REVIEW

CURRENT
OPINION Descemet membrane detachment during cataract
surgery: etiology and management
C. Andres Benatti, Jeffrey Z. Tsao, and Natalie A. Afshari

Purpose of review
The review updates the mechanisms, clinical presentations, diagnoses, and managements of Descemet
membrane detachment during cataract surgery.
Recent findings
The advent of new imaging techniques such as anterior segment optical coherence tomography and
better comprehension of the clinical and pathological aspects of detachment have improved the
diagnosis and treatment of this complication to the extent that the first algorithms and protocols have
been proposed.
Summary
Though infrequent, Descemet membrane detachment is a complication of intraocular surgery, including
cataract surgery and phacoemulsification. Since the first systematic description and classification in the
literature by Samuels in 1928 and its characterization as a potential sight-threatening condition by Scheie
in 1964, plenty of retrospective and anecdotal evidence contribute to uncertainty and debate. The main
controversy still lies in the choice between conservative treatment in hopes of spontaneaous reattachment
and surgical treatment in a timely manner to maximize visual recovery.
Keywords
cataract surgery, complication, Descemet membrane, detachment, etiology, management

INTRODUCTION EPIDEMIOLOGY
The Descemet membrane is the specialized base- Monroe [5] described a high incidence (43%) of focal
ment membrane of the corneal endothelial cells DMD after cataract extraction; later, Anderson [6]
that plays a major role in maintaining layer integrity noted small tags or curls of Descemet membrane
and corneal translucence. Descemet membrane located along the internal incision after extracapsu-
detachment (DMD) was first described in 1927 by lar surgery in 42% of eyes studied and small,
Weve [1], although the first systematic description incidental, non-vision-threatening DMD in 5% by
and classification in the American literature belongs routine gonioscopy.
to Bernard Samuels in 1928 [2]. In 1964, Scheie [3] For many years, the accepted incidence of
characterized it as a potential vision-threatening significant sight-threatening DMD after extracapsu-
complication after cataract extraction and high- lar surgery was 2.6%, or 0.5% after phacoemulsifi-
lighted its surgical relevance. Since then, DMD cation [1]. More recent reports established an
&&
has been recognized as a complication after several incidence of 0.044% [7] to 0.52% [8 ] after phaco
intraocular surgeries including iridectomy, trabecu- surgery.
lectomy, holmium laser sclerostomy, pars plana
vitrectomy, and viscocanalostomy [4]. DMD is an
Shiley Eye Center, University of California, San Diego, San Diego,
unusual complication of phacoemulsification California, USA
surgery, but merits consideration as the surgery is Correspondence to Natalie A. Afshari, Shiley Eye Institute, University of
so commonly performed. California, San Diego, 9415 Campus Point Dr, La Jolla, San Diego, CA
The review updates the mechanisms, clinical 92093, USA. Tel: +1 858 822 1569; fax: +1 858 822 1514;
presentations, diagnoses, and managements of e-mail: cbenatti@ucsd.edu
Descemet membrane detachment during cataract Curr Opin Ophthalmol 2017, 28:35–41
surgery. DOI:10.1097/ICU.0000000000000332

