- Email: [email protected]
Retained nuclear fragment found during Descemet-stripping automated endothelial keratoplasty
CASE REPORT
Retained nuclear fragment found during Descemet-stripping automated endothelial keratoplasty Mark D. Mifflin, MD, Marcus C. Neuffer, MD, Nick Mamalis, MD
An 82-year-old man with a 2- to 3-month history of progressive visual loss due to corneal edema was referred to our center. The ocular history was significant for uneventful cataract surgery approximately 3 years earlier. Pseudophakic bullous keratopathy was diagnosed and Descemet-stripping automated endothelial keratoplasty (DSAEK) performed. During surgery, a retained nuclear fragment was discovered in the anterior chamber. The fragment was removed and the DSAEK completed successfully. At the 4-month follow-up, the symptoms had completely resolved and the uncorrected distance visual acuity in the affected eye was 20/40. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:608–610 Q 2011 ASCRS and ESCRS
Several case reports have described retained nuclear lens fragments discovered weeks to months after phacoemulsification.1–5 We present a case in which pseudophakic bullous keratopathy developed approximately 3 years after phacoemulsification. During Descemetstripping automated endothelial keratoplasty (DSAEK) surgery, a retained nuclear lens fragment was found in the anterior chamber. CASE REPORT An 82-year-old man was referred to our institution for evaluation and treatment of persistent corneal edema in the right eye. The ocular history was remarkable for uneventful cataract surgery approximately 3 years earlier. The patient reported a 2- to 3-month history of markedly decreased vision in the right eye accompanied by foreign-body sensation and photophobia. Prior to referral, he had been treated empirically for presumed herpes simplex keratitis by his community ophthalmologist. On examination, the corrected distance visual acuity was 20/400 in the affected right eye and 20/25C in the left eye. Intraocular pressure was 15 mm Hg and 25 mm Hg,
Submitted: October 24, 2010. Accepted: November 9, 2010. From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City Utah, USA. Corresponding author: Mark D. Mifflin, MD, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, Utah 84132, USA. E-mail: [email protected].
608
Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
respectively, and pachymetry, 897 mm and 550 mm, respectively. Pupils, motility, and confrontational visual fields were normal. Slitlamp examination of the right eye revealed central corneal edema with stromal folds and microcystic changes. No significant anterior chamber inflammation was seen, nor was there any corneal neovascularization or scarring. The posterior chamber intraocular lens (IOL) was in a good position with an intact posterior capsule and no vitreous seen in the anterior chamber. Slitlamp examination of the left eye showed a clear cornea without edema or decompensation and 1 to 2C pigmented endothelial cell changes. The posterior IOL was decentered but stable. Dilated fundoscopic examination of the right eye was partially obscured due to corneal edema; however, no retinal pathology was noted. A large amount of optic nerve head cupping was noted, with a cup-to-disc ratio of 0.7 in the right eye and 0.8 in the left eye. The patient was scheduled to have DSAEK for pseudophakic bullous keratopathy and was also referred to a glaucoma specialist for evaluation and management. The standard DSAEK procedure was started with an 8.0 mm section of Descemet membrane removed from the host and sent to pathology. When the irrigation/aspiration (I/A) handpiece was inserted into the anterior chamber to remove the ophthalmic viscosurgical device, it encountered a small dense nuclear lens fragment (Figure 1). The retained lens fragment was completely removed using the I/A handpiece and a second instrument through the side port. The DSAEK procedure was then continued, and an 8.5 mm graft was placed and positioned without complication. The pathology report of the Descemet membrane specimen was consistent with pseudophakic bullous keratopathy showing extreme endothelial cell loss (Figure 2). The patient had an uneventful recovery after surgery. At the 2-month examination, the uncorrected distance visual acuity in the right eye was 20/50, improving to 20/40 at 4 months. The DSAEK graft was clear and attached, and no inflammation was noted in the anterior chamber. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2010.11.022
CASE REPORT: RETAINED NUCLEAR FRAGMENT FOUND DURING DSAEK
Figure 1. Retained nuclear fragment (green arrow) on the I/A tip during DSAEK (note 8.0 mm mark).
