Eyeworld

I OCTOBER 2020 | EYEWORLD | 51 by Ellen Stodola Editorial Co-Director D escemet's detachment is a poten- tial complication that can arise in conjunction with cataract surgery. Experts share examples of when they encountered this problem, how they approached it, and how it might be avoided. Bullous Descemet's detachment Soosan Jacob, MD, shared a case of bullous Descemet's detachment. Dr. Jacob has devel- oped a classification system for Descemet's detachments and broken it down into different types: rhegmatogenous Descemet's detachment, tractional Descemet's detachment, bullous De- scemet's detachment, and complex Descemet's detachment. Rhegmatogenous is the most commonly seen type after phacoemulsification, accord- ing to Dr. Jacob's classifications. It presents as detachment with a tear and can be treated easily by intracameral air or gas injection to achieve supra-Descemetic fluid drainage through the tear. Those classified as bullous detachments are generally rarer, she said, and often show as Dealing with Descemet's detachments continued on page 52 About the doctors John Hovanesian, MD Harvard Eye Associates Laguna Hills, California Soosan Jacob, MD Dr. Agarwal's Eye Hospital Chennai, India Mark Packer, MD Packer Research Associates Boulder, Colorado Dr. Jacob's patient had a bullous Descemet's detachment following stromal hydration. Source: Soosan Jacob, MD a separation of the Descemet's membrane into the anterior chamber, without a sufficiently large tear in the Descemet's membrane. The problem in these bullous detachments is that air or gas injection that is supposed to push the supra-Descemetic fluid out does not work. The fluid is trapped as there's no actual tear to serve as an egress route for the fluid, Dr. Jacob said. Once you realize what the problem is, it's easy to handle, she said, adding the surgeon can simply intentionally make a break in the Descemet's membrane to create a route for the fluid to come out from. This can be done by a simple keratome entry into the supra-Descem- etic fluid space. The most common instance in which bullous Descemet's detachment occurs is when you've completed phaco and are doing stromal hydration, Dr. Jacob said. The fluid wave from a too posteriorly placed, misdirected cannula may separate the Descemet's membrane from the stroma. This may be recognized as a fluid wave passing across the cornea. Simply putting in air from the opposite side as done for rhegmatogenous Descemet's detachment does

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