Spontaneous hemorrhagic Descemet membrane detachment causing pupillary block.

Purpose: To present a unique case of a 65-year-old man using warfarin who presented with acute unilateral loss of vision due to hemorrhagic Descemet membrane detachment (DMD) with pupillary block and elevated intraocular pressure and its subsequent treatment and challenges.
Method: Case report.
Results: Clinical examination showed a visual acuity of finger counting, central DMD with near contact to the iris and premembrane hemorrhage, an intraocular pressure (IOP) of 19 mmHg, and normal pupillary reaction. An International Normalized Ratio (INR) of 4.9 was treated with dose reduction and vitamin K. Twelve hours later the patient re-presented with an acute increase in pain and an IOP of 78 mmHg with pupillary block and iris bombé. YAG-laser membranotomy, anterior chamber paracentesis, and maximal topical and systemic therapy were unsuccessful in reducing the IOP. Surgical management, including irrigation and aspiration of blood, led to a normalization of the IOP. Descemet stripping automated endothelial keratoplasty (DSAEK) resulted in a visual acuity of 0.3. Deep stromal/pre-Descemet membrane neovascularization was found bilaterally, suspicious for a previous interstitial keratitis.
Conclusions: The previously unreported complication of pupillary block following a pre-Descemet membrane hemorrhage was treated successfully for the first reported time, in a 2-step DSAEK. This indicates that DSAEK could be considered as a treatment option for DMD, especially in traumatic circumstances.