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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 657-664

The tale of torn Descemet's membrane: Conception of diagnosis from a story well heard


Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Bhubaneswar, Odisha, India

Date of Submission26-Apr-2021
Date of Acceptance19-Nov-2021
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Neha G Madan
Former Fellow LVPEI, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_989_21

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  Abstract 


To report three cases of late presentations of forceps birth trauma leading to DM tear and their management. Forceps delivery has become a rare method of child delivery in the modern clinical era. However, in the clinics, we still see patients with Descemet's membrane (DM) tear who have had ocular birth trauma with forceps. Most of the time, it is an incidental finding. Forceps injuries are usually unilateral and affect the left eye as the most common fetal head position is left occiput anterior. In the immediate postpartum period, the rupture in the DM leads to corneal edema, which eventually disappears, leaving the visible edges of the break. In the late presentations, patients can have high myopic astigmatism (steep cornea) and secondary amblyopia, which can mimic unilateral keratoconus and, later in life, can lead to corneal endothelial decompensation leading to bullous keratopathy. Here we report three cases of DM tear due to forceps injury with three late presentations. Patient 1 came with bullous keratopathy; patient 2 presented with high myopic astigmatism, amblyopia, and beaten metal appearance in between the torn edges; and patient 3 presented as keratoconus. To conclude, this case series highlights the various clinical features and signs of forceps induced birth injury to the cornea. In this report, the clinical history, ocular examination, and optical coherence tomography scan confirmed the diagnosis. Early rehabilitation with glasses or contact lenses can prevent the development of deep amblyopia. Corneal decompensation can be a presentation later in life; thus, these patients should have a close follow up. Endothelial keratoplasty helps in visual rehabilitation in cases where bullous keratopathy has developed, which can be up to the preoperative amblyopia state.

Keywords: Birth trauma, DM tear, forceps injury


How to cite this article:
Madan NG, Reddy JC, Das S, Sahu SK, Priyadarshini SR, Soni TK. The tale of torn Descemet's membrane: Conception of diagnosis from a story well heard. Indian J Ophthalmol Case Rep 2022;2:657-64

How to cite this URL:
Madan NG, Reddy JC, Das S, Sahu SK, Priyadarshini SR, Soni TK. The tale of torn Descemet's membrane: Conception of diagnosis from a story well heard. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 19];2:657-64. Available from: https://www.ijoreports.in/text.asp?2022/2/3/657/351223



Forceps delivery has become a rare method of child delivery in the modern clinical era.[1] However, in the clinics, we still see patients with Descemet's membrane (DM) tear who have had ocular birth trauma with forceps. Most of the time, it is an incidental finding.[1] Forceps injuries are usually unilateral and affect the left eye as the most common fetal head position is left occiput anterior. In the immediate postpartum period, the rupture in the DM leads to corneal edema, which eventually disappears, leaving the visible edges of the break. In the late presentations, patients can have high myopic astigmatism (steep cornea) and secondary amblyopia, which can mimic unilateral keratoconus and, later in life, can lead to corneal endothelial decompensation leading to bullous keratopathy.[2] Here we report three cases of DM tear due to forceps injury with three late presentations.


  Case Reports Top


Case 1

A 31-year-old man came to the hospital with complaints of left-eye diminution of vision and whitish appearance of black portion since 1 month which was painful and was associated with watering. There was no recent history of ocular trauma. On detailed questioning, he mentioned birth trauma because of forceps delivery to his left eye. He also had a scar mark on his left upper lid and forehead. On slit-lamp biomicroscopy, he was noted to have an oblique fold of Descemet's membrane (DM) in the left cornea with stromal edema and bullae [Figure 1]a, [Figure 1]b, [Figure 1]c. AS-OCT confirmed Descemet detachment [Figure 2]a and [Figure 2]b. Based on the appearance, orientation of the Descemet, OCT findings, and medical history of forceps delivery, phakic bullous keratopathy following a forceps injury to the left cornea was diagnosed.
Figure 1: (a) Diffuse illumination left eye showing stromal edema, bullae and oblique line of torn descemet, (b) Diffuse illumination left eye showing descemet tear, (c) Optical section illumination left eye showing oblique descemet tear

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Figure 2: (a) AS-OCT showing descemet tear and rolled Descemet, (b) AS-OCT showing torn descemet shown with the red arrow, Development of bullae shown with the green arrow, and increased corneal thickness which is more in the periphery as compared to the center

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Uncorrected visual acuity was 20/20 in the right eye and 20/160 P in the left eye. The best-corrected visual acuity in the left eye was 20/60 p. Intraocular pressures were 12 mm Hg for the RE and 10 mm Hg for the LE on Goldmann tonometry. Corneal pachymetry of the central cornea was 491 microns in the RE and 666 microns in the LE. Pentacam of the right eye was normal [Figure 3]a and [Figure 3]b, and left eye showed a steep keratometry (K1 being 47.3D and K2 being 53.9D) with symmetric bow tie suggestive of high myopic astigmatism [Figure 4]a and [Figure 4]b.
Figure 3: (a) Right eye Topography Quad map, (b) Right eye Belin /Ambrosio Map

