Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Descement’s Membrane Detachment Diagnosis Using a Very High Frequency Ultrasound Scanning System

George D. Kymionis, MD, PhD; Aimilianos A. Stratos, MD; Dimitrios I. Bouzoukis, MD; Miltiadis E. Krokidis, MD; Miltiadis K. Tsilimbaris, MD, PhD

Abstract

A 74-year-old woman was referred to our institute due to persistent corneal edema after cataract surgery. Slit-lamp examination revealed severe total corneal edema (obscuring anterior chamber and iris). Using a very high frequency (VHF) ultrasound scanning system (Artemis 2, Ultralink LLC) descement’s membrane detachment (DMD) was diagnosed. VHF ultrasound scanning system could be a useful instrument in detecting post-cataract surgery DMD especially in patients in which diagnosis is difficult due to significant corneal clouding.

Abstract

A 74-year-old woman was referred to our institute due to persistent corneal edema after cataract surgery. Slit-lamp examination revealed severe total corneal edema (obscuring anterior chamber and iris). Using a very high frequency (VHF) ultrasound scanning system (Artemis 2, Ultralink LLC) descement’s membrane detachment (DMD) was diagnosed. VHF ultrasound scanning system could be a useful instrument in detecting post-cataract surgery DMD especially in patients in which diagnosis is difficult due to significant corneal clouding.

Descement’s Membrane Detachment Diagnosis Using a Very High Frequency Ultrasound Scanning System

From the University of Institute of Vision and Optics, University of Crete, Greece.

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

Address correspondence to George D. Kymionis MD, PhD, Institute of Vision and Optics (IVO), University of Crete, Medical School, 71003 Heraklion, Crete, Greece.

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

Introduction

Descemet’s membrane detachment (DMD) can be a major postoperative complication of phacoemulsification assisted cataract surgery.1 It results in persistent corneal edema and decreased visual acuity. DMD after cataract surgery could be observed during corneal incision, viscoelastic injection, phaco probe insertion into the anterior chamber, enlargement of the wound and hydration of the incision.2 Small detachments resolve with topical medical therapy within a few weeks or months.3,4 Larger detachments usually require surgical intervention.5

The diagnosis of DMD is often uncertain in slit lamp examination due to corneal clouding. In this case report we present a patient with DMD after phacoemulsification cataract surgery diagnosed by using a VHF ultrasound scanning system (Artemis 2, Ultralink LLC).

Case Report

A 74-year-old woman underwent cataract surgery in the left eye. Phacoemulsification was performed through a two level superior clear corneal incision and two paracenteses (temporal, nasal).

Preoperatively, best corrected visual acuity (BCVA) was 20/100. The operation was uneventful. In the immediate postoperative period, persistent corneal edema was observed. Visual acuity (VA) was hand movement and intraocular pressure (IOP) was 7 mm Hg. Slit-lamp examination revealed severe corneal edema. The patient was started on dexamethasone 0,1% (Maxidex, Alcon. Laboratories, INC. Fort Worth, TX) and sodium chloride (hypertonic saline) 5% eye drops four times daily. No surgical method was performed due to the uncertain diagnosis.

An anterior segment examination was performed using a very high frequency (VHF) ultrasound scanning system (Artemis 2, Ultralink LLC) showing DMD (Fig. 1). The patient was treated with anterior chamber air tamponade using a 27-gauge cannula attached to a syringe with a filter riled under topical anesthesia. Descement’s membrane was successfully reattached and corneal edema resolved after 2 weeks.

Very High Frequency (VHF) Ultrasound Scanning System (Artemis 2, Ultralink LLC) Revealed the Detachment of the Descement’s Membrane.

Figure 1. Very High Frequency (VHF) Ultrasound Scanning System (Artemis 2, Ultralink LLC) Revealed the Detachment of the Descement’s Membrane.

Discussion

Detachment of Descemet’s membrane (DMD) can be a major postoperative complication after phacoemulsification assisted cataract surgery.1 It could be observed at any phase of the procedure including more frequently the incision itself, viscoelastic injection, introduction of phaco probe, enlargement of the wound and hydration of the incisions.2 DMD results in persistent corneal edema, which makes the diagnosis uncertain.

In this case report, we present a patient with total DMD after cataract surgery, diagnosed with a VHF ultrasound scanning system (Artemis 2, Ultralink LLC). The patient was referred for postoperative persistent corneal edema. The etiology of the corneal edema was initially identifiable due to significant corneal clouding. An anterior segment examination was performed using a VHF ultrasound scanning system (Artemis 2, Ultralink LLC) showing detachment of the Descement’s membrane (Fig. 1). The patient was treated with anterior chamber air tamponade using a 27-gauge cannula attached to a syringe with a filter riled under topical anesthesia. Descement’s membrane was successfully reattached and corneal edema resolved after 2 weeks.

