Descemet's membrane injury and regeneration, and posterior corneal fibrosis, in rabbits.

The purpose of this investigation was to study Descemet's membrane and corneal endothelial regeneration, myofibroblast generation and disappearance, and TGF beta-1 localization after Descemet's membrane-endothelial excision (Descemetorhexis) in rabbits. Thirty-six rabbits had 8 mm Descemetorhexis and standardized slit lamp photos at 1, 2 and 4 days, 1, 2 and 4 weeks, and 2, 4 and 6 months, as well as multiplex IHC for stromal cell markers keratocan, vimentin, and alpha-smooth muscle actin (SMA); basement membrane (BM) components perlecan, nidogen-1, laminin alpha-5, and collagen type IV; and corneal endothelial marker Na,K-ATPase ß1, and TGF beta-1, with ImageJ quantitation. Stromal transparency increased from the periphery beginning at two months after injury and progressed into the central cornea by six months. At six months, central transparency was primarily limited by persistent mid-stromal neovascularization. Stromal myofibroblast zone thickness in the posterior stroma peaked at one month after injury, and then progressively decreased until to six months when few myofibroblasts remained. The regeneration of a laminin alpha-5 and nidogen-1 Descemet's membrane "railroad track" structure was accompanied by corneal endothelial closure and stromal cell production of BM components in corneas from four to six months after injury. TGF beta-1 deposition at the posterior corneal surface from the aqueous humor peaked at one day after Descemetorhexis and diminished even before regeneration of the endothelium and Descemet's membrane. This decrease was associated with collagen type IV protein production by corneal fibroblasts, and possibly myofibroblasts, in the posterior stroma. Descemet's membrane and the corneal endothelium regenerated in the rabbit cornea by six months after eight mm Descemetorhexis. Real-time quantitative RT-PCR experiments in vitro with marker-verified rabbit corneal cells found that 5 ng/ml or 10 ng/ml TGF beta-1 upregulated col4a1 or col4a2 mRNA expression after 6 h or 12 h of exposure in corneal fibroblasts, but not in myofibroblasts. Stromal cells produced large amounts of collagen type IV that likely decreased TGF beta-1 penetration into the stroma and facilitated the resolution of myofibroblast-generated fibrosis.

Central retinal artery occlusion after Descemet membrane reposition by intracameral air: A case report.

PURPOSE: To report a case of central retinal artery occlusion after Descemet membrane reposition by intracameral air. METHODS: An otherwise healthy 60-year-old woman presented with white mature cataract in her left eye. Ocular exam of both eyes was within normal limits. After an uneventful topical phacoemulsification, a moderate-grade striate keratopathy and non-planar Descemet membrane detachment was noted on first postoperative day, which was confirmed on anterior segment optical coherence tomography. The Descemet membrane was repositioned within 24 h of cataract extraction by intracameral air tamponade (pneumatic descematopexy) under topical anesthesia, and partial air release was done after 2 h. The patient was evaluated for decreased immediate postoperative vision of perception of light. RESULTS: After pneumatic descematopexy, the stromal edema relatively cleared. The intraocular pressure before releasing the intracameral air was 38 mmHg and antiglaucoma medication was started. Dilated fundus exam showed retinal pallor and a cherry-red spot over the macula. A diagnosis of central retinal artery occlusion was confirmed, and thorough systemic workup was done. Systemic investigations were within normal limits. The patient was managed conservatively, but the final visual acuity remained at 1/60. CONCLUSION: Central retinal artery occlusion is not a reported complication after pneumatic descematopexy for Descemet membrane detachment management. The possible mechanism could be sudden increase in intraocular pressure due to pupil block by air, and thus, ocular surgeries with use of intracameral air for prolonged duration warrants close monitoring of intraocular pressure and its subsequent management.

Real-Time Imaging of Incision-Related Descemet Membrane Detachment During Cataract Surgery.