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Ophthalmology

risk factors through the univariate analysis in a

KEY POINTS case–control study; whereas preexisting endothelial
 Most Descemet membrane detachment after cataract disease [odds ratio (OR) ¼ 18.7] and first POD
extraction arise from traumatic tears at the incision site. stromal edema (OR ¼ 7.9) were significant inde-
pendent risk factors for DMD in the multiple logistic
 Primary Descemet membrane abnormalities or regression analysis [7].
endothelial disease may contribute.
 AS-OCT is a very useful tool for the diagnosis and
classification of Descemet membrane detachment, and CLASSIFICATION
it may even be a superior alternative to Samuels [2] classified DMDs in active (pushed back)
ultrasound biomicroscopy. detachments, passive detachments (pulled back or
 There is still no gold standard for treatment of DMDs. torn away), and detachments because of difference
in elasticity between the parenchyma and the glass
 Treatment decisions in Descemet membrane detachment membrane.
must be carried out on a case-by-case basis.
In 1977, Mackool and Holtz [22] classified DMDs
into planar when there was 1 mm or less separation
of the Descemet membrane from its overlying stroma
in all areas, and nonplanar if it exceeded 1 mm
CAUSES AND PREDISPOSING FACTORS of separation. Both were further subdivided into
Most DMDs after cataract extraction are surgically peripheral detachment (of the peripheral 3 mm)
induced and usually arise from traumatic tears at and peripheral and central detachment. The authors
the incision site that progress to the central cornea highlighted important therapeutic and prognostic
as acqueous humor enters the predescemetic implications with a better prognosis in planar DMDs
space. Nevertheless, the occurrence of spontaneous without surgical repair.
[9,10] or familial non-surgical DMDs [11] and A third attempt for classification was made by
bilateral [3,12–15] or late-onset post-surgical DMDs Assia et al. [36] who suggested two groups, DMDs
[15–17] suggests that intrinsic Descemet membrane with and without rolled scroll. The case series
anomalies or endothelial disease may contribute reported long-term spontaneous reattachment in
[18]. nonrolled scroll DMDs even if they corresponded
One proposed mechanism is an abnormality in to the nonplanar category.
the fibrillary stromal attachment to Descemet Recently, Jain et al. [37] categorized DMDs
membrane [19] and weak adhesion of the Descemet into three groups according to the extension of
membrane to the stroma consequent to a transform- detachment described as follows: mild if it involved
ing growth factor b-induced protein dysfunction less than 25% of the cornea and was peripheral,
caused by mutation of the transforming growth moderate if it involved 25–50% cornea and was
factor b-induced gene [20]. peripheral, and severe if it involved more than
Shallowness of anterior chamber has been 50% of the cornea or involved the central cornea.
considered a predisposing factor since the first They correlated with visual outcomes after desce-
description of DMD [2,15,21,22]. Surgical risk fac- metopexy but not with spontaneous reattachment
tors described are the use of dull blades [3,23–25], as previous classifications.
use of blunt instruments [24,26,27], inadvertent With the advent of novel imaging modalities,
insertion of instruments between the corneal new classifications have been proposed. Jacob et al.
stroma and Descemet membrane [3], inappropriate [26] described a clinical and tomographic classifi-
incisions (oblique, excessively anterior, or shelved cation of DMDs according to etiology, clinical
incisions) [14,28], tight main incisions that do features, anterior segment optical coherence tom-
not fit the phaco probe [29], engagement of Desce- ography (AS-OCT), intraoperative features, and
met membrane during the irrigation/aspiration management protocol. Rhegmatogenous DMDs
stage, intraocular lens [25,30] or phaco probe are secondary to tear, hole, or dialysis of Descemet
[1,31] insertion, unexpected injection of antibiotics membrane at Schwalbe’s line. Tractional DMDs
[32], saline [1] or viscoelastic [33–35] into the space are caused by traction and foreshortening of
between the deep stroma and DM, and surgeon Descemet membrane secondary to inflammation,
inexperience [21,29]. fibrosis, or incarceration in any of several
Age greater than 65 years, dense cataract, locations: graft–host junction, peripheral anterior
preexisting or presumed endothelial disease, and synechiae, or suture with subsequent contraction.
presence of severe corneal edema on the first post- Bullous DMDs present as a smooth bulge of
operative day (POD) were also significant DMD Descemet membrane into the anterior chamber

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 Descemet membrane detachment Benatti et al.

