L. V. Prasad Eye Institute - Anatomic and Visual …classroster.lvpei.org/cr/images/ARCHEIVE/2016/MAR/Dr...2016/03/24  · board of L V Prasad Eye Institute, Hyderabad, India. As per

Anatomic and Visual Outcomes ofDescemetopexy in Post-Cataract SurgeryDescemet’s Membrane Detachment

Rajat Jain, MBBS, MS,1 Somasheila I. Murthy, MBBS, MS,1 Sayan Basu, MBBS, MS,1

Md. Hasnat Ali, MBA,2 Virender S. Sangwan, MBBS, MS1

Objective: To study the anatomic and visual outcomes of descemetopexy in Descemet’s membranedetachment (DMD) after cataract surgery.

Design: Retrospective case series.Participants: Clinical notes of 60 patients who underwent DMD after cataract surgery between 2007 and 2011.Methods: Descemetopexy was performed with air or 14% isoexpansile perfluoropropane (C3F8).Main Outcome Measures: Anatomical (reattachment rates) and functional results (best-corrected visual

acuity) were studied. Secondary outcome measures were assessment of surgical complications and associationof various factors with final visual outcome.

Results: The mean age of the patients was 64.3�8.3 years, and the male:female ratio was 21:39. At 1 month,the mean logarithm of the minimum angle of resolution (logMAR) interval visual acuity (IVA) improved from 1.27�0.8to 0.42�0.49 (P � 0.001). Five patients (8.3%) obtained 20/20 vision, and 37 of 60 patients (61.6%) achieved IVA of�20/40. Ninety-five percent (57/60) of patients had successful reattachment of the Descemet’s membrane (DM) afterthe intervention. Multiple linear regression analysis showed that patients with a cataract score of 5 (estimate � 0.38;P�0.014), with a cataract score of 4 with compromised visibility due to a corneal opacity (estimate � 0.45; P�0.039),and prolonged duration between cataract surgery and descemetopexy (estimate � 0.012; P�0.007) were associatedwith a significantly poorer final visual outcome. No association of final visual outcome was observed with age; sex; eyetreated; cataract scores 2, 3, and 4; preoperative visual acuity; and involvement of the visual axis (P � 0.5). The eyesin which air was used for descemetopexy (estimate � �0.2; P�0.009) had statistically significantly better final visualoutcomes. Three patients (5%) had treatment failures and required subsequent endothelial transplantation. Pupillaryblock was observed in the early postoperative period in 7 patients (11.66%) in whom C3F8 had been used and wasnot seen with air (P�0.02).

Conclusions: This study suggests that DMD after cataract surgery can be treated effectively and good visualoutcomes can be expected if the patient is treated in time with anterior chamber injection of gas. Air hasadvantages of better efficacy than C3F8 without the risk of pupillary block and thus should be preferred.

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed

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Descemet’s membrane detachment (DMD) is a well-recognizedand potentially vision-threatening complication of cataract sur-gery. It occurs when fluid enters the corneal stroma through abreak in Descemet’s membrane (DM) or an area of separationbetween the DM and the corneal stroma. Acute loss of visionfrom severe corneal edema can be the first sign and may alsobe the cause of a delayed diagnosis.1

After its earliest descriptions by Samuels (1928)2 andScheie (1964),3 DMD has been studied further in greaterdetail.4–6 It has most often been reported after cataract extrac-tion.7–10 A review of literature revealed that only 1 report hasdetermined the incidence of DMD. It was found to be 2.6% forextracapsular cataract extraction (ECCE) and 0.5% for phaco-emulsification.5 The presence of DM tags or scrolls alongthe interior lip of the sclera-corneal incision have beennoted, with an incidence determined by gonioscopy to be11% to 42%.11,12 Small, subclinical detachments are likely

1366 © 2013 by the American Academy of OphthalmologyPublished by Elsevier Inc.

olve spontaneously within days after surgery. However,arger detachments of DM can lead to more serious postop-rative complications, making their identification and man-gement an important part of the postoperative evaluation.