Importance: Incision-related Descemet membrane detachment (DMD) is a common complication of cataract surgery. Most postoperative severe DMD that leads to corneal decompensation originates from intraoperative incision-related DMD. It is important to determine the incidence, extent, and associated risk factors of intraoperative DMD at each step of surgery to help in formulating precise and effective prevention strategies. Objectives: To investigate the intraoperative development of incision-site DMD associated with a 2.2-mm clear corneal incision during cataract surgery and to analyze its associated factors. Design, Setting, and Participants: In this case series, consecutive, prospectively enrolled 133 patients with cataract 50 to 90 years of age (133 eyes) undergoing coaxial 2.2-mm clear corneal microincision phacoemulsification with intraocular lens (IOL) implantation between January 1 and March 31, 2019, at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China, were studied. Exposures: Coaxial 2.2-mm clear corneal microincision phacoemulsification with IOL implantation. Main Outcomes and Measures: Real-time incidence and extent of intraoperative incision-related DMD at each step of surgery. Results: Among 133 patients with cataracts (mean [SD] age, 72.3 [8.1] years; 77 [57.9%] female), DMD was encountered in 125 eyes (94.0%), occurring at the following steps: capsulorrhexis (2 [1.6%]), hydrodissection (7 [5.6%]), phacoemulsification (69 [55.2%]), irrigation-aspiration (44 [35.2%]), and IOL implantation (3 [2.4%]). The extent of DMD increased during the operation (mean [SD] difference between final and initial relative DMD length, 22.8% [1.4%]; 95% CI, 20.0-25.6; P < .001). Associations for the extent of DMD found in multivariate stepwise analyses included time of ultrasonography (ß = 0.34; 95% CI, 0.17-0.50; P < .001), equivalent mean ultrasonic power (ß = 87.8; 95% CI, 19.1-156.4; P = .01), and the presence of DMD at the anterior and posterior wound margins (coefficient = 16.7; 95% CI, 6.4-26.9; P = .002). Conclusions and Relevance: The results of this case series suggest that friction of surgical instruments has the greatest association with incisional DMD. Decreasing ultrasonic energy and phacoemulsification time may reduce the severity of incisional DMD.

[Descemet's membrane detachment after phacoemulsification: Series of 9 cases]. / Décollement descemétique post-phakoémulsification : à propos de 9 cas.

PURPOSE: Descemet's membrane detachment (DMD) is a rare but potentially serious complication of cataract surgery. Although there are no consensual guidelines regarding the diagnosis or treatment of DMD, incorrect treatment may result in irreversible corneal changes with visual sequellae. The purpose of our study is to describe the diagnosis and treatment of DMD. METHODS: We report a series of 9 cases of DMD, their diagnosis, treatment and outcomes. We tested the HELP protocol retrospectively against our 9 real-life cases. RESULTS: Two cases recovered with simple medical management, 4 required air-bubble descemetopexy, and three required keratoplasty. Our study revealed that the main factor associated with poor outcomes is late diagnosis and management. CONCLUSION: Our series illustrates the importance of proactive management and timely diagnosis by performing anterior segment OCT in the setting of persistent postoperative corneal edema.

Manejo de la rotura de la membrana de Descemet secundaria a traumatismo por fórceps durante el parto / Management of Descemet membrane detachment secondary to forceps assisted delivery in a newborn

Describir los signos clínicos y el manejo del desprendimiento de la membrana de Descemet (MD) secundario a un traumatismo relacionado con fórceps durante el parto. Un recién nacido a término de 2 días de edad se presentó con opacidad corneal del ojo derecho y antecedentes de parto con fórceps. La evaluación oftalmológica fue consistente para traumatismo corneal, y en la tomografía de coherencia óptica del segmento anterior (OCT-SA Visante®) se objetivó un desprendimiento de la membrana de Descemet (MD). El tratamiento tópico prolongado redujo considerablemente el edema, y después de 4 meses con este, el desprendimiento persistía en su porción superior, la inyección de aire en la cámara anterior llegado a este punto tampoco logró la reaplicación. El eje visual se mantuvo parcialmente transparente durante los meses siguientes, y se indicó terapia visual intensiva para evitar la ambliopía. El tratamiento tópico prolongado puede ser útil para reducir el edema y el riesgo de ambliopía severa en las lesiones de la MD secundarias al traumatismo por fórceps durante el parto, pero puede ser insuficiente en casos donde coexista también un desprendimiento de esta

