Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Intracameral Perfluoropropane (C3F8) Gas in the Repair of Extensive Descemet’s Membrane Detachment During Phacoemulsification Surgery

Tugrul Akin, MD; Ali Ayata, MD; Umit Aykan, MD; Ahmet Hamdi Bilge, MD

Abstract

Descemet’s membrane detachment (DMD) is one of the rare complications seen during or after cataract surgery. It can cause permanent corneal decompensation if untreated or not reattached spontaneously. A patient with an extensive DMD (involving approximately upper two-thirds of the cornea) during uncomplicated phacoemulsification surgery is reported. After the aspiration of cortical remnants, Descemet’s membrane was detached progressively from the clear corneal incision. Descemet’s membrane was reattached at the end of the procedure using an air bubble injection. However, DMD was observed again the day after surgery. It was successfully treated with intracameral injection of 0.2 mL volume of 14% perfluoropropane (C3F8) gas with resultant immediate resolution of his corneal edema. It is believed that early surgical intervention (if possible intraoperatively) with intracameral injection of 14% isoexpansile mixture of C3F8 is a safe and efficient treatment modality for DMD. Appropriate and prompt management may prevent the complications and visual loss.

Abstract

Descemet’s membrane detachment (DMD) is one of the rare complications seen during or after cataract surgery. It can cause permanent corneal decompensation if untreated or not reattached spontaneously. A patient with an extensive DMD (involving approximately upper two-thirds of the cornea) during uncomplicated phacoemulsification surgery is reported. After the aspiration of cortical remnants, Descemet’s membrane was detached progressively from the clear corneal incision. Descemet’s membrane was reattached at the end of the procedure using an air bubble injection. However, DMD was observed again the day after surgery. It was successfully treated with intracameral injection of 0.2 mL volume of 14% perfluoropropane (C3F8) gas with resultant immediate resolution of his corneal edema. It is believed that early surgical intervention (if possible intraoperatively) with intracameral injection of 14% isoexpansile mixture of C3F8 is a safe and efficient treatment modality for DMD. Appropriate and prompt management may prevent the complications and visual loss.

Intracameral Perfluoropropane (C3F8) Gas in the Repair of Extensive Descemet’s Membrane Detachment During Phacoemulsification Surgery

From the University of Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Ophthalmology, Istanbul, Turkey.

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

Address correspondence to Tugrul Akin, GATA Haydarpasa Egitim Hastanesi, Goz Hastaliklari Servisi, Tibbiye Caddesi, Uskudar, 34668, Istanbul, Turkey.

Accepted: December 16, 2008
Posted Online: March 09, 2010

Introduction

Descemet’s membrane detachment (DMD) is one of the rare but potentially serious complications seen after cataract surgery.1,2 It can occur both intraoperatively and postoperatively. Small DMDs typically resolve with topical medical therapy; however, larger detachments require surgical intervention and must be treated as soon as possible.3 Early recognition and repair of DMD may prevent complications such as permanent corneal decompensation, corneal edema and opacities, and an overall decline in visual acuity.4

In this case, we report a patient with an extensive DMD during uncomplicated small incision phacoemulsification surgery with foldable intraocular lens implantation that was successfully treated with intracameral injection of 14% isoexpansile mixture of perfluoropropane (C3F8) gas with resultant immediate resolution of his corneal edema.

Case Report

An 80-year-old man was admitted with a dense nuclear cataract in the right eye. The visual acuity was hand movements unaided in the right eye. He was listed for cataract surgery as a day case. He underwent routine phacoemulsification surgery under sub-Tenon anesthesia. He had clear corneal incision at the 11-o’clock position and two paracenteses at the 3- and 9-o’clock positions. Divide and conquer phacoemulsification technique was performed. After the aspiration of cortical remnants, the Descemet’s membrane started to detach from the main incision and the detachment progressed during the surgery. Hyaluronate 3.0% (Vitrax II; AMO, Abbott Park, IL) was used as a viscoelastic material to reattach the DMD. After implantation of a foldable intraocular lens, the corneal incision was closed with one 10-0 nylon monofilament suture. DMD was reattached using an air bubble injection at the end of the procedure.

