1. Pre-Descemet hematoma after non-penetrating deep sclerectomy (NPDS)
Lago MD, de Pablo A, Torres JL, Ortueta A
Hospital Universitario 12 de Octubre, Madrid, Spain
Purpose: To report the case of a pre-Descemet hematoma after NPDS and its surgical management.
Methods: Case report. 76 year-old patient with a history of atrial fibrillation treated with acenocoumarol, hypertension and central retinal vein occlusion of the left eye treated with antiangiogenics. He is referred with the diagnosis of primary open-angle glaucoma in medical treatment with 3 hypotensive drugs. Combined surgery of glaucoma and cataract was decided, despite the visual prognosis. 
Results: A NPDS with intraoperative subconjunctival 5-fluorouracil was performed. Intraocular pressure within 24 hours was 2 mmHg. After 48 hours, the acenocoumarol was reintroduced, and a week later a hematoma in the scleral lake and upper intracorneal predescemetic space of 1mm was observed. A goniopuncture was performed, with blood flow to the anterior chamber (AC). The following week, the pre-Descemet hematoma had increased to 2.5 mm approaching the pupillary border, so surgical drainage was decided.
The procedure consisted of descematorhexis with cystitome and blood drainage using a DSAEK spatula, with hyperpressure controlled with dispersive viscoelastic, achieving the evacuation of the blood clot to the AC. Afterwards the AC was washed and an air bubble was left. In the 5 months follow-up there has been no rebleeding, although some filiform intracorneal blood remains.
Clot drainage by hyperpressure with
dispersive viscoelastic
Predescemet hematoma after NPDS (slit lamp)
Surgical approach: descematorhexis
Washout of blood from the AC
An air bubble is left in the AC
Post-op result with corneal clearing (slit lamp)
Conclusions: Hemorrhagic detachment of the Descemet membrane is a rare complication after NPDS, being described more frequently after canalicular surgery. The mechanism is not clear; it is suggested that it might be due to a reflux of blood of the scleral lake from the Schlemm canal, secondary to surgical hypotension. This blood would dissect the space between the corneal stroma and the Descemet membrane producing a detachment of this layer. In our patient we observed the bleeding after the reintroduction of acenocoumarol, which might have contributed to its etiology. For its management, one option is observation, as long as the hematoma is small and shows signs of resorption. However some authors propose drainage to avoid the residual leukoma. In our case the surgical treatment was effective, achieving almost complete transparency of the area.
References: 1. Casas-Llera P, Arnalich-Montiel F, Muñoz-Negrete FJ, Rebolleda G. Descemet membranotomy to treat pre-descemet haematoma after deep sclerectomy and anterior segment-OCT related findings: a presentation of two clinical cases. Arch Soc Esp Oftalmol Jan;92(1): Kozobolis VP, Christodoulakis EV, Siganos CS, Pallikaris G. Hemorrhagic Descemet's membrane detachment as a complication of deep sclerectomy: a case report. J Glaucoma. 2001;10: Fujimoto H, Mizoguchi T, Kuroda S, Nagata M. Intracorneal hematoma with descemet membrane detachment after viscocanalostomy. Am J Ophthalmol. 2004;137: Jaramillo A, Foreman J, Ayyala RS. Descemet membrane detachment after canaloplasty: incidence and management. J Glaucoma. 2014;23:351-4.
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