DISCUSSION Various studies have reported corneal edema from retained nuclear fragments.1–7 The edema can be diffuse or sectoral, and the presentation can be weeks to months after phacoemulsification.6 One study reported an onset of symptoms 1 year after surgery.7 Our case is unique because the patient presented approximately 3 years after phacoemulsification and the lens fragment was not discovered until it appeared during DSAEK surgery. Some authors hypothesize that small lens fragments can evade initial detection by being concealed in the angle, in iris crypts, or posterior to the iris.4,6 Hui et al.6 report a case series that reviewed preoperative refractive, ultrasonographic, and keratometric information of 10 patients with retained nuclear fragments.
609
All 10 patients were “either myopic with elongated axial lengths or had steep keratometry readings.” A review of our patient’s preoperative chart revealed pre-cataract surgery myopia with a spherical equivalent of 5.50 diopters. This supports the hypothesis of Hui et al.6 that retained lens fragments may be more likely in myopic patients with deep anterior chambers and long axial lengths. This type of eye provides more space for lens fragments to be trapped in the posterior chamber during surgery. The fragments may remain in the posterior chamber or migrate to the inferior angle postoperatively. Yazıcı et al.4 report a case of intermittent corneal edema from a retained nuclear fragment, postulating that the edema was intermittent due to the fragment traveling between the anterior and posterior chambers during postural movements. This theory could also explain the late onset of symptoms in our patient; that is, the retained fragment might have remained behind the iris for more than 2 years and finally dislodged, moving into the anterior segment and resting in the angle. Another theory presumes nuclear fragments contain antigens that cross-react with antigens on endothelial cells, causing an immune response directed at the endothelium.6 Thus, another possible explanation for the late-onset corneal edema in our patient is that the retained lens fragment might have settled in a location away from the endothelium and not caused direct trauma but rather a smoldering immune response to the endothelium. After 2 years, the endothelium decompensated and corneal edema ensued. Several case reports document resolution of corneal edema following removal of retained lens fragments.1,2,4,6,7 This was not an option for us because the retained fragment was not discovered until after the host’s Descemet membrane had been removed. Had the lens fragment been found before Descemet stripping, endothelial replacement would still have been necessary because of the severity and chronicity of the edema and the cell loss noted on the pathologic specimen. However, we do agree with other authors that gonioscopy to look for retained nuclear fragments should be considered in patients with corneal edema after cataract surgery. We add to the recommendation that gonioscopy should be considered even if the cataract surgery had been performed years prior to the onset of corneal edema. REFERENCES
Figure 2. Photomicrograph of Descemet membrane removed during DSAEK procedure. Note the marked attenuation of the endothelial layer (hematoxylin eosin stain; original magnification 100).
1. Bohigian GM, Wexler SA. Complications of retained nuclear fragments in the anterior chamber after phacoemulsification with posterior chamber lens implant. Am J Ophthalmol 1997; 123: 546–547
J CATARACT REFRACT SURG - VOL 37, MARCH 2011
610
CASE REPORT: RETAINED NUCLEAR FRAGMENT FOUND DURING DSAEK
2. Gedde SJ, Karp CL, Budenz DL. Retained nuclear fragment in the anterior segment. Arch Ophthalmol 1998; 116:1532–1533. Available at: http://archopht.ama-assn.org/cgi/reprint/116/11/1532. Accessed November 11, 2010 3. Waheed K, Liu C. Nuclear fragment in the scleral tunneldan unusual cause of postoperative hypotony [letter]. J Cataract Refract Surg 2000; 26:10–11 4. Yazıcı AT, Kaya V, Bozkurt E, Imamoglu S, Yılmaz OF. Intermittent corneal edema due to anterior segment retained lens fragments. J Cataract Refract Surg 2007; 33:1136–1137
5. Goodfellow JFB, Whitefield LA. Retained lens fragments [letter]. Ophthalmology 2008; 115:414–415; reply by CL Karp, J Hui, J Fishler, SJ Gedde, M Shuler, 415 6. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmology 2006; 113:1949–1953 7. Braude LS, Schroeder RP. Retained nuclear fragment 1 year after uncomplicated phacoemulsification cataract extraction with posterior chamber intraocular lens implant [letter]. Arch Ophthalmol 1999; 117:847–848