To describe the clinical signs and management of Descemet membrane (DM) detachment after forceps-related trauma during birth. A 2-day-old term infant presented with right eye corneal clouding and history of forceps assisted delivery. Ophthalmic assessment was consistent for corneal trauma and anterior segment optical coherence tomography (AS-OCT Visante®) revealed DM detachment. Prolonged topical treatment considerably reduced edema, but after four months of treatment superior DM detachment persisted, anterior chamber air injection at this point also failed to achieve apposition. Central visual axis remained partially spared in the months to follow, and intensive amblyopia treatment was indicated. Prolonged topical treatment may be helpful to reduce edema and risk of severe amblyopia in DM tears secondary to forceps traumatism at birth, but insufficient in cases of large DM detachment

Descemet's membrane detachments, ruptures, and separations in ten adult horses: Clinical signs, diagnostics, treatment options, and preliminary results.

OBJECTIVE: To describe the clinical presentation, diagnostic imaging results, and treatment outcomes of a series of presumed spontaneous Descemet's membrane detachments (DMD), ruptures, or separations (DMRS) in the adult horse. ANIMALS STUDIED: Ten adult horses of various breeds with DMD or DMRS. PROCEDURES: Descemet's membrane detachments/DMRS were diagnosed via slit lamp biomicroscopy, ultrasound biomicroscopy (UBM), and/or optical coherence tomography (OCT). Penetrating keratoplasty (PK) with heterologous corneal donor tissue (n = 1), superficial lamellar keratectomy, and Gundersen inlay flaps alone (GF, n = 1) or with subsequent intracamerally assisted corneal tissue welding (CTW, n = 2), or CTW alone (n = 5) were performed in 9/10 horses. One horse underwent spontaneous resolution (n = 1). RESULTS: Ten horses were diagnosed with either unilateral DMD (n = 4) or DMRS (n = 6). Seven of ten eyes remained visual during the follow-up period (8.16 ± 6.57 months). Graft transparency was good for the eye treated with PK. The horse that underwent GF alone was functionally blind due to persistent corneal edema. The clinical signs resolved in 3/5 horses that underwent CTW alone, but 2/5 eyes were enucleated due to corneal perforation. Both eyes treated with combined GF/CTW had significant corneal clearing with one having evidence of reattachment on UBM and OCT. CONCLUSIONS: Descemet's membrane detachments separations presents differently than typical DMD and advanced corneal imaging modalities may aid in their diagnosis. Corneal tissue welding using infraCG as the photosensitive agent, or in combination with Gundersen inlay flaps, represents a feasible treatment option for management of equine DMD/DMRS as described in the present case series.

Total or subtotal full thickness recipient bed cut to repair donor-recipient curvature disparity in cases of DM rupture with manual DALK.