The natural history of DMD and the appropriate timingf intervention have been an ongoing debate. There is nolarity in the existing literature regarding the need for sur-ical reattachment13–16 and the efficacy of various sub-tances used as tamponade, such as 100% air, viscoelasticaterial, 14% isoexpansile perfluoropropane (C3F8) and 20%

ulfur-hexafluoride.10 Potter and Zalatimo17 have reported airo be the least efficacious tamponade for descemetopexy.

The earlier larger series in this regard reported 12 casesver a period of 18 years7 or 15 cases over a period of 15ears.8 Considering the significance of DMD discussedarlier and taking into account the lack of consistency andlarity in the existing literature, we aim to compare the

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spect to the use of air or C3F8. To the best of our knowledge,this is the largest such series, the first comparative studypublished so far and the first to report the association ofvarious factors that could be responsible for the final visualoutcome in these patients.

Materials and Methods

Study Design and Subjects

This retrospective study was approved by the institutional reviewboard of L V Prasad Eye Institute, Hyderabad, India. As perhospital protocol, written informed consent was obtained from allpatients before all the surgical procedures and the investigationsthat they underwent.

This study included patients who underwent anterior chambergas injection (descemetopexy) for the treatment of DMD aftercataract surgery between January 1, 2007, and December 31, 2011.Descemet’s membrane detachment was identified on slit-lampexamination as separation of the DM from the posterior stromawith an area of corneal edema overlying it (Fig 1). Patients whohad DMD that was recognized during surgery and were treatedwith descemetopexy in the same setting, and patients without aminimum follow-up of 1 month were excluded from the study.

Of the approximately 40 000 cataract surgeries that were per-formed at the institute from January 2007 to December 2011, 324eyes (0.81%) developed DMD intraoperatively or postoperatively.Of these, 178 eyes receiving descemetopexy intraoperatively andanother 102 patients without a follow-up of at least 1 month wereexcluded. Therefore, 44 patients who fulfilled the inclusion criteriawere included in the study. Furthermore, 16 patients were referredto the L V Prasad Eye Institute with the diagnosis of post-cataract

Figure 1. A, Slit-lamp photographs of a case of Descemet’s membrane d

urgery DMD and were also included in the study, thus making ittotal of 60 patients.

ata Collectionhe data retrieved from the medical records included age, sex, theye operated, presence of any corneal opacity (which obscured theiew of the anterior segment during the cataract surgery), cataractcore, type of initial cataract surgery, severity of DMD, intervalisual acuity (IVA) in the logarithm of the minimum angle ofesolution (logMAR) (preoperative IVA) and duration betweenescemetopexy and previous cataract surgery. A specialized cata-act scoring system was used to assess the severity of the cataract.uclear cataract was given a score of 0 to 3, as graded in the Lenspacities Classification System II.18 An additional score of 1 eachas added if the patient had a posterior subcapsular cataractbscuring more than 30% or a cortical cataract obscuring morehan 50% of the fundal glow. So the combined cataract score couldange from 1 to 5. The severity of the DMD was classified as mild,oderate, and severe. It was considered to be mild if it involved25% of the cornea and was peripheral, moderate if it involved

5% to 50% cornea and was peripheral, and severe if it involved50% of the cornea or involved the central cornea (Fig 2). Other

etails noted were the type of gas used for anterior chambernjection and any intraoperative or postoperative complications.ostoperative details at 1 month included status of DM attachmentnd best-corrected visual acuity (postoperative logMAR).

utcome Measureshe primary outcome measures were studied at 1 month. Assess-ent was done for the final status of the detached portion of theM (anatomic) and the improvement in the IVA (functional). The

econdary outcome measures included complications of the pro-

ment showing inferior corneal edema with Descemet’s membrane (DM)

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cedure and the association of various factors with the final visualoutcome.

