Hemorrhagic pre-Descemet’s membrane detachment after nonpenetrating deep sclerectomy

Abstract

Introduction

Hemorrhagic Descemet’s membrane (DM) detachment is a rare complication after glaucoma surgery. Related to nonpenetrating deep sclerectomy (NPDS), it is postulated to be caused due to blood reflux from the Schlemm’s canal or from a hemorrhage originated under the scleral flap. Different therapeutic approaches are described: from observation to Nd:YAG laser, ab interno membranotomy or evacuation through corneal incision. This condition might compromise the patient’s visual acuity so the treatment must be done early.

Case report

A 69-year-old black male underwent a phacoemulsification and a NPDS without incidents. In the early postoperative period, an hemorrhagic pre- Descemet detachment associated to an hemorrhagic bleb and an uncontrolled intraocular pressure (IOP) were observed. A Nd:YAG laser endothelial puncture and a suturolysis were performed without an optimal IOP control. After 10 days, an anterior chamber lavage combined with a needling achieved a complete transparent cornea and a controlled IOP without topical treatment.

Discussion

The pathophysiology of the presented case could be explained by an hemorrhage originated from vessels under the scleral flap due to an elevated intrableb pressure that favored the dissection of the weakest connected site, the DM. A Nd:YAG laser puncture was capital to avoid corneal staining and to lower the pressure from the filtration bleb (FB). Nevertheless, IOP was not controlled because of hypema and fibrosis of the trabeculo-descemetic membrane. After anterior chamber lavage and a needling with piercing of the TDM the IOP normalized and the FB was functional again.

The treatment in a hemorrhagic pre-Descemet detachment is personalized and it is very important to understand the pathophysiology to approach it properly.