Postoperative Corneal Edema Secondary to a Free Fragment

of Descemet's Membrane

After cataract extraction in our paa free fragment of Descemet's membrane from the wound edge became adherent to the central cornea and resulted in persistent corneal edema. With the use of sodium hyaluronate the membrane was successfully removed and visual acuity was restored.

tient,

Report of a Case.\p=m-\A66-year-old woman had extracapsular cataract extraction with posterior chamber intraocular lens implantation in the right eye on August 14, 1986. There were no complications during surgery. On the first postoperative day visual acuity in the right eye was counting fingers at 30 cm. There was 3+ microcystic corneal edema, the anterior chamber had 2+ cells and flare, and the intraocular pressure was 38 mm Hg. One drop each of prednisone acetate (1%) four times daily, gentamicin sulfate four times daily, 1% tropicamide every day, and 0.5% timolol maleate twice a day were administered. The intraocular pressure decreased to 22 mm Hg the next day and was 12 mm Hg within a week. A week later visual acuity was 20/200. The upper two thirds of the cornea showed cor¬ neal edema, with the maximum edema overlying the pupil. After 5% sodium chlo¬ ride drops were administered three times a day for 2 days, a triangular, partially rolled membrane measuring 6 mm with a base of 4 to 5 mm was seen adherent to the central corneal endothelium. Descemet's folds were seen anterior to the membrane and were continuous with the folds in the rest of the cornea. Since there was no change in cor¬ neal edema with treatment, we decided to remove the membrane surgically. A corneoscleral suture was removed between the 2and 3-o'clock positions. Hyaluronate so¬ dium was injected under the membrane. This caused the membrane to unroll, and it detached completely from the endothelium. The membrane was then removed with forceps. Pathologic examination showed marked lamination and guttäte excrescenses that indicated it was a fragment of Descemet's membrane. The patient's vi¬ sual acuity was 20/300 the next day. There was considerable edema centrally, with many Descemet's folds. Three weeks after surgery the patient's visual acuity was 20/ 40. There was a faint pigment line on the endothelium at the site where the mem¬ brane had been adherent. Comment.—Descemet's membrane is an elastic membrane that has a loose attachment to the overlying stroma, thereby allowing easy separation. It is resistant to autolysis and therefore maintains its newly assumed configu¬ ration years after the original trauma or surgical insult. Localized bullous keratopathy sec-

ondary to an adherent piece of lens capsule was reported by Moses.1 Champion et al2 described a fragment of stripped Descemet's membrane that was partially in the cataract wound in a postmortem eye. If recognized during surgery, irrigation against the endo¬ thelium or removal with forceps may be tried. However, if it is recognized in the early postoperative period, topical hyperosmotic agents are usually not effective in reducing the edema and surgical intervention may be neces¬ sary.

In this case the fragment of Descem¬ et's membrane most probably was sev¬ ered by surgical manipulation at the corneoscleral junction. It became ad¬ herent to the endothelium, resulting in corneal edema. The edema was maxi¬ mum overlying the adherent mem¬ brane. Since it was located over the pupil, we felt that immediate surgical intervention was required; otherwise permanent damage to the cornea would have resulted. Hyaluronate so¬ dium injected over the free edge of the adherent Descemet's membrane formed a line of cleavage and the membrane rolled away from the en¬ dothelium, allowing it to be easily re¬ moved with forceps. Sasikala Pillai, MD Washington, DC Munecra A. Mahmood, MD Riyahd, Saudi Arabia 1. Moses L. Localized bullous keratopathy secondary to adherent lens capsule. Arch Ophthalmol. 1986;104:639-640. 2. Champion R, McDonnell PJ, Green R. Intraocular lenses: histopathologic characteristics of a large series of autopsy eyes. Surv Ophthalmol. 1985;30:1-32.

or signs of iritis (Fig 1). Gonioscopy revealed normal, wide open angles bilaterally. Corneal thickness, as determined by pachymeter, was 0.54 mm OD and 0.62 mm OS. Significant polymegathism and pleomorphism were detected in specular microscopy of the left eye (Fig 2). There was no history of trauma in this patient and a diagnosis of spontaneous Des¬

out corneal edema

cemet's membrane tear and detachment of

idiopathic origin was made. Although visual acuity remained the same, the area of de¬ tachment gradually increased on subse¬ quent examinations and the membrane fold¬