Preoperative Examination

All patients underwent visual acuity testing, slit-lamp examination,and intraocular pressure measurement on the first postoperativeday when the DMD was noted. It was decided to observe themmedically if the detachments were mild. These patients underwentsurgery if the DMD persisted at follow-up. The timing of thesurgery depended on the treating physician. Other moderate orsevere DMDs were treated surgically on the same day. Somepatients underwent a Visante anterior segment optical coherencetomography (AS-OCT) (Carl Zeiss Meditec, Dublin, CA) to de-lineate the exact location and extent of the DMD.

Surgical Technique

Descemetopexy was performed in the operating room with allaseptic precautions using topical or local anesthesia. Under anoperating microscope, a 26G cannula was taken and mounted on a5-ml disposable syringe. The syringe was filled with 100% air orisoexpansile mixture of 14% C3F8, the choice of which waspredecided and based on the operating surgeon’s preference. Thegas was aspirated into the syringe through a micropore filter. Ananterior-chamber paracentesis was made with a micro vitreoretinalblade (Alcon Surgical, Fort Worth, TX). The site of entry was inan area other than the area of the DMD. Once adequate aqueousfluid was ejected, the syringe filled with gas or air was inserted into

Figure 2. Grading of the severity of Descemet’s membrane detachment. Mto 50% cornea and was peripheral. Severe involved �50% of the cornea

the anterior chamber. A continuous, single bubble of the gas was a

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imed into the anterior chamber. Once a complete gas-filled cham-er was maintained, the side-port entry was hydrated or suturedith a 10-0 monofilament nylon suture. The eye was patched inost cases.

ostoperative Management

n the first postoperative day, the patient was examined specifi-ally to assess the attachment of the DM. A standard postoperativereatment of topical antibiotics (ofloxacin 0.3% or moxifloxacin.5% eye drops) given for 1 week and tapering doses of topicalteroids (betamethasone 1% or prednisolone acetate 1%) given forweeks was followed. Postoperatively, any increase in intraocular

ressure was managed with topical or oral antiglaucoma medica-ion. Further follow-ups were done at 1 week and 1 month. Thenatomic attachment of the DM, vision, and intraocular pressureere noted at every visit. An anterior chamber AS-OCT waserformed in some patients postoperatively to confirm the attach-ent of the DM. The surgical procedure was repeated if the DMD

ersisted on the first postoperative day, as evaluated on a slit lampr AS-OCT.

tatistical Analysis

tatistical analysis was performed using R (version 2.14.2) statis-ical software (http://www.r-project.org). All the descriptive pa-ameters were noted in the form of mean and standard deviation ifhe data were parametric or in the form of median with interquar-ile range if the data were nonparametric. A 2-tailed t test was

volved �25% of the cornea and was peripheral. Moderate involved 25%ntral cornea.

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after the surgical procedure. A multiple linear regression analysiswas performed in this study because the outcome (visual acuity) isa continuous variable. The linear regression analysis provides uswith individual P values and the least-square estimates. The largerthe value of the estimate the greater the impact on the outcome; thesign of the estimate (positive or negative) indicates the nature ofthe relationship between the independent variables and the out-come (available at: http://www.stat.yale.edu/Courses/1997-98/101/linmult.htm; accessed September 20, 2012).

Results

Patient Population

The mean age of the patients was 64.3�8.28 years, the male:female ratio was 21:39, and the ratio of the right and left eyeinvolvement was 36:24. A corneal scar obscured the view duringthe cataract surgery in 9 patients (15%), and 6 patients (10%) hada pterygium that extended more than 3 mm into the cornea. Themedian DMD severity was 3 (interquartile range, 0), and themedian cataract score was 3 (interquartile range, 1.25). The dis-tribution of DMD severity and cataract score with the visual acuityis summarized in Tables 1 and 2. Descemet’s membrane detach-ment most commonly occurred in our series after small-incisioncataract surgery (SICS; n�44). Other surgical procedures includedphacoemulsification via scleral incision (n�14) and conventionalECCE (n�2).