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Figure 4: (a) Left eye topography map (b) Left eye Belin /Ambrosio Map

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As the patient had bullous keratopathy changes, he was started on hyperosmotic agents. Hyperosmotic agents were given for almost 2 months but hardly made any clinical beneficial effect; therefore, the patient was planned for left-eye endothelial keratoplasty. He underwent left-eye Descemet stripping automated endothelial keratoplasty, where the endothelial surface was smoothened after removing the torn DM. Donor lenticule was well-attached post-surgery and graft was clear postoperatively 1 month as seen in the clinical pictures [Figure 5]a and [Figure 5]b, and AS-OCT [Figure 6] and visual acuity was 20/60. Mild interface haze and preexisting amblyopia limited final visual acuity.
Figure 5: (a) Slit lamp picture of Left eye diffuse illumination -showing clear graft with mild interface haze 1 month postoperatively, (b) Slit lamp picture of Left eye-optical section showing clear graft with mild interface haze 1 month postoperatively

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Figure 6: Left eye Anterior segment OCT -1 month post operatively

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Case 2

A 36-year-old male came to the hospital with chief complaints of diminution of vision in his right eye for 2 months. There was no history of wearing glasses or contact lenses or recent history of ocular trauma. On detailed history, he gave a positive history of forceps injury at birth. On examination, his right eye unaided visual acuity was 20/600, which improved to 20/100 with −5 sphere and −4.5 cylinder at 180°. His left eye unaided visual acuity was 20/20.

On slit-lamp examination, right eye linear DM tear with beaten metal appearance between the two ends of torn Descemet was noted; the rest of the anterior segment examination was within normal limits [Figure 7]a, [Figure 7]b, [Figure 7]c. Based on the history and clinical examination, a diagnosis of right-eye DM tear due to forceps injury was made. The patient had developed right-eye amblyopia and was advised for glasses. For documentation purposes, slit-lamp pictures, A-scan [Figure 8], anterior segment OCT [Figure 9], and Orbscan [Figure 10] were performed. The patient was advised for a close to follow up.
Figure 7: (a) Optical section slit lamp illumination showing the vertical DM tear, (b) Diffuse illumination showing vertical DM tear with beaten metal appearance between the torn edges, (c) diffuse illumination (magnified view) showing vertical DM tear with beaten metal appearance between the torn edges

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Figure 8: A-scan of case 2

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Figure 9: Anterior segment OCT showing the rolled Descemet's tear

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Figure 10: Orbscan depicting high myopic astigmatism

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Case 3

A 10-year-old female came to the clinic with the chief complaints of left eye appearing to be larger than the right eye since 8 months. She had coronary heart disease and thyroid disease for which she was under treatment for 3 years. After the initiation of treatment, thyroid profile was never repeated. She had consulted elsewhere where she was diagnosed with left eye Keratoconus and was referred here for further management. There was a history of birth trauma with forceps. On examination, her unaided visual acuity in the right eye was 20/60 with best-corrected visual acuity of 20/30 with +7 dioptric sphere and 20/200 in the left eye improving to 20/125 with −4.0 dioptric cylinder at 180° axis. Both eyes showed proptosis (OS > OD) with normal ocular motility and no resistance to retropulsion. On examination of the left eye, vertical DM tear was noted surrounded by stromal haze, which was better seen under retroillumination [Figure 11]. An Orbscan was done [Figure 12], which revealed a left eye steep cornea with K1 59.7 and K2 − 52.8, and the thinnest pachymetry was 325 microns. As there were no active signs of thyroid eye disease, she was referred to the endocrinologist for thyroid function tests and further management. She was prescribed glasses and was asked to follow up after 3 months.
Figure 11: Slit lamp picture (Retroillumination View) case 3 showing Vertical Descemet membrane tear with corneal scarring

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Figure 12: Orbscan showing steep cornea

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  Discussion Top


Forceps injury to the cornea is a rare injury to happen now with the modern clinical settings.[1] It occurred during complicated forceps delivery. The infant cornea does not fully develop until 6 months of age. The application of the forceps can cause accidental rupture of the cornea at the level of the DM. At birth, the DM is much thinner (3–4 mm) than in an adult (10–12 mm) and more prone to injury. During forceps-assisted birth, accidental forceps-induced eye injury occurs when the blade of the obstetric forceps slips over the inferior orbital rim, compressing the globe vertically. This causes a rise in the intraocular pressure (IOP), acutely stretching the ocular globe horizontally. The pressure exerted exceeds the elasticity of the DM, which characteristically splits vertically or obliquely. This injury commonly affects the left eye as the left occiput anterior is the most common fetal presentation.[2]

The forceps-induced vertical rupture in the DM differs from the horizontal tears that occur in the DM in congenital glaucoma. Congenital glaucoma causes a chronic rise in the IOP, which also stretches the DM. However, unlike forceps injury, the force exerted does not act in one direction. Consequently, the tears in the DM are bilateral and more random in distribution, commonly being horizontal or circumferential to the limbus.[3]

In the immediate postpartum period, DM rupture caused by forceps injury leads to diffuse corneal edema. The edema resolves spontaneously within a few weeks or months, eventually leaving the visible edges of the break and a clear cornea. The ruptured edges of the DM coil in the direction of the corneal stroma. In between the two cut edges, the endothelium layer of the cornea lays a new irregular basement membrane, which has a beaten metal appearance, as seen in case 2 [Figure 7]a, [Figure 7]b, [Figure 7]c. Anterior optical coherence tomography is a very helpful tool in establishing the correct diagnosis of DM rupture.