PURPOSE: To report how to manage a specific type of Descemet's membrane (DM) rupture during manual DALK with a concurrent donor-recipient disparity of curvature. METHODS: Case report of two patients that had DM rupture during manual DALK with a concurrent donor-recipient disparity of curvature; the recipient bed was flatter (post-infectious scar, case 1) and steeper (keratoglobus, case 2) than the donor. Preoperative diagnosis, clinical exam, and best spectacle correct visual acuity (BSCVA) have been reported. A subtotal full-thickness circular cut of the recipient bed was performed to resolve a persistent double AC in case 1 (recipient flatter than donor). A total full-thickness circular cut of the recipient bed, creating a graft made by a DALK allograft and a "DSEK autograft," was performed to avoid a refractory double AC in case 2 (recipient steeper than donor). Evaluated outcomes included postoperative BSCVA, endothelial cell count (ECC), graft clarity, rejection, and presence/absence of double AC. RESULTS: Surgery was successful in resolving/avoiding double AC. VA improved in both cases. No episodes of rejection were recorded. Graft remained clear at the last follow-up (6 years for case 1 and 4 years for case 2). CONCLUSION: The existence of a donor-recipient curvature disparity should be investigated as a possible underlying mechanism of refractory double AC. Total or subtotal full thickness recipient bed cut may be considered to repair donor-recipient curvature disparity in cases of DM rupture occurring during manual DALK. Repairing the DM rupture and avoiding a conversion to PK in high-risk transplant cases are crucial.

Descemet Membrane Detachment After Penetrating Keratoplasty for Keratoconus.

PURPOSE: To describe the risk factors, management, and outcome of delayed Descemet membrane (DM) detachment after penetrating keratoplasty (PK) for keratoconus. METHODS: We report 7 eyes from 6 cases and combine these data with 7 previous case reports identified by a search of PubMed. RESULTS: DM detachment occurred at a median of 25 years (range, 7-33 years) after PK. One individual had bilateral detachments. There was typically a mild ocular discomfort accompanied in some cases by a rapid onset of visual blur. Cases were often treated for allograft rejection before a DM detachment was suspected and confirmed by optical coherence tomography. Detachments were limited to the donor tissue in 11 eyes, but a DM break was identified at the time of onset in only 4 eyes. Thinning of the host corneal rim with ectasia was reported in 8 eyes (57%). In 3 eyes, the detachment resolved spontaneously, but in 2 eyes, a detachment was still present at 12 months. Gas tamponade to reattach the DM was performed in 9 eyes and was effective in 4 eyes. Five eyes underwent a repeat PK or endothelial keratoplasty. Histology showed fibroblastic proliferation on the stromal surface of the folded DM. CONCLUSIONS: The cause for DM detachment many years after PK is unknown, although progressive thinning of the host cornea and secondary graft ectasia may be implicated. Gas tamponade can be effective, but a repeat keratoplasty might be necessary. DM detachment should be included in the differential diagnosis for late-onset corneal edema after PK.

Use of Fibrin Glue in the Management of Descemet Membrane Perforation during Deep Anterior Lamellar Keratoplasty.

PURPOSE: To describe the use of fibrin glue to seal Descemet membrane (DM) microperforation and macroperforation during deep anterior lamellar keratoplasty (DALK). METHODS: A retrospective chart review was performed on patients who had DM perforation managed by fibrin glue during DALK at King Khaled Eye Specialist Hospital (KKESH) between June 2014 and February 2019. RESULTS: One thousand two hundred and eighty-eight DALK surgeries were performed at KKESH during the study period. Fibrin glue was used to seal DM perforations in four cases of DALK for keratoconus. CONCLUSION: Fibrin glue is an effective method to seal DM microperforations and macroperforations during DALK, which reduces the rate of conversion to penetrating keratoplasty (PK), preserving the advantage of DALK over PK.

Desgarros obstétricos de la membrana de Descemet / Obstetric tears of the Descemet membrane

No disponible

Stromal Patch with fibrin glue as a novel surgical technique to seal peripheral Descemet's membrane perforations in deep anterior lamellar keratoplasty.

