Spontaneous Descemet Membrane Detachment After Penetrating Keratoplasty—Clinical Presentation and Outcome of Air/Gas Descemetopexy

Abstract

Purpose: To describe the clinical characteristics and treatment of spontaneous Descemet membrane (DM) detachment occurring decades after penetrating keratoplasty (PK). Methods: A multicenter interventional case series design was used. We reviewed the medical records of 4 patients with a history of PK presenting with spontaneous DM detachment at 3 university hospitals in Israel and an ocular surgery institute in The Netherlands in 2016 to 2019. Patient demographic and clinical data, postoperative best corrected visual acuity, findings on preoperative and postoperative anterior segment optical coherence tomography (AS-OCT), and graft survival were recorded. Results: Patients were aged 46 to 50 years. All had undergone PK for keratoconus 20 to 26 years previously. Patients presented within 18 to 180 days of onset of visual disturbance. Symptoms included sudden painless visual loss (2 patients), gradual visual loss and foreign body sensation (1 patients), and visual loss not otherwise specified (1 patient). Slit-lamp examination showed corneal edema, and AS-OCT showed DM detachment of variable extent. In 2 patients, the initial diagnosis was graft rejection and failure. Treatment consisted of anterior chamber injection of air (n = 3) or 20% SF6 (n = 1). In 3 patients, the DM reattached and the cornea regained its clarity. The fourth patient had persistent DM detachment that required repeated PK. Conclusions: Spontaneous DM detachment can mimic late graft failure in patients after PK. If diagnosed early, DM reattachment may be performed by air/gas injection, avoiding repeated keratoplasty. Eyes with presumed late penetrating graft rejection or failure should be examined by AS-OCT to exclude DM detachment.

Management of Late Descemet's Membrane Detachment After Penetrating Keratoplasty in Keratoconus

“…However, reports in the literature have shown successful air descemetopexy up to 30 to 180 days after onset of symptoms. 5 Furthermore, air injections had not been successful in cases with short interval between onset of symptoms and intervention, for example, in a patient with a 2-week history of symptoms as reported by Gorski et al 7 Thus, other factors than cells between the DM layers seem to be crucial for the success of air injections. The EM findings do not have direct impact on clinical work but give evidence for the pathophysiology of late DMD.…”

“…Several therapeutic strategies have been described: observation until spontaneous resolution, 4,8,9,11 descemetopexy by air or SF 6 gas injection, 4,5,7,11 partial descemetorhexis with air injection, 6,7,10 graft repositioning/resuturing, 10 DSAEK, 6,7 and repeat PK. 4,5,8 This is the first report on 4 cases with successful DMEK for the treatment of spontaneous DM detachment after PK.…”

Comment on: Nahum et al “Spontaneous Descemet Membrane Detachment After Penetrating Keratoplasty—Clinical Presentation and Outcome of Air/Gas Descemetopexy” (Cornea 2020;39:1499–1502)

“…We read with interest the article by Nahum et al 1 entitled "Spontaneous Descemet Membrane Detachment After Penetrating Keratoplasty-Clinical Presentation and Outcome of Air/Gas Descemetopexy." The authors described a case series of 4 patients who presented with spontaneous Descemet membrane (DM) detachment after a previous penetrating keratoplasty (PK) for keratoconus 20 years earlier or more.…”

“…1 Three patients were treated with air injection into the anterior chamber with good anatomical success, whereas 1 patient was treated with 20% sulfur hexafluoride, but the DM detachment (DMD) persisted requiring a repeat PK. 1 The authors emphasized the importance of anterior segment optical coherence tomography (AS-OCT) for early identification of DM detachment and expedite reattachment through air or gas tamponade once the diagnosis is visualized. 1 Importantly, however, the authors have not discussed the conservative approach with the observation, which may be a clinically preferable option in some cases avoiding risks of intraocular procedures.…”

“…1 The authors emphasized the importance of anterior segment optical coherence tomography (AS-OCT) for early identification of DM detachment and expedite reattachment through air or gas tamponade once the diagnosis is visualized. 1 Importantly, however, the authors have not discussed the conservative approach with the observation, which may be a clinically preferable option in some cases avoiding risks of intraocular procedures. We do acknowledge that their cases presented with more than 18 days from the onset of symptoms.…”