The average time period between the cataract surgery and thedescemetopexy after DMD was 11.46�13 days. The mean preop-erative logMAR IVA of the group was 1.27�0.8 (range, �0.18 to3). Whereas DMD was seen at the anterior chamber maintainer(ACM) port in 81.8% of patients (36/44) who had undergoneSICS, it was most commonly seen at the sideports and the mainincision in patients who underwent phacoemulsification or SICS.Also, 96.6% (58/60) of DMDs were moderate or severe (Table 1).Air was used for anterior chamber injection in 24 cases, and C3F8

Table 1. Interval Visual Acuity by Severity of Descemet’sMembrane Detachment

DMDSeverity

Patients(n)

Preoperative IVA(logMAR)

Postoperative IVA(logMAR) P Value

Mild 2 1.1�0.1 0.3�0.15 NAModerate 5 0.99�1.15 0.2�0.127 0.16Severe 53 1.31�0.78 0.45�0.52 �0.0001

DMD � Descemet’s membrane detachment; IVA � interval visual acuity;logMAR � logarithm of the minimum angle of resolution; NA � notapplicable.

Table 2. Interval Visual Acu

CataractScore

CornealOpacity (n) Patients (n)

P

2 5 153 3 214 2 135 5 12

IVA � interval visual acuity; logMAR � logarithm of

as used in 36 cases. Table 3 shows that the preoperative data inhese 2 groups were comparable.

utcome Assessment

t 1 month, the mean logMAR IVA improved from 1.27�0.8range, 0.18–3; 95% confidence interval, 1.07–1.47) to 0.42�0.49range, 0–2; 95% confidence interval, 0.3–0.54). This differenceas statistically significant (P � 0.001). Five patients (8.3%)

chieved 20/20 vision, and 61.6% of patients (37/60) achieved anVA of �20/40. Ninety-five percent of patients (57/60) had auccessful reattachment of the DM after the intervention. The IVAmproved in patients with all grades of severity of DMD butttained statistical significance only in patients with severe DMDP � 0.001) (Table 1). The IVA was significantly better in patientsith all pre-intervention cataract scores (P � 0.05) (Table 2).igure 3 shows a representative case with DMD after cataracturgery treated with air descemetopexy. The cornea of the patientradually cleared over 1 month.

Upon subgroup analysis, we found that 9 patients requiredhe intervention to be repeated twice. Preoperatively, this groupas comparable to the group of patients in whom descem-

topexy was done only once in age (P�0.93), cataract scoreP�0.47), DMD severity (P�0.78), and preoperative IVAP�0.30). In a repeat descemetopexy, the same gas that wassed initially was used again for anterior chamber injection inpatients. In 2 patients, air had been used earlier and the repeat

ntervention was done with C3F8. At 1 month, although none ofhe patients attained IVA of 20/20, there was no statisticalifference in the mean postoperative IVA (P�0.77), patientsttaining 20/20 vision (P�0.43), patients attaining �20/40 vi-ion (P�0.28), rates of failure of DM attachment (P�0.33), andncidence of pupillary block (P�0.42).

Multiple linear regression showed that the factors associatedith a significantly poorer final visual outcome were found inatients with a cataract score of 5 (estimate � 0.38; P�0.014), aataract score of 4 with compromised visibility due to a cornealpacity (estimate � 0.45; P�0.039), and prolonged duration be-ween the cataract surgery and the descemetopexy (estimate �.012; P�0.007). The factors associated with statistically signifi-antly better IVA were found in patients in whom phacoemulsifi-ation from the scleral incision (estimate � �0.18; P�0.02) oronventional ECCE (estimate � �0.55; P�0.013) was done andn whom air was used as the agent for anterior chamber injectionestimate � �0.2; P�0.009). No association of final visual out-ome was observed with age, sex, eye treated, cataract scores 3nd 4, preoperative visual acuity, involvement of the visual axis,nd intraoperative visibility as regards the corneal pathologyP � 0.5).