PURPOSE: The purpose of this article was to introduce a novel surgical technique for the management of peripheral Descemet's membrane perforation during deep anterior lamellar keratoplasty (DALK). METHODS: First, a thin stromal patch was prepared either from the anterior stromal lamella cut during DALK or from the anterior stroma of a Descemet's stripping automated endothelial keratoplasty button. The stromal patch was secured in a stromal pocket dissected deep in the trephination edge along the perforation site. Fibrin glue was applied to the stromal patch. Finally, the graft was sutured to the recipient bed. RESULTS: We used this technique in 3 cases with peripheral DM perforations during DALK. The first case was a persistent postoperative double anterior chamber who developed Urrets-Zavalia syndrome after air injection in an attempt to seal the perforation. In the second case, this technique was applied to seal an intraoperative DM perforation, without which the procedure would have been converted to penetrating keratoplasty. The third case had a persistent postoperative double chamber despite multiple air injections and fibrin glue application. The technique was effective in the management of all DM perforations with a resolution of double anterior chamber. CONCLUSION: This technique is safe and effective as an intraoperative method or a postoperative measure to seal peripheral DM perforations. We recommend this technique for repairing peripherally located DM perforations during DALK not amenable to simple measures like air injection or fibrin glue application.

Haab striae: Optical coherence tomographic analysis.

PURPOSE: To study Haab striae in adults with primary congenital glaucoma and describe them by anterior segment optical coherence tomography, as well as analyze their evolution over the patient's lifetime. MATERIAL AND METHODS: Three patients with primary congenital glaucoma were recruited, aged between 17 and 48 years old, with incidentally noted Haab striae on glaucoma consultation. They were studied by: slit lamp; anterior segment optical coherence tomography, Heidelberg Engineering Inc., Germany, (with anterior segment module) and Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, California, USA (with 3D reconstruction); and specular biomicroscopy. The results obtained were contrasted with other studies performed in children. RESULTS: Rounded excrescences protruding towards the anterior chamber were found, as well as dense, irregular tissue between them. In addition, endothelial abnormalities (polymegathism and polymorphism) were found. These findings fit the evolution of those obtained in pediatric studies and remain stable in adult life. CONCLUSIONS: Through noninvasive methods such as optical coherence tomography and specular biomicroscopy, it is possible to make the diagnosis and follow up these patients. The findings suggest posterior corneal topographic changes; additional studies on this subject may be necessary.

Incidence and Outcomes of Intraoperative Descemet Membrane Perforations During Deep Anterior Lamellar Keratoplasty.

PURPOSE: To report the incidence and outcomes of intraoperative Descemet membrane (DM) perforations during deep anterior lamellar keratoplasty (DALK). DESIGN: Retrospective, consecutive, interventional case series. METHODS: A retrospective audit of all DALK cases performed from 2004 to 2015 in a tertiary center, with and without intraoperative DM perforations. We excluded cases with preexisting corneal perforations before surgery. RESULTS: There were a total of 540 eyes, of which 101 (18.7%) had intraoperative DM perforations. These included 79 eyes (78.2%) with microperforations and 15 eyes (14.9%) with macroperforation. The most common steps at which DM perforation occurred intraoperatively were during deep lamellar dissection (32 cases; 31.7%), air injection (27 cases; 26.7%), and suturing (21 cases; 20.8%). Management of the DM perforations included a combination of intracameral air tamponade (49 cases; 48.5%), stromal patching (10 cases; 9.9%), fibrin glue (8 cases; 7.9%), and suturing of the defect (1 case; 1.1%). There were 2 eyes (2/540; 0.37%) that were converted to penetrating keratoplasty (PK). There were no significant differences in the postoperative unaided or best-corrected visual acuity, or in the numbers of patients with postoperative graft failure, graft rejection, or subsequent surgery at postoperative years 1 and 3. CONCLUSIONS: DALK cases with DM perforations intraoperatively are often able to be managed without conversion to PK. Cases with DM perforations intraoperatively have equivalent visual acuity outcomes compared to those without DM perforations, and did not have any increased risk of graft failure, rejection, or subsequent surgery at postoperative years 1 and 3.

Intraoperative Descemet's membrane detachment in a case of phacomorphic glaucoma.