to the inferior temporal quadrant In July 1989, slit-lamp examination disclosed that the membrane was lying free¬ ly in the anterior chamber angle below. The membrane was surgically removed through a limbal incision. During the procedure, 1% sodium hyaluronate was used to maintain the anterior chamber; it was partially removed at the end of surgery. On the first postoperative day, ocular pressure was 56 mm Hg with significant corneal edema presumably due to residual sodium hyaluronate and intraocular inflam¬ mation. The pressure was controlled with medication, and the cornea cleared. There was residual partial sphincter muscle paral¬ ysis nasally due to the transient, high in¬ traocular pressure. In March 1990, the best corrected visual acuity was 20/20 OS and intraocular pres¬ sure was 12 mm Hg without medication. The pupil was 5 mm and irregular (Fig 4). Histopathologic examination of the surgi¬ cal specimen showed curled fragments of basement membrane that were rounded by masses of periodic acid-Schiff-positive ex¬ tracellular material displaying a fine granu¬ lar appearance with no endothelial cells (Fig 5). These findings were consistent with the microscopy of Descemet's membrane and supported the clinical diagnosis.

ed

over

(Fig 3).

Comment.—There

are

only

ture of Descemet's membrane.

Spontaneous Descemet's

Membrane

Tear and Detachment

Breaks of Descemet's membrane may in congenital glaucoma, birth

occur

trauma, keratoconus, keratoglobus,

Terrien's marginal degeneration, surgical and accidental trauma.1-3

or

Report of a Case.\p=m-\A 34-year-old healthy

examined in 1972 and treated for retinal holes with lattice degeneration by transconjunctival cryopexy to the right eye. From 1972 to 1982 she underwent five complete ophthalmologic examinations with normal findings. In February 1988, the patient was again examined, complaining of intermittent halos of short duration and decreased visual acuity in her left eye of 1 month's duration. Her best corrected visual acuity was 20/20 OD and 20/25 OS. Intraocular pressure was 17 mm Hg OU. Slit-lamp examination of the right eye was unremarkable. In the left eye, a membrane that was separated from the stroma was hanging down with a free edge at the central posterior cornea, withwoman was

Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/19/2015

a

few

reports describing spontaneous rup¬ Tucker1

described a case of spontaneous tear in Descemet's membrane associated with osteogenesis imperfecta, and McGrand" reported another case but provided no details. Our patient was followed up for 16 years before the tear occurred and the case is docu¬ mented clinically and histopathologically. The spontaneous occurrence, ab¬ sence of corneal edema despite the widely affected area, and histopatho¬ logic absence of endothelial cells at¬ tached to Descemet's membrane were striking and interesting features of the present case. To our knowledge, this is the only case of spontaneous rupture and detachment of Descemet's mem¬ brane with no trauma or associated disease clinically and histopathological-

ly reported.

Richard S. Ruiz, MD Osman A. Saatci, MD Houston, Tex

Reprint requests to the Hermann Eye Center, 6411 Fannin, Houston, TX 77030 (Dr Ruiz).

Fig 1.—Slit-lamp photographs of detached Descemet's membrane (February 1988).

Fig 2.—Specular microscopic photograph polymegathism and pleomorphism.

demonstrated

significant

Fig 4. Postoperative view of the cornea with the slightly dilated pupil due to residual partial sphincter paralysis nasally. —

1. Waring GO, Laibson PR, Rodrigues M. Clinical and pathologic alterations of Descemet's membrane: with emphasis on endothelial metaplasia. Surv Ophthalmol. 1974;18:325-368. 2. Kenyon KR, Fogle JA, Grayson M. Dysgeneses, dystrophies and degenerations of the cornea. In: Duane TD, Jaeger EA, eds. Duane's Clinical Ophthalmology. Philadelphia, Pa: JB Lippincott; 1989;4:1-56. 3. Soong HK, Fitzgerald J, Boruchoff A, Sugar A, Meyer RF, Gabel MG. Corneal hydrops in Terrien's marginal degeneration. Ophthalmology.

1986;93:340-343.

Fig

3. —Folded Descemet's membrane to the inferior quadrant.

Fig 5. —Curled fragments of Descemet's membrane without any at¬ tached endothelial cells (periodic acid-Schiff, original magnification x100).

4. Tucker DP. Blue sclerotics syndrome simulat-

ing buphthalmos.

Am J

348. 5. McGrand JC. cornea.

Ophthalmol.

1959;47:345\x=req-\

Hyaline ridges on the posterior Br J Ophthalmol. 1968;52:257-261.

Spontaneous Collapse of a Primary Cyst Associated With an Iris Nevus

Iris

Primary

iris cysts are unusual ocular abnormalities that may be congenital.

Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 05/19/2015

We describe a primary iris cyst associated with an iris nevus that spontaneously collapsed within a 1-year followup period. Report of a Case.\p=m-\A 13-year-old white

was seen on February 21, 1989, for evaluation of a pigmented iris lesion. The patient had no previous history of ocular surgery or trauma and had not been receiving topical medications. Visual acuity was 20/20 OU. Intraocular pressures and dilated

boy