On the first postoperative day, his visual acuity was counting fingers at 1 meter unaided. The Descemet’s membrane was detached involving the upper two-thirds of the cornea and the anterior chamber details could be seen despite a mild corneal edema. intraocular pressure (IOP) was 11 mm Hg in the right eye. The air bubble was seen in the superior part of the anterior chamber. Dexamethasone and fluoroquinolone drops were used on a hourly basis.

The visual acuity and corneal edema deteriorated 2 days after surgery. DMD was still involving approximately two-thirds of the cornea (Fig. 1).

Three Days after Surgery, a Slit Lamp View of the Right Eye shows an Extensive Corneal Edema and the Detachment of the Descemet’s Membrane.

Figure 1. Three Days after Surgery, a Slit Lamp View of the Right Eye shows an Extensive Corneal Edema and the Detachment of the Descemet’s Membrane.

Finally, we decided to treat DMD using an anterior chamber tamponade of 0.2 mL 14% C3F8 gas. The injection procedure was uneventful. To prevent the development of pupillary block by the gas bubble, the patient was asked to keep a postoperative face-up position for 1 week and was administered 500 mg of acetazolamide that evening. The following day, the corneal epithelial edema had cleared and the Descemet’s membrane appeared to have reattached completely (Fig. 2). The IOP was measured as 29 mm Hg and acetazolamide treatment was continued to control IOP. The patient was instructed to maintain a strict face-up position.

Three Days after Intracameral C3F8 Gas Injection, Slit Lamp View shows a Clear Cornea and a Bubble.

Figure 2. Three Days after Intracameral C3F8 Gas Injection, Slit Lamp View shows a Clear Cornea and a Bubble.

Twenty-one days after the injection, the gas bubble disappeared completely. His right visual acuity was 20/32 (20/25 with correction). The Descemet’s membrane remained attached and the cornea was clear. The IOP was 14 mm Hg in the right eye (Fig. 3).

Three Weeks after the C3F8 Gas Injection.

Figure 3. Three Weeks after the C3F8 Gas Injection.

Discussion

DMD is one of the complications seen after cataract surgery.1,2 In the literature, there are some reports either suggesting a surgical intervention for large detachments5 or recommending a repair of large DMD that should be recognized intraoperatively and treated using an expanding gas.3,5,6 DMD incidence was reported as 2.6% for extracapsular cataract surgery and 0.5% for phacoemulsification.7 Most of the detachments are small and resolve quickly within time, but larger detachments are more serious and and may cause persistent corneal edema, corneal decompensation, and scarring that can cause severe vision loss. Early recognition and appropriate management is the key to favorable outcome. DMD can occur both intraoperatively and postoperatively, and large detachments must be treated surgically as soon as possible since early recovery is difficult in these cases. Descemet’s membrane is so thin and delicate in some patients that it must be recognized by the surgeon carefully during the operation as soon as it is detached. Otherwise, it can be peeled totally by the phacoemulsification tip. Early recognition of detachment and meticulous surgical intervention may prevent further enlargement of tear and keep it from being damaged by the phacoemulsification tip. Large DMD is one of the important causes of postoperative persistent corneal edema after cataract surgery. Thin Descemet’s membranes cannot be differentiated in cases of severe corneal edema that prevents the visualization of details of the anterior chamber, so the surgeon needs to be aware of this complication. Longer clear corneal tunnel incisions, and surgical trauma by the phacoemulsification probe and other surgical instruments during entrance to the anterior chamber are predisposing factors for DMD development. But we believe that the anatomical predisposition is most important of all.

In this case, the patient underwent routine, small-incision phacoemulsification cataract surgery with foldable intraocular lens implantation and developed spontaneous and extensive DMD intraoperatively during the cleaning of cortical material. The DMD appeared to be progressive during the surgery. The signs of the detachment were remarkable and the examination was made easily because of minimal corneal edema permitting the details of the anterior chamber to be seen well. Detached Descemet’s membrane was reattached by using viscoelastic material and foldable intraocular lens implanted into the capsular bag with extreme caution. After aspiration of viscoelastic material, an air was injected into the anterior chamber and Descemet’s membrane was reattached by an anterior chamber full of air.

