Often, novel surgical techniques develop as the result of the appearance of new intraoperative complications. We must not only know and understand these complications but also find ways to resolve them.
In this article, we present a clinical case that illustrates how the risk of Descemet's membrane detachment was increased after a new intraocular surgery, lamellar keratoplasty, was performed in a patient.
CASE PRESENTATION
A 25-year-old man visited our clinic in 2004 for a refractive surgery evaluation (Figure 1). His visual acuity was 20/80 (+1.50 -6.00 X 50) in his right eye and 20/50 (+2.50 -6.00 X 110) in his left. We diagnosed keratoconus and axial myopia in both eyes.
We decided to perform lamellar keratoplasty in the patient's right eye (Figure 2) and implant an Intacs intrastromal corneal ring segment (Addition Technology, Inc., Des Plaines, Illinois) in his left. The surgery was without complications; however, 3 months postoperatively the patient developed a major refractive defect (10.00 D of myopia; refraction, -11.00 -2.00 X 70; visual acuity, 20/40) and could not adapt to a contact lens in his right eye. With the patient's consent, we implanted a phakic IOL (Kelman Duet IOL; Tekia, Inc., Irvine, California; Figure 3) for the correction of his myopia.1,2
The Kelman Duet is an angle-supported IOL with two independent parts (haptic and optic) that are introduced into the anterior chamber through a sub–3-mm incision. The optic diameter is 6.6 mm. Once inside the eye, the optic is mounted to the haptic on two small hinges that hook the lens. With the Kelman Duet IOL, there is no induced cataract or glaucoma and no risk of endothelial damage.
HOW WOULD YOU PROCEED?
During surgery, we made a 3-mm incision and placed the haptic with three points of angular support (Figure 4). Using the same incision, we implanted the optic, which entered the anterior chamber and unfolded without complication; however, as the optic was assembled in the haptic across the two anchoring hinges, we discovered an almost invisible membrane separating the two parts of the lens (Figure 5). This complication occurred upon introduction of the IOL, when we accidentally dissected Descemet's membrane. Descemet's membrane, together with the endothelium, were caught under the optic.
We knew explantation of the IOL was necessary but we also knew it would be extremely difficult to execute. Whatever maneuver we chose, we needed to be careful not to further damage Descemet's membrane or the endothelium.
If this were your patient, how would you proceed?
HOW WE PROCEEDED
After extending the incision and placing methylcellulose between Descemet's membrane and the stroma, we explanted the lens without further complication. We then placed air and more methylcellulose into the anterior chamber to reposition Descemet's membrane and adhere the endothelium to the corneal stroma. We closed the incision with a 10-0 nylon suture (Figure 6).
FOLLOW-UP
After surgery, Descemet's membrane was supported and adhered to the stroma (Figure 7A); however, by the fifth day we noticed a total detachment of Descemet's membrane and corneal edema (Figure 7B). We then decided to administer sulphur hexafluoride (SF6) into the anterior chamber3,4,5 and aspirate the methylcellulose. First, we repositioned Descemet's membrane and the endothelium onto the corneal stroma. An SF6 gas bubble was then injected to help Descemet's membrane stick to the stroma. The bubble disappeared 10 days later (Figures 7C, 7D).
The next day, the patient's intraocular pressure was 35 mm Hg, which we controlled with oral acetazolamide and hypotensive eyedrops. Figure 8 shows Descemet's membrane in good position without detachment. The SF6 gas was reabsorbed 10 days after surgery.
We monitored the patient for the next 6 months. No new complications developed, and his corneal edema diminished (Figure 9). When the patient returned for 10-month follow-up, his cornea was transparent, his endothelial cell count was 1,600 cells/mm2, and Descemet's membrane was well adhered to the corneal stroma. The patient's BCVA was 20/30 (-11.00 -2.50 X 180).
At that time, we contemplated implanting the Kelman Duet phakic IOL for the second time in this patient. The previously implanted haptic was still in the eye and in good position. After explaining the high risk of corneal decompensation, the patient agreed to the procedure. This time, surgery was carried out without complications (Figure 10).
His visual acuity is now 20/25 (+1.50 -2.25 X 160), the cornea is transparent, and the endothelial cell count is 1,550 cells/mm2 (Figure 11).
WHAT HAVE WE LEARNED FROM THIS CASE?
Results of this clinical case could help us prevent new complications that may occur during any surgery that implants a foldable IOL, via a corneal incision, into a patient with a history of lamellar keratoplasty. Peripheral corneal incisions should be used to avoid the risk of dissection of Descemet's membrane when introducing a phakic or pseudophakic IOL into the eye.
Jorge L. Alió, MD, PhD, is Professor and Chairman of Ophthalmology, Miguel Hern·ndez University, Alicante, Spain, and Medical Director of Vissum Corp. Professor Alió states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +34 96 515 00 25; e-mail: jlalio@vissum.com.
Gonzalo Bernabeu, MD, practices with the Vissum-Instituto de Oftalmológico de Alicante, Spain. Dr. Bernabeu states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +34 96 515 00 25; e-mail: gonbernabeu@hotmail.com
