Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Descemet’s Membrane Detachment Caused by the Improper Injection of Sodium Hyaluronate

David Mostafavi, MD; Guojin Zhang, PhD; Richard Mendelsohn, PhD; David S. Chu, MD

Abstract

A case of a Descemet’s membrane detachment (DMD) caused by the inadvertent intracorneal injection of sodium hyaluronate was presented. This was concluded after chemical analysis of a viscous substance found in a patient’s cornea showed to be a breakdown product of sodium hyaluronate. Surgical correction of the detachment included removing the viscous substance and tamponading the detachment with an air bubble. Although other gases such as sulfur hexafluoride (SF6) provide longer means of tamponade, they have increased postoperative risks like glaucoma associated with their use. Air can provide an effective means of tamponade with minimal postoperative risks.

Abstract

A case of a Descemet’s membrane detachment (DMD) caused by the inadvertent intracorneal injection of sodium hyaluronate was presented. This was concluded after chemical analysis of a viscous substance found in a patient’s cornea showed to be a breakdown product of sodium hyaluronate. Surgical correction of the detachment included removing the viscous substance and tamponading the detachment with an air bubble. Although other gases such as sulfur hexafluoride (SF6) provide longer means of tamponade, they have increased postoperative risks like glaucoma associated with their use. Air can provide an effective means of tamponade with minimal postoperative risks.

Descemet’s Membrane Detachment Caused by the Improper Injection of Sodium Hyaluronate

From the University of Medicine and Dentistry of New Jersey, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey.

Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York.

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

Address correspondence to David Chu, MD, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Doctors Office Center Bldg., 6th Floor, P. O. Box 1709, Newark, NJ 07101-1709.

Accepted: July 22, 2009
Posted Online: March 09, 2010

Introduction

Descemet’s membrane detachment (DMD) is the separation of Descemet’s membrane (DM) from the corneal stroma most commonly from shear force during ocular surgeries.1 It is rare but a potentially serious complication that can lead to more serious postoperative events if not diagnosed and managed early.2 Small detachments can be managed with topical treatment; however, larger detachments require surgical involvement.1 We chronicle a case DMD caused by the inadvertent injection of sodium hyaluronate that was diagnosed 2 months after inciting event and discuss the surgical technique used for correction.

Case Report

A 19-year-old man reported to the emergency room after a nail gun injury at work. He was noted to have a perforating scleral wound. The patient underwent removal of the nail and pars plana vitrectomy. On postoperative day seven, the patient was reoperated because of extensive hyphema and vitreous hemorrhage. During the anterior chamber washout, in addition to BSS, sodium hyaluronate was used to help mobilize dense fibrinous membrane on the crystalline lens.

On postoperative week 1 from the washout, the cornea remained hazy. After unresolved corneal edema for 2 months duration, patient was consulted for evaluation by the cornea service at Institute of Ophthalmology and Visual Science New Jersey Medical School. OCT (Status version 4.0.1) was performed and showed a complete central detachment of DM with a 360° attachment with the stroma in the periphery. (Fig. 1C)

Images Delineate Extent of DMD by External, with Slit Beam, and OCT of Cornea, Respectively. (A, B) Diffuse and Slit Beam Images, Respectively, of Descemet’s Membane Detachment at Time of Presentation. (C) OCT Image Confirming DM Attachment After Surgery.

Figure 1. Images Delineate Extent of DMD by External, with Slit Beam, and OCT of Cornea, Respectively. (A, B) Diffuse and Slit Beam Images, Respectively, of Descemet’s Membane Detachment at Time of Presentation. (C) OCT Image Confirming DM Attachment After Surgery.

The patient was taken to the operating room to reattach DM. Using a blunt tipped cannula, sodium hyaluronate (Healon) and saline were injected in the anterior chamber posterior to the detached DM through another corneal incision in the far periphery forcing out a viscoelastic substance from the mid-peripheral corneal incision between the corneal layers (DM and stroma). This also helped tamponade the detached DM. The unknown viscous substance was placed on a glass slide. Air was also injected into the anterior chamber to assist in the tamponade of the DM and occupied approximately 40% of the anterior chamber volume at the conclusion of the case, as usually performed during Descemet’s Stripping Endothelial Keratoplasty (DSEK).3 On postoperative day 1 of his third ocular surgery, the patient’s vision was 20/400 with an IOP of 12. OCT confirmed DM attachment (Fig. 2C). Patient’s DM remains attached and the cornea stayed clear 2 months postoperatively.

Images Show Post-Operation Images. Note No Detachment Is Seen on Slit Lamp or OCT. (A, B) Diffuse and Slit Beam Images, Respectively, of Cornea After Surgical Correction. (C) OCT Confirming DM Attachent After Surgery.

