Ripple-Like Descemet Membrane Folds Following Combined Microhook Ab Interno Trabeculotomy and Cataract Surgery: A...

We report a case of distinctive ripple-like Descemet membrane folds after combined microhook ab interno trabeculotomy (µLOT) and cataract surgery. A 70-year-old Japanese man with primary open-angle glaucoma and cataract underwent nasal µLOT followed by phacoemulsification and intraocular lens implantation in the right eye. At 1 week postoperatively, unusual ripple-like Descemet membrane folds, which had not been noted at the examination on postoperative day 1, were observed in the inferior cornea with localized corneal edema. Best-corrected visual acuity was 0.4 in decimal notation. Multimodal imaging revealed no apparent Descemet membrane detachment or tears. Review of the surgical video showed inadvertent aspiration of the Descemet membrane during irrigation/aspiration (I/A), followed by the appearance of the folds. The patient was managed conservatively, and the folds resolved completely by 3 months postoperatively, with best-corrected visual acuity improving to 1.2. We hypothesize that incision of peripheral supporting structures during µLOT may have reduced tangential tension in the Descemet membrane, increasing its susceptibility to aspiration during subsequent I/A. This mechanism remains unconfirmed. Careful I/A manipulation following µLOT is warranted, and conservative management may be appropriate for similar folds without associated Descemet membrane detachment or tears. As minimally invasive glaucoma surgery is often performed by ophthalmology trainees and surgeons with limited surgical experience, this report may serve as an educational example of an intraoperative complication during combined surgery.