in the absence of any Descemet membrane break microscopy reveals Descemet membrane and endo-
or with a small needle puncture. Complex DMDs thelium microstructural changes [44,45].
include Descemet membrane macrofolds, rolls or Ultrasound biomicroscopy (UBM) is a useful
scrolled edges as well as combinations of other tool to visualize, locate, and guide surgical repair
variants of DMD. of DMDs, particularly if hazy media impede satis-
&&
In the algorithm proposed by Kumar et al. [8 ] factory visualization [45–48]. Scheimpflug images
[height, extent, length, and pupil-based (HELP) pro- and AS-OCT are noncontact imaging methods of the
tocol], AS-COT imaging parameters of DMDs were cornea and anterior chamber [30]. AS-OCT remains
considered as follows: height less than 100 mm, 100– the best imaging tool and allows high-resolution
300 mm, and more than 300 mm; length less than cross-sectional images of the anterior segment use-
1 mm, 1–2 mm, and more than 2 mm; extent and ful for diagnosis, treatment, and monitoring of
&
pupil involvement classified in zone 1 (central anterior segment disorders [7,38 ,48–53].
5 mm), zone 2 (paracentral, 5–8 mm), and zone Radhakrishnan et al. [49] assessed the accuracy
3 (periphery, >8 mm). They assigned the eyes to of AS-OCT versus UBM in identifying narrow
either medical or surgical treatment and correlated angles with image-derived anterior chamber angle
that with functional and anatomic outcomes. parameters, and although both had similar reprodu-
cibility and sensitivity–specificity profiles, AS-OCT
might be a superior alternative to UBM because of
DIAGNOSIS the speed and ease of image acquisition, the ability
DMDs at the main incision or side port may be to image patients in the upright position, and acqui-
observed intraoperatively through the operating sition of images without direct corneal contact.
microscope, or in the first POD by slit-lamp biomi- Winn et al. [48] compared AS-OCT and UBM with
&
croscopy [27,38 ,39]. They present early as localized study DMDs before surgical repair, the image quality
or diffuse corneal edema usually beginning over of AS-OCT was superior and they proposed that the
the area of detachment. Persistent corneal edema absence of corneal contact reduces the risk
(>2 weeks), a hazy cornea, and decreased visual of infection.
acuity are common. Most recently, a case series of eyes with persist-
Corneal edema is a frequent postoperative ent edema after intraocular surgery was described
complication after cataract surgery, including pha- in which slit-lamp biomicroscopy was not helpful in
coemulsification. Severe non-DMD-related corneal visualizing the posterior surface of the cornea but
edema occurred up to 32.5% in the first POD after AS-OCT detected DMDs in 68% of eyes [52]. AS-OCT
phacoemulsification and reduced to 4.5% after is a very useful tool for the diagnosis and classifi-
10–14 PODs in a case–control study [40]. The cation of DMD and is becoming a standard method
&&
estimated incidence of persistent corneal edema of diagnosis [8 ,10,26,27,33,37,43,51,53–56]. In
was 0.15% in a large multinational database report the presence of corneal edema in the postoperative
[41]. Improper surgical technique, suboptimal setting, AS-OCT should be performed principally if
quality of surgical equipment, and phacoemulsi- available, as slit-lamp examination of the posterior
fication of hard nuclear cataracts are known causal cornea and DM may be unsatisfactory or partial due
factors [7]. to opacification.
Direct exposure of the corneal endothelium to
excessive ultrasonic energy during phacoemulsifica-
tion may result in endothelial damage, cell loss, and MANAGEMENT
secondary corneal swelling [42]; in fact, Descemet There is no gold standard for the treatment of
endothelium complex has shown edematous DMDs. Options include observation, topical treat-
thickening and different degrees of morphological ment with steroids and hyperosmotic agents,
changes with usual recovery of endothelial function intracameral air or expandable gases injection
1 week after surgery [43]. descemetopexy, viscoelastic injection, transcorneal
Consequently, clinical awareness and a careful suturing, endothelial keratoplasty, and convention-
examination are crucial to intentionally look for al penetrating keratoplasty.
DMDs in patients with corneal edema after phaco.
Scheie [3] described the relevance of careful slit-
lamp study after clearing the cornea with topical CONSERVATIVE TREATMENT
glycerin, and Mackool and Holtz [22] applied it Spontaneous reattachment of DMDs with good vis-
systematically to dehydrate the swelled cornea. ual outcome is not unusual but unpredictable and
Gonioscopy improves accuracy of diagnosis of small coincidental. Prolonged DMDs can lead to delayed
and peripheral DMDs [5,6,36], whereas confocal visual rehabilitation or visual loss because of corneal