VHF ultrasound scanning system (Artemis 2, Ultralink LLC) can detect subsurface fine structures and create thickness maps of each corneal layer including LASIK flaps.6 Accurate measurements of the anterior chamber depth and angle to angle or sulcus to sulcus dimension of an eye are important for correct selection of the introcular lenses (IOLs) size.7 Additional, the Artemis epithelial-thickness profile allows early recognition of keratokonic or others outer surface dystrophies undetectable in topographic systems.8 Post-LASIK complications such as buttonholed flaps or microfolds in Bowman’s membrane can also be distinguished. In addition, VHF digital US-assisted transepithelial phototherapeutic keratectomy in combination with a wavefront-guided treatment was used to improve stromal surface irregularities and higher-order aberrations.9 Delineation of anterior segment is also possible even in opacified eyes.

Anterior segment optical coherence tomography (AS-OCT) is another instrument that can be used in similar cases. Using an optical phenomenon called interference it provides high-quality images of the anterior chamber components and can make precise measurements of the thickness of all corneal layers, anterior chamber depth, angle to angle distance and intracorneal angle in degrees. AS-OCT in comparison with Artemis 2 cannot measure parameters behind the iris, such as sulcus to sulcus distance or ciliary body size but it can be more useful when a non contact instrument is needed.10,11

In conclusion this case report demonstrate, that the VHF ultrasound scanning system (Artemis 2, Ultralink LLC) could be a useful instrument for the early recognition and possible management of DMD after cataract surgery, especially in patients in which diagnosis is difficult due to significant corneal clouding.

References

  1. Marcon AS, Rapuano CJ, Jones MR, Laibson PR, Cohen EJ. Descemet’s membrane detachment after cataract surgery: management and outcome. Ophthalmology. 2002;109:2325–2330. doi:10.1016/S0161-6420(02)01288-5 [CrossRef]
  2. Macsai MS. Total detachment of Descemet’s membrane after small-incision cataract extraction. Am J Ophthalmol. 1992;114:365–366.
  3. Sugar HS. Prognosis in stripping of Descemet’s membrane in cataract extraction. Am J Ophthalmol. 1967;63:140–143.
  4. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolution of an extensive detachment of Descemet’s membrane following phacoemulsification. Arch Ophthalmol. 1994;112:551–552.
  5. Gault JA, Raber IM. Repair of Descemet’s membrane detachment with intracameral injection of 20% sulfur hexafluoride gas. Cornea. 1996;5:483–489.
  6. Reinstein DZ, Silverman RH, Trokel SL, Coleman DJ. Corneal pachymetric topography. Ophthalmology. 1994;101:432–438.
  7. Werner L, Lovisolo C, Chew J, et al. Meridional differences in internal dimensions of the anterior segment in human eyes evaluated with 2 imaging systems. J Cataract Refract Surg. 2008;34:1125–1132. doi:10.1016/j.jcrs.2008.03.033 [CrossRef]
  8. Reinstein DZ, Silverman RH, Raevsky T, et al. Arc-scanning very high-frequency digital ultrasound for 3D pachymetric mapping of the corneal epithelium and stroma in laser in situ keratomileusis. J Refract Surg. 2000; 6:414–430.
  9. Reinstein DZ, Archer T. Combined Artemis very high-frequency digital ultrasound-assisted transepithelial phototherapeutic keratectomy and wavefront-guided treatment following multiple corneal refractive procedures. J Cataract Refract Surg. 2006;32:1870–1876. doi:10.1016/j.jcrs.2006.07.016 [CrossRef]
  10. Pinero DP, Plaza AB, Alio JL. Anterior segment biometry with 2 imaging technologies: very-high-frequency ultrasound scanning versus optical coherence tomography. J Cataract Refract Surg. 2008;34:95–102. doi:10.1016/j.jcrs.2007.08.033 [CrossRef]
  11. VanderBeek BL, Silverman RH, Starr CE. Bilateral Salzmann-like nodular corneal degeneration after laser in situ keratomileusis imaged with anterior segment optical coherence tomography and high-frequency ultrasound biomicroscopy. J Cataract Refract Surg. 2009;35:785–787. doi:10.1016/j.jcrs.2008.09.033 [CrossRef]
Authors

From the University of Institute of Vision and Optics, University of Crete, Greece.

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

Address correspondence to George D. Kymionis MD, PhD, Institute of Vision and Optics (IVO), University of Crete, Medical School, 71003 Heraklion, Crete, Greece.

10.3928/15428877-20100215-67

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