A 60-year-old female patient with phacomorphic glaucoma underwent initial medical management to control the intraocular pressure (IOP). After 48 hours, a stable IOP was achieved and subsequently the patient was planned for phacoemulsification followed by intraocular lens implantation. There was initial difficulty while reconstructing the corneal wounds; however, phacoemulsification and IOL implantation were uneventful but during viscoelastic removal, an inadvertent Descemet's membrane detachment involving the central cornea was noted. Postoperatively corneal oedema persisted till 1 week, following which there was a gradual improvement with topical antibiotics, steroids and hyperosmotic agents. At the end of 6 months, the best corrected visual acuity was 20/25 with a central corneal thickness of 580 µm without any need for additional endothelial replacement surgery.

Outcome of deep anterior lamellar keratoplasty patients with intraoperative Descemet's membrane perforation: A retrospective cross-sectional study.

PURPOSE: To evaluate functional and anatomical outcome in patients undergoing deep anterior lamellar keratoplasty (DALK) with intraoperative Descemet's membrane (DM) perforation (macro and micro). METHODS: A retrospective cross sectional study (January 2009 to December 2015) of sixteen eyes of sixteen patients which included nine patients of advanced keratoconus (KC), two patients with paracentral DM scarring post hydrops, KC with Bowman's membrane scarring, macular corneal dystrophy and one patient of advanced Pellucid Marginal Degeneration (PMD). All underwent DALK with intraoperative DM perforation. Big bubble technique was attempted in all except in the two patients with post hydrops DM scar. Preoperative and postoperative best corrected visual acuity (BCVA), astigmatism and endothelial count (EC) were compared. RESULTS: Postoperative BCVA and astigmatism were found to be better and statistically significant ('p value' 0.00 and 0.003 respectively). BCVA preoperative and postoperative was 1.07± 0.3 and 0.28 ± 0.09 in LogMAR respectively and astigmatism pre and postoperative 4.14 ± 1.5 D and 2.7 ± 0.97 D respectively. Percentage decrease in EC at sixth postoperative week was 7.48% and at sixth month and 1 year postoperative was 15.1%. Two patients developed postoperative double anterior chamber and two patients developed pupillary block glaucoma and all were successfully managed. CONCLUSION: Not all patients of intraoperative DM perforation (including macro perforation) needs to be converted to penetrating keratoplasty. DALK can be successfully done if the perforation is identified early and managed adequately. This is the only known study which has shown a large series of successful DALK even with macro perforations.

Study on the classification of Descemet membrane detachment after cataract surgery with AS-OCT.

In this article, the significance of anterior segment optical coherence tomography (AS-OCT) to aid the clinical diagnosis and treatment of Descemet membrane (DM) detachment after phacoemulsification combined with intraocular lens implantation was retrospectively analyzed using 26 patients (26 eyes). The location and scope of DM detachment, its causative factors and the percentage of each detachment type are considered for clinical treatments. Based on the location and scope, the detachment can be divided into three types: (1) simple, (2) symmetrical and (3) complete DM detachment. Simple detachment, confined to the area of surgical incision (detachment range <1/4 corneal area), occurred in 69.20 % of cases (18/26), in which the DM detachment in the anterior lip accounted for 42.30% (11/26) and in the posterior lip accounted for 26.90% (7/26). Symmetrical DM detachment, referring to detachment (1/4 cornea area < detached area <1/2 corneal area) that appeared symmetrically on the surgical incision and the opposite site, accounted for 19.20% (5/26). Complete DM detachment (>1/2 of the corneal area), accounted for 11.50% (3/26). Interestingly, our findings suggest that the DM detachment after phacoemulsification is closely related to the location (simple and symmetrical DM detachment) and the skillfulness (complete DM detachment) of the surgical incision. Therefore, appropriate classification of DM detachment by AS-OCT and wise selection of surgical location can better guide cataract surgery in the future.