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Ophthalmology

&&
opacification, Descemet membrane fibrosis, scars, intervention. We consider the HELP protocol [8 ]
contractions, and folds [4,57]. However, conserva- the most comprehensive criteria described for
tive treatment and waiting for spontaneous directing treatment; this algorithm reserves surgical
reattachment avoids surgery and perioperative risks. treatment for DMDs 1–2 mm with a height of 100–
Conservative treatment can be either through 300 mm in zone 1 and DMDs longer than 2 mm and
observation or medication. Though there is not higher than 300 mm in zones 1 and 2; with a reat-
enough evidence about efficacy of drugs, many tachment rate of 95.8% and a corrected distance
have reported the use of topical prednisolone 1% visual acuity of 20/40 or better in 83.3% eyes.
eye drops, topical dexamethasone 0.1% eye
drops, topical betamethasone 0.1% eye drops,
sodium chloride 5% eye drops, or/and sodium DESCEMETOPEXY
chloride 6% eye ointment with mixed results Sparks [12] described this procedure in 1967 after
&&
[4,7,8 ,27,29,30,52,58,59]. withdrawing aqueous and injecting air into the
Mackool and Holtz [22] suggested that spon- anterior chamber of three eyes with extensive
taneous reattachment of nonplanar DMDs was DMDs. Since then descemetopexy has shown good
infrequent and required surgery, whereas planar anatomic attachment rates and visual outcomes
DMDs showed spontaneous reattachment and a and has become the standard surgical treatment
better prognosis with conservative treatment. [7,54,55,68,69]. Concerns about fast absorption
Later, Assia et al. [36] reported spontaneous of the air bubble led to the use of long-lasting
reattachment in nonplanar nonscrolled DMDs gases like 15–20% sulphur hexafluoride (SF6)
suggesting that a nonscrolled detachment would [4,13,14,19,21,57,70] and 12–14% perfluoropro-
reattach even if the separation between the pane (C3F8) [12,21,61,71] successfully.
Descemet membrane and stroma was greater Repeat injection of long-lasting gases has been
than 1 mm. reported as a useful method in cases with failed
Spontaneous reattachment has been observed initial descemetopexy before performing more com-
through a wide timeframe (some weeks to several plex surgical procedures [4,71–73]. Sukhija et al. [71]
months) [17,36,60–62]. In one study reattachment described C3F8 repeated injection in three of 11 eyes
presented in 53% of nonscrolled DMDs between with DMDs after phacoemulsification, with DMDs
weeks 3 and 20 with a mean time for resolution involved more than 50% of the cornea with sub-
of 9.8 weeks [4]. stantial separation and curling or folding of Desce-
In the HELP protocol described by Kumar et al. met membrane. At last follow-up, 10 eyes retained
&&
[8 ], DMDs less than 1.0 mm long and less than clear corneas and one had residual DMD not involv-
100 mm high in any zone, DMDs 1.0 to 2.0 mm long ing the visual axis. Jain and Mohan [72] reported a
and 100 to 300-mm high in zones 2 and 3 and DMDs success rate of 92.3% in cases with repeat desceme-
longer than 2.0 mm and higher than 300 mm in zone topexy after a failed initial procedure following
3 were treated with medication and a 4-week obser- cataract surgery DMDs; they used the same gases
vation period for signs of spontaneous reattachment (air–air and C3F8–C3F8) and also C3F8 after air.
were given; they observed reattachment in 96.9% Datar et al. [73] described effective repeat desceme-
of eyes, with 92.3% reaching a corrected distance topexy with C3F8 after a primary air injection
visual acuity of 20/40 or better. attempt.
Thus far there is no strong evidence supporting
the use of a particular gas. Sharma et al. [52]
SURGICAL TREATMENT described an algorithm where planar DMDs located
As described before, medical treatment alone might in the superior half of the cornea were managed
not be sufficient in all cases and it prolongs using intracameral air, and those with scrolled
the mean time to spontaneous reattachment and edges or located inferiorly were managed using
resolution. intracameral 14% C3F8; all DMDs resolved success-
Early surgical intervention to reattach DMDs is fully within 6–32 days, and only one patient who
generally preferred as it successfully quickens visual underwent C3F8 descemetopexy initially required
recovery, avoid permanent corneal damage, and a second injection.
prevents more complex surgeries like keratoplasty Descemetopexy consists of injecting gas with a
&&
[8 ,12,13,59,61,63–67]. 27 or 30G needle to create a bubble that flattens the
On the whole, peripheral, planar, nonscrolled detached membrane against the stroma and acts
and short DMDs are often treated conservatively, as a tamponade from either the original side-port
whereas central, nonplanar, scrolled, and large incision or a new incision near the site of the
detachments are often managed with surgical detachment, preferably from a site where Descemet

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 Descemet membrane detachment Benatti et al.

