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Bilateral spontaneous rupture of the anterior capsule
CASE REPORT
Bilateral spontaneous rupture of the anterior capsule Sunita Chaurasia, MS, Prashant Garg, MD
We report an unusual case of bilateral anterior capsule rupture in a healthy 8-year-old child. J Cataract Refract Surg 2008; 34:1413–1415 Q 2008 ASCRS and ESCRS
Lens capsule rupture is seen in various conditions. Spontaneous capsule rupture has been described in association with hypermature cataracts,1 and a propensity for capsule rupture has been described with steroid-induced cataract.2 Gaviria et al. 3 describe a case of anterior capsule rupture in association with anterior polar cataract in a 59-year-old woman, and there are reports of cataract formation following spontaneous capsule rupture in patients with Alport syndrome.4 We report a case of bilateral spontaneous capsule rupture in a young, otherwise healthy child.
oblique biconvex tear in the anterior capsule associated with diffuse opacification of underlying lens matter; the lens matter was prolapsing from the breach in the capsule (Figure 2). The fundus examination was within normal limits in the right eye, and the B-scan ultrasonography revealed a normal posterior segment in the left eye. Lens aspiration with intraocular lens implantation was performed in the left eye. The surgery and postoperative course were uneventful. At the 5-week follow-up, the best corrected visual acuity in the left eye was 20/20. The fundus examination showed clear media with a normal retina up to the ora serrata. Because of the possibility of Alport syndrome, the child was advised to get an otorhinology and nephrology consultation to rule out sensorineural deafness and renal problems. No abnormality was reported.
CASE REPORT An 8-year-old boy presented to us with a complaint of sudden onset of blurred vision associated with the appearance of a white spot in the black portion of the left eye of 4 days duration. There was no history of wearing glasses or antecedent trauma and no other significant systemic history. On examination, the visual acuity was 20/20 in the right eye and counting fingers close to the face with accurate projection of light in the left eye. Intraocular pressure by applanation tonometry was 10 mm Hg in both eyes. Ocular alignment was central, and ocular motility was full in all directions. The adnexa were within normal limits. The conjunctiva was quiet, the cornea clear, the anterior chamber deep and quiet, and the iris pattern normal; the pupils were round, regular, and reactive in both eyes. Examination of the crystalline lens in the right eye showed a rupture in the center of the anterior capsule associated with localized cortical opacity (Figure 1). The lens in the left eye revealed an Accepted for publication April 9, 2008. From the Cornea and Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, India. Neither author has a financial or proprietary interest in any material or method mentioned. Supported in part by the Hyderabad Eye Research Foundation, Hyderabad, India. Corresponding author: Prashant Garg, MD, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500 034, India. E-mail: [email protected]. Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
DISCUSSION A capsule rupture can be traumatic or spontaneous. While spontaneous rupture of the capsule in an elderly patient is usually seen in association with hypermature cataract, it has been reported in young patients in association with anterior lenticonus. In the latter situation, it is due to thinning of the anterior capsule.5 A normal capsule comprises a 3-dimensional molecular meshwork made up primarily of type IV collagen6 and other extracellular matrix constituents, such as collagen types I and III, laminin, and fibronectin. Each constituent is important to the biomechanical properties of the capsule.6–8 Mutation in the gene that codes for these constituents will result in capsule fragility. As more and more lens fibrils are laid down, the lens increases in volume, leading to rupture of the capsule at its weakest point. Histopathologic examination of an anterior capsule from a patient with Alport syndrome revealed multiple capsule dehiscence containing fibrillar material and vacuoles.5,9 In our patient, the exact etiology could not be ascertained because the boy presented with ruptured anterior capsules in both eyes. He did not have other systemic abnormalities suggestive of Alport syndrome, a disorder frequently associated with anterior lenticonus. However, keeping in mind the age of the patient and the central location of the rupture, the 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.04.032
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CASE REPORT: BILATERAL SPONTANEOUS RUPTURE OF ANTERIOR CAPSULE
Figure 1. Slitlamp photographs of the right eye showing partial rupture of the anterior capsule.