DM tear can lead to high myopic astigmatism, keratoglobus, and deep amblyopia in the affected eye as was seen in all three cases. Therefore, early correction of refractive error with spectacles or contact lenses and amblyopia treatment is crucial in children.[4] Each newborn with signs of periorbital trauma should undergo ophthalmological examination in the first days of life. Early detection of eye disturbances, treatment initiation, and further monitoring of visual system development may protect against vision impairment in children with forceps-assisted corneal injury.[5]

Endothelial dysfunction due to corneal endothelial injury after forceps injury is rare but is clinically encountered in cornea clinics. The cause for it being an osmotic gradient created by the endothelial cells of the cornea responsible for the deturgescence of the cornea is no longer maintained in such eyes. Fluid diffuses into the layers of the cornea, causing edema and haziness, which resolves but later in life, the initial trauma to the cornea may lead to endothelial decompensation.

In symptomatic cases, corneal transplant surgery may be beneficial. Urgent surgical intervention may be helpful in treating excessive corneal edema due to DM detachment after birth. In cases with progressive endothelial decompensation and keratopathy, penetrating keratoplasty or endothelial keratoplasty may be taken into consideration. Irregular retro-corneal surface is one of the contraindications of DSAEK surgery as perfect smoothness is required for donor host attachment. Therefore, in case 1, the endothelial surface was smoothened after DM removal, which led to a perfect lenticule attachment.[5]

The clinical outcome in case 1 post DSAEK for severe bullous keratopathy after forceps delivery was fair with rapid corneal clearance but was limited due to the level of preexisting amblyopia. Meticulous care was required for postoperative complications, including intraocular pressure rise and endothelial rejection.[3]

Case 2 showed a steep cornea with amblyopia with vertical DM tear along with a beaten metal appearance at the level of DM in between the torn edges.

Case 3 was confused with keratoconus. This patient had other comorbidities, namely thyroid eye disease and coronary artery disease, which further made the diagnosis confusing. The right eye showed hyperopia and left eye myopic astigmatism, which was very unusual. On detailed questioning, a positive history of birth trauma was fetched. Thus, the patient had both-eye proptosis due to the deranged thyroid profile and DM tear was an incidental finding which had led to the steep cornea which was confused as keratoconus. Apart from the confusion with congenital glaucoma in the early presentation, forceps injury at a later date is confused with keratoconus as both cause axial myopia, corneal steepening, thinning, scarring, and large amounts of corneal astigmatism. In adults, the two entities can easily be confused, and often the distinction is made according to whether the observed changes are unilateral (forceps injury) or bilateral (true keratoconus) and whether the involved eye is amblyopic (suggesting a birth injury).


  Conclusion Top


To conclude, this case series highlights the various clinical features and signs of forceps-induced birth injury to the cornea. In this report, the clinical history, ocular examination, and optical coherence tomography scan confirmed the diagnosis. Early rehabilitation with glasses or contact lenses can prevent the development of deep amblyopia. Corneal decompensation can be a presentation later in life; thus, these patients should have a close follow-up. Endothelial keratoplasty helps in visual rehabilitation in cases where bullous keratopathy has developed, which can be up to the preoperative amblyopia state.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Hyderabad Eye Research Foundation, Hyderabad.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patel RR, Murphy DJ. Forceps delivery in modern obstetric practice. Br Med J 2004;328:1302–5.  Back to cited text no. 1
    
2.
Alobaidy R, Srinivasan S. Forceps-induced birth injury to the cornea. BMJ Case Reports 2014(apr09 1), bcr2013201786–bcr2013201786.  Back to cited text no. 2
    
3.
Kancherla S, Shue A, Pathan MF, Sylvester CL, Nischal KK. Management of descemet membrane detachment after forceps birth injury. Cornea 2017;36:375–6.  Back to cited text no. 3
    
4.
Pecorella I, Tiezzi A, Appolloni R, Plateroti A, Plateroti R. Late corneal decompensation after obstetrical forceps ocular trauma at birth. Clin Exp Optom 2015;98:387–9.  Back to cited text no. 4
    
5.
Angell LK, Robb RM, Berson FG. Visual prognosis in patients with ruptures in the descemet's membrane due to forceps injuries. Arch Ophthalmol 1981;99:2137–9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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