Air injection is not an efficient surgical approach in the treatment of DMD because resorption of air is fast and the half-life is too short, and therefore the tamponade effect is not long enough for Descemet’s membrane reattachment. The residual hyaluronate 3.0% in the interface may also prevent reattachment. In this case, repeating air injection after the clearance of viscoelastic material would have achieved the same result with less potential for endothelial cell loss. After resorption of air bubble injected into the anterior chamber, the reattached Descemet’s membrane detached again. Then, we used 14% isoexpansile mixture of C3F8 gas injection with a longer half-life and a better tamponade effect than air into the anterior chamber. At the end of 2 weeks postoperatively, DMD was successfully reattached and corneal edema resolved completely.

Intracameral injection of 20% isoexpansile mixture of sulphurhexafluoride (SF6) is another choice of treatment,8,9 but its half-life is shorter than that of 14% isoexpansile mixture of C3F8 gas and resorption is faster. Mannan et al. report that for the treatment of DMD after cataract surgery in an operated case of deep anterior lamellar keratoplasty, the 14% isoexpansile mixture of C3F8 gas is effective.10

DMD is a rare, unexpected complication of phacoemulsification even in an uncomplicated surgery. Appropriate and prompt management may prevent visual loss for the patient. Early surgical intervention (if possible intraoperatively) with intracameral injection of 14% isoexpansile mixture of C3F8 gas is a safe and efficient treatment modality.

References

  1. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane detachment during phacoemulsification surgery. Br J Ophthalmol. 1996;80:185–186. doi:10.1136/bjo.80.2.185 [CrossRef]
  2. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of Descemet’s membrane detachment. J Cataract Refract Surg. 1995;21:714–717.
  3. Vastine DW, Weinberg RS, Sugar J, Binder PS. Stripping of Descemet’s membrane associated with intraocular lens implantation. Arch Ophthalmol. 1983;101:1042–1045.
  4. Macsai MS, Gainer KM, Chisholm L. Repair of Descemet’s membrane detachment with perfluoropropane (C3F8). Cornea. 1998;17:129–134. doi:10.1097/00003226-199803000-00002 [CrossRef]
  5. Potter J, Zalatimo N. Descemet’s membrane detachment after cataract extraction. Optometry. 2005;76:720–724.
  6. Walland MJ, Stevens JD, Steele AD. Repair of Descemet’s membrane detachment after intraocular surgery. J Cataract Refract Surg. 1995;21: 250–253.
  7. Kansal S, Sugar J. Consecutive Descemet membrane detachment after successive phacoemulsification. Cornea. 2001;20:670–671. doi:10.1097/00003226-200108000-00025 [CrossRef]
  8. Gault JA, Raber IM. Repair of Descemet’s membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;15:483–489. doi:10.1097/00003226-199609000-00008 [CrossRef]
  9. Ellis DR, Cohen KL. Sulfur hexafluoride gas in the repair of Descemet’s membrane detachment. Cornea. 1995;14:436–437. doi:10.1097/00003226-199507000-00014 [CrossRef]
  10. Mannan R, Jhanji V, Sharma N, Titiyal JS, Vaipayee RB. Intracameral C(3)F(8) injection for descemet membrane detachment after phacoemulsification in deep anterior lamellar keratoplasty. Cornea. 2007;26:636–638.
Authors

From the University of Gulhane Military Medical Academy, Haydarpasa Training Hospital, Department of Ophthalmology, Istanbul, Turkey.

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

Address correspondence to Tugrul Akin, GATA Haydarpasa Egitim Hastanesi, Goz Hastaliklari Servisi, Tibbiye Caddesi, Uskudar, 34668, Istanbul, Turkey.

10.3928/15428877-20100215-01

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