Hemorrhagic Descemet Membrane Detachment during Ab Interno Canaloplasty

Case Reports in Ophthalmological Medicine
10 Jun, 2019 ,

A 60-year-old male with uncontrolled primary open-angle glaucoma (POAG) underwent ab interno canaloplasty in the left eye. The previous corrected visual acuity was 20/400 and intraocular pressure 26 mmHg with maximum medical therapy. There was evidence of minor intrastromal bleeding and limited Descemet membrane detachment during the introduction of intracanalicular viscoelastic. Speculate that the Descemet detachment occurred owing to the excessive pressure while injecting the viscoelastic. A conservative management was decided due to the size of the detachment outside the visual axis. On the first postsurgical day, the slit lamp biomicroscopy confirmed that the paralimbal extension of the pre-Descemet hemorrhage was 3mm and the radial extension was 2mm. Moreover the initial thickness of the pre-Descemet hemorrhage measurement with anterior segment OCT was 0.6mm. The follow-up was done weekly. At 3 months postoperatively, cornea recovered its transparency and morphology and intraocular pressure was 18mmHg with maximum medical therapy.

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A 60-year-old man with advanced bilateral open-angle glaucoma for 3 years, not controlled with maximum medical therapy in the left eye, underwent phacoemulsification in the left eye in 2014. The medical records did not register coagulation disorders and the patient denied to have taken antiplatelet medicine or anticoagulants.

Before the surgery, the uncorrected visual acuity (UCVA) was 2.5 and 1.3 LogMAR in the right and left eye, respectively. The intraocular pressure was 12mmHg in the right eye and 26mmHg in the left eye with maximum medical therapy. On Humphrey Field Analyzer (HFA) 24-2 automated perimetry mean deviation (MD) was -16.92 in the left eye, pachymetry was 517 microns in the right eye and 492 microns in the left eye, and the number of central endothelial cells was 2127 cells/mm2 in the right eye and 1312 cells/mm2 in the left eye.

Ab interno canaloplasty was performed routinely in the left eye by a glaucoma specialist. The temporary corneal incision was made at hour 9 and another lateral incision was made at hour 2 to introduce the iTrack catheter (iTrack-250A; iScience Interventional, Menlo Park, CA, USA). Sodium hyaluronate was injected (Healon GV; Abbott Medical Optics, Santa Ana, CA, USA) in the anterior chamber. Gonioscopy was used (AVG; Surgical Gonio Lens, Volk Alcon, Mentor, OH, USA) for goniotomy with Kahook dual blade (KDB; New World Medical, Rancho Cucamonga, CA, USA), and by using tying forceps (Intraocular Tying Forceps, 23G 4-1891, Rumex, USA) the catheter was pushed circumferentially through 360°, by applying two viscoelastic clicks per hour when removing it.

The procedure was performed correctly; however, during the viscodilation of the Schlemm canal with sodium hyaluronate, a small hemorrhage was observed with viscoelastic related to the Descemet membrane detachment. The paralumbar extension was 3.0 mm and radial extension was 2.0 mm between hours 4 and6 in peripheral inferonasal quadrant. At first we opted for observation because the injury did not compromise the visual axis and the size of the detachment was not large enough to indicate a surgical procedure immediately.

(A) First day after the surgery. Picture of the slit lamp showing a Descemet membrane detachment with partial intrastromal hemorrhage. (B) Gonioscopy evidencing Descemet detachment with intrastromal hemorrhage, 1st day after the surgery. (C) Gonioscopy evidencing Descemet detachment with intrastromal hemorrhage 1st month after the surgery with a reduction of the extent of the injury. (D) OCT of anterior segment (Visante, Model 1000, Carl Zeiss Meditec, Dublin CA, USA), showing intrastromal hemorrhage. (E) OCT Anterior Section, second week after the surgery (4 January 2018). (F) OCT Anterior Section, sixth week after the surgery (2 February 2018). (G) OCT Anterior Section, tenth week after the surgery (1 March 2018). (H) OCT Anterior Section, twelfth week after the surgery (19 March 2018).

A serial control with anterior segment OCT (Visante, Model 1000, Carl Zeiss Meditec, Dublin CA, USA) has been done to follow the thickness; the initial thickness of intrastromal hemorrhage was 0.6mm, and at the first week it was 0.51mm, at the first month 0.42mm, and at the second month 0.28 mm and third month 0.03 mm. The examination evidenced presence of blood in the peripheral inferonasal quadrant of the pre-Descemet area at hours 4-6.

Considering the extension of the detachment, a conservative management was decided, monitoring the progressive reabsorption of the hemorrhage and viscoelastic, which progressively occurred.

The intraocular pressure levels remained lower than 21mmHg in the early postoperative period with glaucoma medications; 3 months after the surgery the intraocular pressure was 18mmHg with 3 antiglaucoma medications. The uncorrected visual acuity (UCVA) showed a significant improvement from 1.30 in the preoperative period to 0.8 LogMAR in the left eye after 3 months of monitoring. Final BCVA was 0.6 LogMAR.

According to Hodapp classification, the visual field defect 10-2, stimulus III, and white-on-white of the left eye indicated a stable advanced stage glaucoma with a MD of -31.4.

Three months after the surgery, the Descemet membrane detachment with intrastromal hematoma completely recovered; the membrane was reattached correctly and remained that way during the monitoring with the transparent cornea along with no visual consequences.