Video of the month | May 2023 | Management of Partial Descemet's Membrane Tear - Bubble, the Instrument

Presented and operated by: Miltos Balidis MD, PhD, FEBOphth, ICOphth

Edited by: Penelope Burle de Politis MD

Descemet’s membrane tears and detachments are relatively common transoperative complications in cataract surgery. The management of each lesion depends on the extent and configuration of the lesion itself. Nevertheless, the torn or detached segment of Descemet’s membrane must be restored to its normal position in order to prevent postoperative short-term and long-term complications. In the process of repairing a descemet’s tear or detachment, the cataract surgeon can conjugate intra- and extraocular forces to work to his advantage.

This video is a courtesy of a young ophthalmologist in his learning curve of phacoemulsification under the supervision of Dr. Miltos Balidis, MD, PhD, FEBOphth, ICOphth, specialist in Anterior Segment Surgery of the Ophthalmica Eye Institute, in Thessaloniki, Greece. It features a partial Descemet’s tear occurring with the injection of the IOL and the maneuvers adopted to bring the detached segment back into place. “Handling” of the mobile end of the tear was achieved through the creation of an ideally-sized air bubble in the anterior chamber (AC) and stroking the globe exteriorly next to the tearing site to make the margin of the bubble lift the apex of the detached segment and push it towards the periphery restoring its contact with the corneal stroma.

The surgical events and timing in the video are as follows: the IOL is injected through a normal superior limbal incision (00:03 to 00:40). After centration of the IOL, a partial tear and detachment of the Descemet’s membrane at about 11 o’clock becomes visible (00:55). After viscoelastic aspiration (01:15), the surgeon injects some air into the AC and tries to mechanically unfold the detached segment with the aspiration tip (01:30), with no effect. The AC is then replenished with air (01:50) and a more easily movable air bubble is fashioned to a diameter slightly smaller than the pupil’s size (02:05). Strokes to the corneal area opposite to the tear are attempted but prove ineffective due to the margin of the bubble being over the edge of the tear (02:10). Only when the maneuver is switched to the other side, the margin of the bubble can act as a spatula between the free segment of Descemet’s and the remaining attached membrane (02:33). The segment then smoothly slides back and stays in place (02:45).

«Little by little does the trick.» (Aesop)