The intervening corneal endothelium between the two points of attachment showed mild irregularities and focal excrescences (arrowhead). The nature of this membrane was difficult to ascertain because the left eye was not available to provide diagnostic clues. Iridocorneal adhesions, as seen in Peter's anomaly, seemed unlikely because there was no overlying corneal opacity. The surgery for congenital glaucoma was a combined trabeculectomy with trabeculotomy, during which the detachment of Descemets's membrane may have occurred accidentally when rotating Harm's trabeculotome anterior to Schlemm's canal. Milder forms of descemetolysis are known to occur in approximately 8% of eyes undergoing trabeculotomy with a metallic probe.1 In an adult cornea, the detachment of Descemet's membrane to such a large extent would result in corneal decompensation.2 However, overlying corneal clarity despite the large Descemet's membrane detachment could possibly be due to the regeneration of endothelium in young individuals.3 No intervention was planned because stripping off the membrane could have led to further disinsertion of Descemet's membrane and possible corneal decompensation.4

References

  1. Hoffmann E, Schwenn O, Karallus M, Krummenauer F, Grehn F, Pfeiffer N. Long-term results of cataract surgery combined with trabeculotomy. Graefes Arch Clin Exp Ophthalmol. 2002;240:2–6. doi:10.1007/s004170100337 [CrossRef]
  2. Jacob S, Agarwal A, Chaudhry P, Narasimhan S, Chaudhry VN. A new clinico-tomographic classification and management algorithm for Descemet's membrane detachment. Cont Lens Anterior Eye. 2015;38:327–333. doi:10.1016/j.clae.2015.03.012 [CrossRef]
  3. Chaurasia S, Ramappa M, Rao HL. Descemet membrane detachment in a child with anterior megalophthalmos managed using intracameral perflouropropane (C3F8) gas injection. Cornea. 2015;34:1516–1518. doi:10.1097/ICO.0000000000000618 [CrossRef]
  4. Haab O. Die Lageveränderungen der Linse. Atlas der Äusseren Erkrankungen des Auges: Nebst Grundriss ihrer Pathologie und Therapie. München, Deutschland: J. F. Lehmann; 1899:210–213.
Authors

From Glaucoma Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Shikha Gupta, MD, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029 India. E-mail: dr.shikhagupta84@gmail.com

10.3928/01913913-20190405-01

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