Figure 2. Images Show Post-Operation Images. Note No Detachment Is Seen on Slit Lamp or OCT. (A, B) Diffuse and Slit Beam Images, Respectively, of Cornea After Surgical Correction. (C) OCT Confirming DM Attachent After Surgery.

The unknown substance removed from the space between DM and corneal stroma was analyzed by the Rutgers University Newark Chemistry Department. Prior to analysis, we strongly suspected that the unknown substance to be sodium hyaluronate because it had appeared viscous in composition and was also used in the patient’s last ocular surgery. It would also explain why the DMD had occurred. Raman spectroscopy, which analyzes the characteristic vibrational frequencies of compounds, was used to compare a known compound of sodium hyaluronate (the control) with the unknown sample isolated from the patient’s cornea (Fig. 3). Three different substances were found by the chemical analysis. One of the compounds had some spectral similarities to the control compound and is suggested to be a breakdown product of sodium hyaluronate (Fig. 4).

Raman Spectroscopy, Which Analyzes the Characteristic Vibrational Frequencies of Compounds, of Sodium Hyaluronate. Notice Characteristic Vibrational Frequency at 2925 cm−1

Figure 3. Raman Spectroscopy, Which Analyzes the Characteristic Vibrational Frequencies of Compounds, of Sodium Hyaluronate. Notice Characteristic Vibrational Frequency at 2925 cm−1

Raman Spectroscopy of Unknown Sample Isolated from Patient’s Cornea. Notice Similar Vibrational Band at 2928 cm−1

Figure 4. Raman Spectroscopy of Unknown Sample Isolated from Patient’s Cornea. Notice Similar Vibrational Band at 2928 cm−1

Discussion

The unintended injection of sodium hyaluronate intracorneally can cause DMD, as chronicled by past case reports. Six of the seven cases reported in the literature were noted to have DMD within 1 week after the viscoelastic injection.4–10 Our case is unique in that sodium hyaluronate was present in the patient’s cornea for 2 months until it was suspected there was a DMD.

Spontaneous resorption of hyaluronate is possible and was reported by Hoover in 1985, however the surgical removal of sodium hyaluronate provides a faster and better outcome for DM reattachment.4 Our case showed that surgical correction of DMD is effective, even several months after the detachment. Some surgical techniques reported include manual reposition of DM or reposition with air, gas, or viscoelastic material. Many of the reported cases of DMD have been secondary to cataract surgery. The favored surgical technique in these cases have used the gases sulfur hexafluoride (SF6) and perfluoropropane (C3F8) to reposition and maintain DM due to their long staying time in the eye. Air, which lasts a few to several days in the eye, has not been popular because it has been speculated that it does not allow time for adequate attachment compared with the aforementioned gases which last several weeks in the eye.1 Although it is difficult to compare surgical techniques due to the variability of DMDs, we conclude that air can successfully reposit, tamponade, and ultimately reattach large DMDs. However, it is important to note that much of the success of using air depends on the area of detachment. In our case, DM was attached 360° in the periphery, which allowed for easier tamponade. Other surgical procedures like DSEK also use air as a tamponade tool because of its effectiveness.

Air may be a better option sometimes in DMD repair due to SF6 and C3F8’s higher complication rate, most notably increased intraocular pressure which was chronicled in Ellis’ case report using SF6.11 Fould’s study on C3F8’s effect on rabbit and cat cornea showed that it caused corneal edema due to endothelial dysfunction and Saeed concluded that these two gases caused subsequent intraocular lens haze.12,13 Although we recognize that there are many successful cases of DMD repair using gases SF6 and C3F8, especially DMDs secondary to cataract surgery, our case shows that air can be as effective with less potential risk of postoperative complications.

References

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  3. Price F, Price M. Descemet’s stripping with endothelial keratoplasty in 200 eyes: early challenges and techniques to enhance donor adherence. J Cataract Refract Surg. 2006;32:411–418. doi:10.1016/j.jcrs.2005.12.078 [CrossRef]
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  10. Ostberg A, Törnqvist G. Management of detachment of Descemet’s membrane caused by injection of hyaluronic acid. Ophthalmic Surg. 1989;20:885–886.
  11. 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]
  12. Fould GN, deJuan E, Hatchell DL. The effect of perfluoropropane on the cornea in rabbits and cat. Arch Ophthalmol. 1987;105:256–259.
  13. Saeed MU, Singh AJ, Morrell AJ. Sequential Descemet’s membrane detachment and intraocular lens haze secondary to SF6 or C3F8. Eur J Ophthalmol. 2006;16:758–760.
Authors

From the University of Medicine and Dentistry of New Jersey, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey.

Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York.

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

Address correspondence to David Chu, MD, The Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Doctors Office Center Bldg., 6th Floor, P. O. Box 1709, Newark, NJ 07101-1709.

10.3928/15428877-20100215-69

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