n Different Cataract Scores

rative IVAgMAR)

Postoperative IVA(logMAR) P Value

8�0.92 0.55�0.61 0.0075�0.82 0.29�0.35 �0.001

.3�0.83 0.48�0.52 0.0084�0.64 0.428�0.531 0.0011

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Treatment Failures and Adverse Events

Three patients (5%) with persistent DMD and corneal edemarequired subsequent endothelial transplantation for visual rehabil-itation. There was no difference in the failure rate, whether air orC3F8 was used (P�0.44). Early post-descemetopexy pupillaryblock was seen in 7 cases (11.66%) in which C3F8 had been usedand in none of the eyes treated with air (P�0.02). This wastransient, and appropriate medical management relieved the pupil-lary block. None of these eyes showed a persistent increase inintraocular pressure or glaucoma.

Discussion

Descemet’s membrane detachment is a rare but vision-threatening complication of cataract surgery.1,5 There is arelative paucity in the literature regarding the guidelines forthe management of DMD. Some of the questions that stillremain unanswered are whether an intervention is warrantedin all cases of DMD and, if required, what duration is ideal,which is the best agent to treat it with, and whether anyother factors influence its final outcome.

Observation in cases of smaller or inferior DMD mightavoid the inherent risks of intervention,13,14 but a delay inrepair may be complicated by fibrosis, shrinkage, and wrin-kling of DM, which may subsequently prevent reattach-ment.7 In a series of 5 patients, Assia et al6 stated thatobserving a nonscrolled DMD conservatively might lead toits resolution, but the duration of recovery was prolonged,ranging from 1 to 3 months. Modern cataract surgery isconsidered to be a refractive surgery, and patients expectexcellent vision almost immediately. Thus, despite severalreports of spontaneous DMD reattachment,13,14 an earlyrepair is advocated.15–17

Anterior chamber injection of gas as the primary man-agement strategy has been well described.1 It can hasten theabsorption of corneal edema and, thus, visual recovery.There is a paucity of existing literature, with only isolatedcase reports or small case series published so far.5–9,19,20

Also, none of the previous reports were able to demonstratethe association between the various factors and the finalvisual outcome. This study presents the largest case series ofmanagement of DMD published to date. We have attempted

Table 3. Preoperative Data in Groups of P

Air (n � 24)

Mean SD 95% CI

Age, yrs 64.16 9.33 60.72–67.6Sex (male) 10/24 21.88–61.3Eye (OD) 6/24 7.68–42.3Cataract score 3.41 1.13 2.97–3.85Corneal pathology 5/24 4.56–37.0DM severity 2.95 0.2 2.78–3.13Preoperative IVA 0.12 0.15 0.05–0.2

CI � confidence interval; C3F8 � perfluoropropane; DM � Descemet’s meye); SD � standard deviation.

to analyze the various risk factors that affect the occurrence m

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nd resolution of a DMD. In this study, we found thatescemetopexy with air or C3F8 for DMD after cataracturgery had good anatomic and functional outcomes. How-ver, the final visual acuity in our series was adverselyffected if the Descemet’s detachment occurred in patientsho had a more advanced cataract, underwent an SICS,r had a prolonged duration of intervention after cataracturgery.

Similar to our findings, the existing literature states thathe visual acuity of patients with DMD after the descem-topexy procedure is significantly better than their preoper-tive visual acuity,8,19 proving the necessity of treatment forMD. A repeat descemetopexy also is not uncommon. Ninef 60 patients (15%) required repeat intervention in oureries, with comparable visual and functional outcomes at 1onth. Mahmood et al7 and Marcon et al8 also had to resort

o repeat injections in a few patients in their study becausehe primary injections failed to successfully attach the de-ached DM.

