|Year : 1977 | Volume
| Issue : 4 | Page : 47-49
Bullous separation of the Descemet's membrane
Daljit Singh, Mohindar Singh
Department of Ophthalmology, Medical College, Amritsar, India
Department of Ophthalmology, Medical College, Amritsar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh D, Singh M. Bullous separation of the Descemet's membrane. Indian J Ophthalmol 1977;25:47-9
During the past two years we have seen and followed two cases in which there was a large sharply defined separation of the Descemet's membrane without any tear or curling. The space between the separated descemet's membrane and the corneal stroma was filled with fluid. We propose to term this condition as "Bullous separation of the Descemet's membrane". Both these cases occured after cataract operation.
| Case Report|| |
Case no. 1:
G., 70 years old female was operated upon for cataract in early March 1975. Intracapsular cataract extraction was done after making a flange incision. There was no operative or postoperative complication. But, three weeks later when she came for follow up, there was absence of the anterior chamber and the tension was very low. A choroidal detachment was present. It was treated by the drainage of the suprachoroidal fluid and injection of air into the anterior chamber. The anterior chamber and the intraocular pressure returned to normal. Slit lamp examination 8 days later showed a few vertical lines at the level of the Descemet's membrane. This was labelled as striate keratitis and the [patient was discharged with local atropine and steroid drops.
Three months later, slit lamp examination showed that the Descemet's membrane was separated from the back of the cornea in a fairly large triangular area. The edges of the separation gave a shining golden reflex. Optical section clearly showed that the descemet's membrane was indeed separated from the rest of the cornea and the affected area could be very easily marked out.
Nowhere did the membrane show any tear or retroflexion. There was no thickening of the cornea. The epithelium was entirely normal looking. The patient did not have any complaint about her eye. Her corrected vision was 6/9. No further treatment was given. Thirteen months later, there was no change in the condition of the cornea or the vision.
Case no. 2:
C.L., 55 years old male, farmer by profession was operated upon for cataract in the left eye in 1975 at an eye camp. He came to us in January 1976. He complained of some mistiness, even though vision with glasses was very satisfactory.
Biomicroscopy showed the presence of a scar of a knife section. A large peripheral iridectomy had been done on the upper temporal side. Intracapsular cataract extraction seemed to have been done. In the upper half of the cornea there was a circular area of separation of the descemet's membrane. The diameter of the separated area was about 5.5 mm and its lower edge came almost at the middle of the pupil. Near the lower edge of the separation, there was a whitish horizontal, planoconvex opacity about 4.5 mm. long, the central portion being about 0.5 mm. wide. Optical section showed that the separated Descemet's membrane and the back of corneal stroma enclosed a biconvex space containing a faintly opalescent fluid. At the bottom of this space, shining white material was visible [Figure - 1]. The depth of this space in its central part was about 1.5 mm. The upper edge of the separated descemet's membrane could not be traced with any certainty because of scarring produced by the cataract section. The corneal stroma and the epithelium were normal looking all over.
The corrected vision was 6/9.
A small horizantal incision was made in the cornea opening into the middle of the bullous separation. The fluid inside the space was easily sucked out with the help of a fine cannula. The space was then washed repeatedly with normal saline. The anterior chamber was not opened during this procedure.
The aspirated fluid was examined under the microscope. It showed the presence of large number of crystals of calcium oxalate as well as cellular debris [Figure - 2]. Serum calcium, phosphorus and alkaline phosphate were normal.
One month later, slit lamp examination showed that the Descemet's membrane was in its normal place. However one year and two months later the Descemet's membrane was seen to have gone to its original separated position and the space in front of it was filled with clear fluid. The cornea had remained perfectly clear and the corrected vision was unaffected.
| Discussion|| |
The pure separation of the descemet membrane without any tear or curl in it gives the appearance of a big bulla on the back of the cornea. Therefore the condition has been termed as "Bullous separation of the Descemet's membrane".
This condition needs to be differentiated from cases of retroflexion of descemet membrane. The latter condition is always accompanied by a tearing and curling of the Descemet's membrane and most of these cases show changes in the corneal stroma and the epithelium. In comparison "Bullous separation of the Descemet's membrane" is a benign condition which is not accompanied by changes in the epithelium and the vision is not adversely affected.
The mechanism of production of bullous separation of the descemet's membrane in the first case appears to be very simple. Prolonged absence of the anterior chamber probably produced adhesions between the iris and the corneal endothelium. When the chamber was reformed surgically, the iris pulled back the endothelium and the Descemet's membrane from the rest of the cornea.
In the second patient, the exact mechanism of separation is difficult to make out. The possibility of epithelial down-growth resulting in cyst formation, Descemet's membrane being incorporated in some way may be considered in such a case. But since the cornea remained perfectly clear, this possibility is unlikely in our case.
Surgical intervention in the second case brought the Descemet's membrane and the corneal stroma together but the two failed to unite. May be, long standing separation has reduced the affinity between the two tissues.
Intraocular oxalate deposits have been noted in eyes with long standing retinal detachments or Morgagnian cataracts  .
Needle like crystals in the corneal stroma have been reported in cases of keratoconjunctivitis produced by certain plants known to contain calcium oxalate in their juices  .
The source of calcium oxalate crystals in our second case is difficult to explain.
| Summary|| |
Reported here are two cases with a large separation of Descemet's membrane seen without the presence of any tear or curl. The space thus created was filled with fluid. In one of the patients, the fluid contained a large number of calcium oxalate crystals. In both the cases there was no oedema of the corneal stroma or the epithelium and the corrected vision was good. The condition has been called "Bullous separation of the Descemet's membrane". In one case it occured after surgery for choroidal detachment but the reason for separation in the second case could not be found out. The condition has been differentiated from retroflexion of the descemet's membrane.
| References|| |
Ellis, W., Barfort, P. and Mastman, G.J., 1973, Amer. J. Ophthal., 76,143.
Greer, C.H., 1976, Personal communication.
[Figure - 1], [Figure - 2]