Friction From Surgical Instruments Tied to Descemet Membrane Detachment in Cataract Surgery

By David Douglas

December 17, 2020

NEW YORK (Reuters Health) - Real-time imaging via intraoperative optical coherence tomography indicates that Descemet membrane detachment (DMD) during cataract surgery is largely associated with friction caused by surgical instruments.

"This new imaging method allows researchers to accurately examine when DMD started during surgery and how the degree of dissociation increased throughout the procedure," Dr. Yizhi Liu told Reuters Health by email.

In a paper in JAMA Ophthalmology, Dr. Liu and Dr. Lixia Luo of Sun Yat-Sen University, in Guangzhou, China, and colleagues note that DMD is a common complication in cataract surgery and the incidence a day after phacoemulsification is documented to range beyond 80%.

Slight DMD can be self-healing, they note, but in circumstances involving inexperienced surgeons or unhealthy corneas, severe DMD may result in corneal decompensation requiring transplantation.

Effective strategies to avoid or diminish DMD are hampered by lack of knowledge of the specific surgical steps during which incisional DMD is most likely to be initiated.

To shed more light on the matter, in 2019, the researchers used intraoperative optical coherence tomography to document procedures in 133 eyes in 133 patients with cataract. They underwent coaxial 2.2 mm clear corneal microincision phacoemulsification with intraocular lens (IOL) implantation. The operations were performed by the same experienced surgeon.

DMD was seen intraoperatively in 125 eyes (94%) and was most common during phacoemulsification (69 eyes, 55.2%) and irrigation-aspiration (44 eyes, 35.2%). The length of the DMD increased significantly during surgery, with the initial and the final relative length showing a mean increase of 22.8%.

In multivariate stepwise analyses, associations with the extent of DMD included the time of ultrasonography, the equivalent mean ultrasonic power and the presence of DMD at the anterior and posterior wound margins.

The findings "suggest that friction of surgical instruments may have the greatest association with incisional DMD," the researchers say. Decreasing ultrasonography time and equivalent mean ultrasonic energy, they add, may be associated with reductions in the severity of incisional DMD.

They suggest that "handpiece types and materials could be optimized to prevent DMD caused by mechanical friction, or the construction of the incision could be modified for the enlarged incision mechanically at the end of surgery."

"Based on the evidence obtained in this and other DMD studies," concluded Dr Liu, "we can further understand how modified surgical techniques, such as incision configuration, nuclear segmentation, and selection of machines with different hydrodynamic characteristics, will affect the incidence of DMD."

Dr. Yuzhen Jiang, who wrote an accompanying editorial, told Reuters Health by email, "Using an innovative imaging technology, intraoperative anterior segment optical coherence tomography, the researchers were able to reveal exactly when and how Descemet membrane detachment occurred during cataract by making real-time assessment."

Dr. Jiang, of Moorfields Eye Hospital and University College London Institute of Ophthalmology, concluded, "This is potentially of great help for surgeons to make informed decisions in the development of prophylactic strategies."

SOURCE: and JAMA Ophthalmology, online December 10, 2020.