Several authors have found that DMD was most com-only associated with SICS,7,8,16,21 especially in the pres-

nce of incisions anterior to the DM.16,21,22The majority ofatients in our series underwent SICS, and thus DMD wasost commonly seen after SICS followed by phacoemulsi-cation and ECCE. In these patients, DMD occurred invari-bly at the ACM port. This is because we perform SICSith the Blumenthal and Moisseiev technique23 but do notse an ACM port for phacoemulsification or ECCE. Weelieve that improper insertions or inadvertent movementsf the ACM port during the surgery may be responsible forhese cases of DMD, rather than those occurring at thencision. Contrary to our findings, Marcon et al8 and Kim etl20 reported that DMDs did not require urgent surgicalepair, and the decision on when to intervene in DMDs muste made on a case-by-case basis.

The use of 100% air as a tamponade has been believed toe least effective, and success has been shown with long-tanding intracameral gases such as sulfur-hexafluoride or3F8.

17 In this series, we compared the use of 14% isoex-ansile C3F8 and 100% air for descemetopexy and foundhat anatomic and functional outcomes of descemetopexyith air were better than C3F8 with reduced incidence ofupillary block. Therefore, simple use of air for reattach-

nts Treated with Air or Perfluoropropane

C3F8 (n � 36)

P ValueMean SD 95% CI

64.4 7.76 61.63–67.25 0.911/36 15.46–45.54 0.1518/36 33.67–66.33 0.03

3.3 1.04 2.94–3.66 0.710/36 13.08–42.32 0.2

2.77 0.45 2.63–2.92 0.120.19 0.2 0.13–0.25 0.21

ne; IVA � interval visual acuity; M � male; OD � oculus dexter (right

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Jain et al � Descemetopexy in Post-Cataract Surgery DMD

The findings of this study suggest that the final visualoutcome for the descemetopexy procedure done for DMD incataract of higher scores is poor. Thus, we recommend thatprocedures in these cases should be performed by trainedsurgeons who should be cautious about this complication ateach step of the surgery.

Study Limitations

The findings of this study also should be seen in the contextof its limitations. First, ours is a retrospective study that hasits inherent limitations. But considering the incidence of

Figure 3. A, Slit-lamp photograph of a case of a large area of Descemet’s mday 1 slit-lamp photograph showing the decreased corneal edema and ancoherence tomography (AS-OCT) image of the same case preoperatively s1 showing Descemet’s membrane apposed to the posterior stroma. Slit-lam

DMD after cataract surgery, the number of patients needed v

o do a randomized control trial with statistical significanceill be difficult to obtain. Second, several patients were

xcluded from the study because of inadequate follow-up.he natural history of DMD is still unknown, and how manyf the patients who were lost to follow-up might have hadpontaneous resolution is unknown. A control group, inhich the patients were only observed or medical therapyas given, would have been ideal for comparison.In conclusion, DMD is a rare occurrence after cataract

urgery. The majority of DMDs were noted in SICS at theCM port in our series. An early intervention by descem-

topexy was associated with a good final anatomic and

rane detachment (DMD) with profound corneal edema. B, Postoperativebble filling half of the anterior chamber. C, An anterior segment opticalng a DMD. D, An AS-OCT image of the same case on postoperative dayotographs of the same case on postoperative days 8 (E) and 30 (F).

embair buhowi

isual outcome. Air descemetopexy is recommended over

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C3F8 injection because of its equal efficacy and lack ofcomplications. To our knowledge and after a literaturesearch using PubMed, this is the only study that describesthe risk factors for visual prognosis and compares the visualand safety outcomes of air and C3F8.

References

1. Makley TA Jr, Keates RH. Detachment of Descemet’s mem-brane (an early complication of cataract surgery). OphthalmicSurg 1980;11:189–91.

2. Samuels B. Detachment of Descemet’s membrane. Trans AmOphthalmol Soc 1928;26:427–37.

3. Scheie HG. Stripping of Descemet’s membrane in cataractextraction. Trans Am Ophthalmol Soc 1964;62:140–52.

4. Mackool RJ, Holtz SJ. Descemet membrane detachment. ArchOphthalmol 1977;95:459–63.

5. Mulhern M, Barry P, Condon P. A case of Descemet’s mem-brane detachment during phacoemulsification surgery [letter].Br J Ophthalmol 1996;80:185–6.

