SOOSAN JACOB, MS, FCRS,DNBSOOSAN JACOB, MS, FCRS,DNB
ATHIYA AGARWAL, MD, DO;ATHIYA AGARWAL, MD, DO;
AMAR AGARWAL, MS, FRCS, FRCOAMAR AGARWAL, MS, FRCS, FRCO
GAURAV PRAKASH, MD GAURAV PRAKASH, MD
DR. AGARWAL’S GROUP OF EYE HOSPITALS DR. AGARWAL’S GROUP OF EYE HOSPITALS
&&
EYE RESEARCH CENTRE,EYE RESEARCH CENTRE,
CHENNAI, INDIACHENNAI, INDIA
NONE OF THE AUTHORS HAVE ANY FINANCIAL DISCLOSURES
BACKGROUNDBACKGROUND : : Relaxing retinotomy is used when retinal foreshortening does not
allow retina to settle down unless relaxing retinotomies are made. A similar
situation can arise in the cornea when there is traction on the Descemet’s
Membrane (DM) secondary to inflammation or fibrosis or if the DM gets
incarcerated in a wound or suture. This can lead to a Taut Descemet’s Membrane
Detachment (TDMD) as opposed to a DM which is torn and detached from the
overlying stroma such as seen following phacoemulsification. Injecting air or long
acting gas into the anterior chamber (AC) in an eye with TDMD does not allow the
DM to appose against the corneal stroma because of the foreshortening . Relaxing
Descemetotomy based on a principle similar to relaxing retinotomy would be the
solution in this scenario.
PURPOSEPURPOSE :: TO DESCRIBE A NEW SURGICAL TECHNIQUE FOR TAUT DMD (TDMD) AND
TO PROPOSE A NEW ETIO-CLINICO-PATHOLOGICAL CLASSIFICATION SCHEME FOR
DMD VIZ. STRIPPED DSCEMET’S MEMBRANE DETACHMENT (SDMD) AND TDMD
INTRA-OPERATIVE
EVALUATION:
TRYPAN BLUE DYE IS INJECTED
ANTERIOR CHAMBER IS
IRRIGATED WITH BALANCED
SALT SOLUTION (BSS) TO WASH
AWAY EXCESS TRYPAN BLUE
AND TO STUDY THE DYNAMICS
OF THE DETACHED DM
PRE-OPERATIVE
EVALUATION:
PATIENTS WITH CORNEAL
EDEMA AND DESCEMET’S
MEMBRANE DETACHMENT
(DMD) WERE STUDIED.
THOROUGH PRE-OPERATIVE
EVALUATION WAS DONE
ANTERIOR SEGMENT OPTICAL
COHERENCE TOMOGRAPHY
(ASOCT) WAS DONE
EXTENT OF DETACHMENT AND
THE DEGREE OF TAUTNESS
ASSESSED
Taut Descemet’s Membrane Detachment
•.
26 gauge needle with tip bent in the
reverse direction as capsulotomy needle
AC is filled with BSS/air. Air aids visualization of
edge of DM
Bent needle is introduced into the AC and relaxing Descemetotomy incisions are made
Non-expansile C3F8 (14%) or SF6 (12%)for post-operative tamponade
Extent of incision is determined real time during surgery by assessingdegree of residual foreshortening
Descmetotomy continued till DM isfully apposed against stroma.
Patient maintains a face up positionfor 1 hour.
2 eyes of 2 patients underwent Relaxing Descemetotomy (RD) for TDMD.
The patients tolerated the procedure well and neither required a repeat surgery.
For both cases, the cornea became clearer post-operatively and the RDs could be seen on slit lamp imaging
ASOCT showed an attached DM
• Iso-expansile concentration of SF6 (12%) injected into the AC with face up positioning for 1 hr.
58 yo lady status post therapeutic PK (10 mm graft). Immediate post-op clear graft but at 2 months : corneal edema with TDMD in superior quadrant associated with graft-host junction synechiae.
Long acting SF6 failed to appose DM.
Two Relaxing Descemetotomy incisions were made while AC was filled with BSS.
Post op day 1
Post op ASOCT
Pre-op ASOCT
Multiple small relaxing Descemetotomy incisions made superiorly under air.Air then exchanged with long acting gas (C3F8, 14%) Face up positioning for 1 hour
27 yo female with peripheral corneal thinning and ectasia presented with traumatic rupture globe & inferior corneal tear. Underwent corneal tear suturingSeven weeks later: corneal edema/ epithelial bedewing secondary to TDMD stretching upwards from the wound and iris adhered to wound
Pre-op: Gas tamponade alone was not successful.
PRE-OP ASOCT
Post-op day 1
POST-OP ASOCT
•DMD is occasionally faced by the ophthalmologist after surgery.
•Various techniques have conventionally been proposed:
• observation• viscoelastic injection•air injection and the use of long acting intra-cameral gas• trans-corneal mattress sutures
DMD can be classified as
SDMD and TDMD and
management should be
tailored according to the
type of DMD.
SDMD
TDMD
DMD previously classified as planar or nonplanar based on morphology
We propose new classification of DMD based on etio-pathogenesisStripped Descemet’s Membrane
Detachment (SDMD) Taut Descemet’s Membrane Detachment
(TDMD)
This new classification helps in guiding management of DMD
SDMD TDMDTiming Intra-operative event Intra-operative or post-
operative event
Etiology Pushing force on DM, eg. during viscoelastic injection or due to insertion of blunt instruments or intra-ocular lens
Due to inflammation and fibrosis of DM Due to incarceration of DM within peripheral anterior synechiae/ graft-host junction/ wound/ sutureDue to adhesion and fibrosis of long standing SDMD to intra-ocular contents
Clinical features Undulating/ scrolled/ crumpled membrane in AC
DM stretched out tight like a trampoline between points of attachment
Anterior Segment Optical Coherence Tomography
Undulating linear hyperreflective echo
Straight taut line between two points of attachment
Intra-operative features Typical fluttering movement on irrigation with BSS
No fluttering movements on irrigation with BSS
Management Air or long acting non-expansile gas injection/ suturing/
Relaxing Descemetotomy with long acting non-expansile gas injection
Rationale of surgery Once apposed against overlying stroma, the endothelial pump makes the DM adhere permanently
Relaxing descemetotomy breaks stress forces acting on DM, relieving tautness of DM and allowing gas bubble to appose now lax DM against overlying stroma.
TDMD needs to be differentiated from SDMD as management differs.
Relaxing Descemetotomy is the treatment of choice for TDMD
Relaxing descemetotomy incisions act by breaking stress
forces acting on the DM. The tautness of the DM is relieved
and air or gas bubble is able to appose the now lax DM
against the overlying corneal stroma.
DMD can be classified based on etio-pathogenesis as either Stripped Descemet’s Membrane Detachment (SDMD) or a Taut Descemet’s Membrane Detachment (TDMD).
This classification helps in guiding the line of management
TDMDSDMD
