Navigating extensive Descemet’s membrane detachment challenges and its management

Background: Descemet’s membrane detachment (DMD) is a dreaded complication of routine cataract surgery. Although DMD can occur after any intraocular surgery and sometimes even spontaneously, it is most common after cataract surgery. Purpose: Perioperative challenges in managing near-total DMD in an elderly patient during routine phacoemulsification surgery. Synopsis: While DMD has garnered extensive research, a consensus on the best timing and approach for intervention remains unclear. In this case, we outline a simplified approach that includes the stages and management strategies for DMD complications. Initially, we attempted descemetopexy with air tamponade upon identifying the DMD. However, the decision to abort the surgery followed the failure of both air tamponade and C3F8 descemetopexy to achieve DM reattachment. The situation escalated due to increasing intraocular inflammation from anterior capsular removal, necessitating cataract extraction. Phacoemulsification was conducted with a detached DM by first stabilizing the DM with two tenting sutures to mitigate the risk of the DM being drawn into the phaco probe. We utilized low-flow phacoemulsification parameters, along with viscoelastic agents, retroillumination, and light pipe for improved visualization. Cortical aspiration was performed carefully, with focus on securing the DM, which exhibited a tendency to flutter. The procedure culminated in the successful use of dispersive viscoelastics to gently uncurl the scrolled DM. We anchored the DM using six full-thickness sutures arranged in a hexagonal pattern using 10-0 nylon monofilament sutures. A nonexpansile 14% C3F8 was used to appose the DM sagging in the center. For interface fluid drainage, we created paired ab externo venting incisions and performed gentle surface massage. The final action involved achieving a complete fill with C3F8, securing the DM in its proper position. Highlights: This case illustrates that, despite the complexities involved, a structured intraoperative strategy can lead to favorable anatomical and clinical outcomes after a near-total DMD, ultimately preserving ocular integrity and minimizing the need for future interventions. Video Link: https: //youtu. be/VYjf9IkiYs