membrane is still attached. A better adherence of Amaral and Palay [85] described a technique
Descemet membrane to corneal stroma can be that comprises a paracentesis whereby the anterior
achieved by draining the fluid in predescematic chamber is entered with the first needle and Desce-
space with an external stab incision or by internal met membrane is attached by passing the needle
aspiration with a needle. through the cornea to exit on the epithelial surface.
The incidence of pupillary block was 7.7% in A second needle is then passed through in the same
&&
two studies [8 ,72]; to avoid this complication, way as the first and the suture is tied. The same
surgeons have used cycloplegics, prophylactic laser technique is repeated for the second suture.
iridotomy, oral and topical antiglaucoma drugs, or a Suture fixation alone leaves some areas of
partial fill of anterior chamber with air or gas. Descemet membrane still detached and can cause
Several reports [74–78], in rabbit and cat animal deleterious stretch lines [59], but combination with
models, suggest the presence of corneal endothelial descemetopexy [64] or viscoelastic tamponade [32]
toxicity from using air and expansive gases. Landry can lead to better results.
et al. [78] recommended that these gases be used
with caution, at the minimal dose necessary to
obtain the desired tamponade effect and for no KERATOPLASTY
longer than required. Air should be favored over Penetrating keratoplasty [4,16,26], Descemet
&
SF6 even though previous reports found similar membrane endothelial keratoplasty [26,87 ], and
toxicity among three gases [76]. Nevertheless, as Descemet-stripping automated endothelial kerato-
yet, adverse effects related to these gases have not plasty [88] are the final therapeutic options for
been reported when applied in descemetopexy. DMDs. These procedures are reserved for long-term,
persistent DMDs with severe corneal edema, scar-
ring, and shrinking of Descemet membrane. The
MECHANICAL TAMPONADE main limitations are the availability of corneal tis-
Injection of viscoelastic into the anterior chamber sue, need for long-term follow-up, and risk of infec-
was described in literature by Donzis et al. [79] in tion and rejection [72,89]. Some case series have
1986 and confirmed by later studies [32,53,80] as a reported that 11.5–13.3% of eyes with DMDs
means of successfully reattaching DMDs. require keratoplasty [4,39].
Generally, viscoelastic tamponade is applied Kim and Kim [88] reported three cases of exten-
with recurrence of detachment after air or gas injec- sive DMDs after phaco that were treated unsuccess-
tion. However, Sharma et al. [52] reported a mixed fully with air descemetopexy. Descemet-stripping
method with the injection of viscoelastic immedi- automated endothelial keratoplasty was performed
ately after detachment is detected intraoperatively, achieving faster visual recovery with reduced post-
such that Descemet membrane is transiently reat- operative astigmatism and decreased risk for suture-
tached and repaired at the end of the surgery via related complications. The authors recommended
air descemetopexy. Because injection of viscoelastic intraocular lens exchange for hyperopic shift.
material can lead to increased intraocular pressure,
treatment with topical or oral intraocular-pressure-
reducing drugs may be indicated. CONCLUSION
Other agents such as intracameral perfluoro- Treatment decisions in DMDs should consider a
n-octane (PFCL) have successfully reattached persist- case-by-case evaluation of the detachment, prob-
ent DMD [81]. Though concerns about the toxicity of ability of spontaneous resolution, need for surgery,
perfluorocarbons were raised after reports of the optimal time for intervention, surgical technique,
effect of perfluorodecalin on human corneal endo- and risks. Although there is still no gold standard for
thelium [82], a study showed that residual PFCL in treatment of DMDs, those peripheral, planar, non-
anterior chamber is well-tolerated and does not scrolled, and short are often treated conservatively,
induce corneal damage or ocular inflammation [83]. and those central, nonplanar, scrolled, and large are
often managed with surgical intervention. New
imaging modalities and improvements in surgical
SUTURE FIXATION techniques allow for better visual outcomes and
DMDs can be repaired with sutures as reported by recovery. The prevalence of anecdotal and retro-
numerous authors with variable degrees of success spective evidence makes the diagnosis and manage-
[12,25,60,63,64,67,84 – 86]. Commonly, trans- ment of this sight-threatening complication an area
corneal interrupted 10-0 nylon suture is applied to of uncertainty and debate. A large prospective and
reattach Descemet membrane to corneal stroma at multi-center study would help clear many doubts
one or several positions, usually four. and concerns.

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