6. Assia EI, Levkovich-Verbin H, Blumenthal M. Managementof Descemet’s membrane detachment. J Cataract Refract Surg1995;21:714–7.

7. Mahmood MA, Teichmann KD, Tomey KF, al-Rashed D.Detachment of Descemet’s membrane. J Cataract Refract Surg1998;24:827–33.

8. Marcon AS, Rapuano CJ, Jones MR, et al. Descemet’s mem-brane detachment after cataract surgery: management andoutcome. Ophthalmology 2002;109:2325–30.

9. Potter J, Zalatimo N. Descemet’s membrane detachment aftercataract extraction. Optometry 2005;76:720–4.

10. Al-Mezaine HS. Descemet’s membrane detachment after cat-aract extraction surgery. Int Ophthalmol 2010;30:391–6.

11. Anderson CJ. Gonioscopy in no-stitch cataract incisions. J

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2. Monroe WM. Gonioscopy after cataract extraction. SouthMed J 1971;64:1122–4.

3. Minkovitz JB, Schrenk LC, Pepose JS. Spontaneous resolu-tion of an extensive detachment of Descemet’s membranefollowing phacoemulsification. Arch Ophthalmol 1994;112:551–2.

4. Morrison LK, Talley TW, Waltman SR. Spontaneous detach-ment of Descemet’s membrane. Case report and literaturereview. Cornea 1989;8:303–5.

5. Bergsma DR Jr, McCaa CS. Extensive detachment of De-scemet membrane after holmium laser sclerostomy. Ophthal-mology 1996;103:678–80.

6. Macsai MS. Total detachment of Descemet’s membrane aftersmall-incision cataract extraction [letter]. Am J Ophthalmol1992;114:365–6.

7. Potter J, Zalatimo N. Descemet’s membrane detachment aftercataract extraction. Optometry 2005;76:720–4.

8. Chylack LT Jr, Leske MC, McCarthy D, et al. Lens OpacitiesClassification System II (LOCS II). Arch Ophthalmol 1989;107:991–7.

9. Chaurasia S, Ramappa M, Garg P. Outcomes of air descem-etopexy for Descemet membrane detachment after cataractsurgery. J Cataract Refract Surg 2012;38:1134–9.

0. Kim IS, Shin JC, Im CY, Kim EK. Three cases of Descemet’smembrane detachment after cataract Surgery. Yonsei Med J2005;46:719–23.

1. Zusman NB, Waring GO III, Najarian LV, Wilson LA.Sulfur hexafluoride gas in the repair of intractable Descem-et’s membrane detachment. Am J Ophthalmol 1987;104:660 –2.

2. John ME, Noblitt RL, Boleyn KL, et al. Effect of a superficialand a deep scleral pocket incision on the incidence of hy-phema. J Cataract Refract Surg 1992;18:495–9.

3. Blumenthal M, Moisseiev J. Anterior chamber maintainer forextracapsular cataract extraction and intraocular lens implan-

Footnotes and Financial Disclosures

Originally received: July 27, 2012.Final revision: December 16, 2012.Accepted: December 20, 2012.Available online: March 16, 2013. Manuscript no. 2012-1132.

1 Cornea and Anterior Segment, L V Prasad Eye Institute, Hyderabad,India.

2 Department of Clinical Epidemiology and Biostatistics, L V Prasad Eye

inancial Disclosure(s):he author(s) have no proprietary or commercial interest in any materialsiscussed in this article.

unding: Hyderabad Eye Research Foundation, Hyderabad, India. The sponsor orunding organization had no role in the design or conduct of this research.orrespondence:omasheila I. Murthy, MBBS, MS, Head, Cornea Services, L V Prasad Eyenstitute, Kallam Anji Reddy Campus, Banjara Hills, Road No 2, Hyderabad