J CATARACT REFRACT SURG - VOL 37, MARCH 2011
Retained nuclear fragment found during Descemet-stripping automated endothelial keratoplasty Mark D. Mifflin, MD, Marcus C. Neuffer, MD, Nick Mamalis, MD
An 82-year-old man with a 2- to 3-month history of progressive visual loss due to corneal edema was referred to our center. The ocular history was significant for uneventful cataract surgery approximately 3 years earlier. Pseudophakic bullous keratopathy was diagnosed and Descemet-stripping automated endothelial keratoplasty (DSAEK) performed. During surgery, a retained nuclear fragment was discovered in the anterior chamber. The fragment was removed and the DSAEK completed successfully. At the 4-month follow-up, the symptoms had completely resolved and the uncorrected distance visual acuity in the affected eye was 20/40. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:608–610 Q 2011 ASCRS and ESCRS
Several case reports have described retained nuclear lens fragments discovered weeks to months after phacoemulsification.1–5 We present a case in which pseudophakic bullous keratopathy developed approximately 3 years after phacoemulsification. During Descemetstripping automated endothelial keratoplasty (DSAEK) surgery, a retained nuclear lens fragment was found in the anterior chamber. CASE REPORT An 82-year-old man was referred to our institution for evaluation and treatment of persistent corneal edema in the right eye. The ocular history was remarkable for uneventful cataract surgery approximately 3 years earlier. The patient reported a 2- to 3-month history of markedly decreased vision in the right eye accompanied by foreign-body sensation and photophobia. Prior to referral, he had been treated empirically for presumed herpes simplex keratitis by his community ophthalmologist. On examination, the corrected distance visual acuity was 20/400 in the affected right eye and 20/25C in the left eye. Intraocular pressure was 15 mm Hg and 25 mm Hg,
Submitted: October 24, 2010. Accepted: November 9, 2010. From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City Utah, USA. Corresponding author: Mark D. Mifflin, MD, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, Utah 84132, USA. E-mail: [email protected].
608
Q 2011 ASCRS and ESCRS Published by Elsevier Inc.
respectively, and pachymetry, 897 mm and 550 mm, respectively. Pupils, motility, and confrontational visual fields were normal. Slitlamp examination of the right eye revealed central corneal edema with stromal folds and microcystic changes. No significant anterior chamber inflammation was seen, nor was there any corneal neovascularization or scarring. The posterior chamber intraocular lens (IOL) was in a good position with an intact posterior capsule and no vitreous seen in the anterior chamber. Slitlamp examination of the left eye showed a clear cornea without edema or decompensation and 1 to 2C pigmented endothelial cell changes. The posterior IOL was decentered but stable. Dilated fundoscopic examination of the right eye was partially obscured due to corneal edema; however, no retinal pathology was noted. A large amount of optic nerve head cupping was noted, with a cup-to-disc ratio of 0.7 in the right eye and 0.8 in the left eye. The patient was scheduled to have DSAEK for pseudophakic bullous keratopathy and was also referred to a glaucoma specialist for evaluation and management. The standard DSAEK procedure was started with an 8.0 mm section of Descemet membrane removed from the host and sent to pathology. When the irrigation/aspiration (I/A) handpiece was inserted into the anterior chamber to remove the ophthalmic viscosurgical device, it encountered a small dense nuclear lens fragment (Figure 1). The retained lens fragment was completely removed using the I/A handpiece and a second instrument through the side port. The DSAEK procedure was then continued, and an 8.5 mm graft was placed and positioned without complication. The pathology report of the Descemet membrane specimen was consistent with pseudophakic bullous keratopathy showing extreme endothelial cell loss (Figure 2). The patient had an uneventful recovery after surgery. At the 2-month examination, the uncorrected distance visual acuity in the right eye was 20/50, improving to 20/40 at 4 months. The DSAEK graft was clear and attached, and no inflammation was noted in the anterior chamber. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2010.11.022
CASE REPORT: RETAINED NUCLEAR FRAGMENT FOUND DURING DSAEK
Figure 1. Retained nuclear fragment (green arrow) on the I/A tip during DSAEK (note 8.0 mm mark).
