|Year : 1972 | Volume
| Issue : 1 | Page : 20-22
Reposition of Descemet's membrane after cataract extraction
Aswini Hospital, I. N. Bombay, India
A B Das
Aswini Hospital, I. N. Bombay
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das A B. Reposition of Descemet's membrane after cataract extraction. Indian J Ophthalmol 1972;20:20-2
One of the causes of corneal oedema after catract extraction is seperation of descemet's membrane from corneal stroma (Donn)  Unless the descemet's membrane is reposited during the immediate post operative period, the prognosis is usually poor. Since the endothelium is absent and unable to cover the bare stroma, corneal oedema and bullous keratopathy result. Sparks  describes two cases which were successfully treated after the membrane was reposited and held in position with a bubble of air. Sugar  described three cases, two of which improved spontaneously whereas the third was successfully treated by reposition of membrane with the help of of an iris repositor. Wyatt and Ghosh  reported a similar case where the decemet's membrane folded on itself, forming an encysted space, which was reposited by an expanding bubble of air and the membrane was held in place with a large air bubble in the anterior chamber.
| Case Report|| |
A 75 year old lady, mother of A. G., was admitted on 26-10-71 for cataract extraction. Patient had immature cataract in both eyes. Left cataract was more advanced than the right cataract. Vision in the left eye was 3/60 and the right eye 6/60. Cornea was clear and intraocular tension was normal.
On 27th October 1971 an intracapsular cataract extraction of the left eye was done under local anaesthesia. The eye was opened by an ab-externo incision using a von Graefe knife and the wound was extended with scissors. Three pre placed and one post placed corneoscleral sutures were used. A broad sector iridectomy was done and the lens was delivered without difficutly with Arruga's forceps. Copious iris pigment was liberated in the anterior chamber and this had to be washed away using normal saline with an anterior chamber canula. Sterile air was injected in the anterior chamber after the sutures were tied.
On the following day mild keratitis was noted. But on the 7th day definite corneal oedema with thickening of the corneal stroma was seen in the upper part. On the 8th day slit lamp examination showed that the Descemet's membrane had stripped from the upper and outer part of the cornea and had folded down in the anterior chamber. The free edge of the membrane was curled up on itself. See [Figure - 1]. The corneal stroma was oedematous in the upper part, so that its thickness had increased about one and a half times, but no epithelial bullae were present [Figure - 2]. After observing the patient for another four days it was decided to reposit the Descemet's membrane. On the 13th post operative day under local anesthesia an ab-externo incision was made just inside the limbus between 10 and 1 O'clock position with a B.P. knife.
The Descemet's membrane was reposited with an iris spatula without any difficulty and a large air bubble was injected with canula and the incision was closed with a cornea-scleral stitch. 1% pilocarpine drop and local antibiotic was instilled and the patient was nursed flat in bed with sand bags on each side of the head. By the third post operative day the corneal oedema had disappeared to a large Extent By 8th day the air bubble got absorbed. The eye remained quiet post operatively and on the 9th day Descemet's membrane to be in slit lamp examination showed the apposition with the cornea. The patient was discharged on the 30th day after operation and corrected vision was 6/12 in the left eye
| Discussion|| |
Mc Pherson  recommended use of corneal microscope while closing the corneal wound to avoid stripping of Descemet's damage. Here stripping of Descemet's membrane was due to repeated washing of the anterior chamber to clear it of liberated iris pigment. Stripping of Descemet's membrane was only diagnosised on slit lamp examination on the 8th post operative day as much concern was caused by increasing cornal oedema. As the Descemet's membrane had curled on itself and was hanging free in the anterior chamber, there was no possibility that the cornea would be covered by endothelium if it was left alone and since oedema of corneal stroma increased further, operative repair was imperative.
If stripping of Descemet's membrane is recognised at the time of surgery attempt may be made to reposit the same using an iris repositor or it can be removed from the anterior chamber. Some even lifted up the membrane and held it in position with a stitch (Sugar  ) In this case the reposition of the membrane was possible with an iris repossitor and it was possible to hold the membrane in possition with a large air bubble.
Many causes have been attributed to post operative detachment of Descemet's membrane for example keratome point, the iris repositor, the cryoprobe and as in this case the irrigation nozzle.
It is necessary that all cases of post operative oedema should be properly examined on a slit lamp with stripping of Descemet's membrane in mind and operative repair should be undertaken without much delay.
| Summary|| |
The case which is described, developed corneal oedema (caused by stripping of descemet's membrane) following cataract operation. The membrane was replaced surgically with the help of iris repositor and was held in position by a large air bubble in the anterior chamber. The final visual result was good. Damage by anterior chamber canula was probably the cause of the detechment.
My thanks are due to Dr. T. N. Ursekar who examined this case on the 8th post operative day.
| References|| |
DONN, A. (1966) Arch, Ophthal. 75,
MC PHERSON, S. D. JR (1967) "Proc. XX Int. Congr. Ophthal.. MUNICH. 1966". part 2, pp 815-817.
SPARKS, G. M. (1967) A.M.A. Arch. Ophthal. (Chicago) 78, 31.
SUGAR, H. S. (1967) Amer. J. Ophthal. 63, 140.
SUGAR, H. S. (1967) Amer. J. Ophthal, 63, 140.
WYATT. H. and GHOSH. J. (1969) Brit. J. Ophthal, 53, 167.
[Figure - 1], [Figure - 2]