DISCUSSION Various studies have reported corneal edema from retained nuclear fragments.1–7 The edema can be diffuse or sectoral, and the presentation can be weeks to months after phacoemulsification.6 One study reported an onset of symptoms 1 year after surgery.7 Our case is unique because the patient presented approximately 3 years after phacoemulsification and the lens fragment was not discovered until it appeared during DSAEK surgery. Some authors hypothesize that small lens fragments can evade initial detection by being concealed in the angle, in iris crypts, or posterior to the iris.4,6 Hui et al.6 report a case series that reviewed preoperative refractive, ultrasonographic, and keratometric information of 10 patients with retained nuclear fragments.
609
All 10 patients were “either myopic with elongated axial lengths or had steep keratometry readings.” A review of our patient’s preoperative chart revealed pre-cataract surgery myopia with a spherical equivalent of 5.50 diopters. This supports the hypothesis of Hui et al.6 that retained lens fragments may be more likely in myopic patients with deep anterior chambers and long axial lengths. This type of eye provides more space for lens fragments to be trapped in the posterior chamber during surgery. The fragments may remain in the posterior chamber or migrate to the inferior angle postoperatively. Yazıcı et al.4 report a case of intermittent corneal edema from a retained nuclear fragment, postulating that the edema was intermittent due to the fragment traveling between the anterior and posterior chambers during postural movements. This theory could also explain the late onset of symptoms in our patient; that is, the retained fragment might have remained behind the iris for more than 2 years and finally dislodged, moving into the anterior segment and resting in the angle. Another theory presumes nuclear fragments contain antigens that cross-react with antigens on endothelial cells, causing an immune response directed at the endothelium.6 Thus, another possible explanation for the late-onset corneal edema in our patient is that the retained lens fragment might have settled in a location away from the endothelium and not caused direct trauma but rather a smoldering immune response to the endothelium. After 2 years, the endothelium decompensated and corneal edema ensued. Several case reports document resolution of corneal edema following removal of retained lens fragments.1,2,4,6,7 This was not an option for us because the retained fragment was not discovered until after the host’s Descemet membrane had been removed. Had the lens fragment been found before Descemet stripping, endothelial replacement would still have been necessary because of the severity and chronicity of the edema and the cell loss noted on the pathologic specimen. However, we do agree with other authors that gonioscopy to look for retained nuclear fragments should be considered in patients with corneal edema after cataract surgery. We add to the recommendation that gonioscopy should be considered even if the cataract surgery had been performed years prior to the onset of corneal edema. REFERENCES
Figure 2. Photomicrograph of Descemet membrane removed during DSAEK procedure. Note the marked attenuation of the endothelial layer (hematoxylin eosin stain; original magnification 100).
1. Bohigian GM, Wexler SA. Complications of retained nuclear fragments in the anterior chamber after phacoemulsification with posterior chamber lens implant. Am J Ophthalmol 1997; 123: 546–547
J CATARACT REFRACT SURG - VOL 37, MARCH 2011
610
CASE REPORT: RETAINED NUCLEAR FRAGMENT FOUND DURING DSAEK
2. Gedde SJ, Karp CL, Budenz DL. Retained nuclear fragment in the anterior segment. Arch Ophthalmol 1998; 116:1532–1533. Available at: http://archopht.ama-assn.org/cgi/reprint/116/11/1532. Accessed November 11, 2010 3. Waheed K, Liu C. Nuclear fragment in the scleral tunneldan unusual cause of postoperative hypotony [letter]. J Cataract Refract Surg 2000; 26:10–11 4. Yazıcı AT, Kaya V, Bozkurt E, Imamoglu S, Yılmaz OF. Intermittent corneal edema due to anterior segment retained lens fragments. J Cataract Refract Surg 2007; 33:1136–1137
5. Goodfellow JFB, Whitefield LA. Retained lens fragments [letter]. Ophthalmology 2008; 115:414–415; reply by CL Karp, J Hui, J Fishler, SJ Gedde, M Shuler, 415 6. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmology 2006; 113:1949–1953 7. Braude LS, Schroeder RP. Retained nuclear fragment 1 year after uncomplicated phacoemulsification cataract extraction with posterior chamber intraocular lens implant [letter]. Arch Ophthalmol 1999; 117:847–848
J CATARACT REFRACT SURG - VOL 37, MARCH 2011