Figure 2. Slitlamp photographs of the left eye showing oblique rupture of the anterior capsule. J CATARACT REFRACT SURG - VOL 34, AUGUST 2008
CASE REPORT: BILATERAL SPONTANEOUS RUPTURE OF ANTERIOR CAPSULE
most likely etiology is anterior lenticonus. If the history of sudden onset of visual complaints in a child who had no previous visual problems were reliable, it would partly rule out this diagnosis. Absence of systemic abnormalities does not rule out anterior lenticonus because this can occur as an isolated entity without systemic association, and our patient may be such a case. Histopathology of the anterior capsule would probably have given us more information about this isolated entity. REFERENCES 1. Scott JG. Spontaneous rupture of the lens capsule. Br J Ophthalmol 1953; 37:58–60. Available at: http://www.pubmedcentral.nih. gov/picrender.fcgi?artidZ1324055&blobtypeZpdf. Accessed April 29, 2008 2. Sukhija J, Ram J, Brar GS, Bandhyopadhyaya S. Spontaneous rupture of the anterior lens capsule [letter]. Indian J Ophthalmol 2006; 54:216–217. Available at: http://www.ijo.in/temp/ IndianJOphthalmol543216_154845.pdf. AccessedApril 29, 2008 3. Gaviria JG, Johnson DA, Scribbick FW III, Gallardo MJ. Spontaneous anterior capsular rupture associated with anterior polar cataract. Arch Ophthalmol 2006; 124:134–135 4. Olitsky SE, Waz WR, Wilson ME. Rupture of anterior lens capsule in Alport syndrome. J AAPOS 1999; 3:381–382
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5. Streeten BW, Robinson MR, Wallace R, Jones DB. Lens capsule abnormalities in Alport’s syndrome. Arch Ophthalmol 1987; 105:1693–1697 6. Barnard K, Burgess SA, Carter DA, et al. Three-dimensional structure of type IV collagen in the mammalian lens capsule. J Struct Biol 1992; 108:6–13 7. Marshall GE, Konstas AGP, Bechrakis NE, Lee WR. An immunoelectron microscope study of the aged human lens capsule. Exp Eye Res 1992; 54:393–401 8. Kohno T, Sorgente N, Ishibashi T, Goodnight R, Ryan SJ. Immunofluorescent studies of fibronectin and laminin in the human eye. Invest Ophthalmol Vis Sci 1987; 28:506–514. Available at: http://www.iovs.org/cgi/reprint/28/3/506. Accessed April 29, 2008 9. Blaise P, Delanaye P, Martalo O, Pierard GE, Rorive G, Galand A. Le lenticoˆne ante´rieur: aide diagnostique au syndrome d’Alport. [Anterior lenticonus: diagnostic aid in Alport syndrome.] J Fr Ophtalmol 2003; 26:1075–1082
J CATARACT REFRACT SURG - VOL 34, AUGUST 2008
First author: Sunita Chaurasia, MS Cornea and Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, India
Bilateral spontaneous rupture of the anterior capsule Sunita Chaurasia, MS, Prashant Garg, MD
We report an unusual case of bilateral anterior capsule rupture in a healthy 8-year-old child. J Cataract Refract Surg 2008; 34:1413–1415 Q 2008 ASCRS and ESCRS
Lens capsule rupture is seen in various conditions. Spontaneous capsule rupture has been described in association with hypermature cataracts,1 and a propensity for capsule rupture has been described with steroid-induced cataract.2 Gaviria et al. 3 describe a case of anterior capsule rupture in association with anterior polar cataract in a 59-year-old woman, and there are reports of cataract formation following spontaneous capsule rupture in patients with Alport syndrome.4 We report a case of bilateral spontaneous capsule rupture in a young, otherwise healthy child.
oblique biconvex tear in the anterior capsule associated with diffuse opacification of underlying lens matter; the lens matter was prolapsing from the breach in the capsule (Figure 2). The fundus examination was within normal limits in the right eye, and the B-scan ultrasonography revealed a normal posterior segment in the left eye. Lens aspiration with intraocular lens implantation was performed in the left eye. The surgery and postoperative course were uneventful. At the 5-week follow-up, the best corrected visual acuity in the left eye was 20/20. The fundus examination showed clear media with a normal retina up to the ora serrata. Because of the possibility of Alport syndrome, the child was advised to get an otorhinology and nephrology consultation to rule out sensorineural deafness and renal problems. No abnormality was reported.
CASE REPORT An 8-year-old boy presented to us with a complaint of sudden onset of blurred vision associated with the appearance of a white spot in the black portion of the left eye of 4 days duration. There was no history of wearing glasses or antecedent trauma and no other significant systemic history. On examination, the visual acuity was 20/20 in the right eye and counting fingers close to the face with accurate projection of light in the left eye. Intraocular pressure by applanation tonometry was 10 mm Hg in both eyes. Ocular alignment was central, and ocular motility was full in all directions. The adnexa were within normal limits. The conjunctiva was quiet, the cornea clear, the anterior chamber deep and quiet, and the iris pattern normal; the pupils were round, regular, and reactive in both eyes. Examination of the crystalline lens in the right eye showed a rupture in the center of the anterior capsule associated with localized cortical opacity (Figure 1). The lens in the left eye revealed an Accepted for publication April 9, 2008. From the Cornea and Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, India. Neither author has a financial or proprietary interest in any material or method mentioned. Supported in part by the Hyderabad Eye Research Foundation, Hyderabad, India. Corresponding author: Prashant Garg, MD, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad 500 034, India. E-mail: [email protected]. Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
DISCUSSION A capsule rupture can be traumatic or spontaneous. While spontaneous rupture of the capsule in an elderly patient is usually seen in association with hypermature cataract, it has been reported in young patients in association with anterior lenticonus. In the latter situation, it is due to thinning of the anterior capsule.5 A normal capsule comprises a 3-dimensional molecular meshwork made up primarily of type IV collagen6 and other extracellular matrix constituents, such as collagen types I and III, laminin, and fibronectin. Each constituent is important to the biomechanical properties of the capsule.6–8 Mutation in the gene that codes for these constituents will result in capsule fragility. As more and more lens fibrils are laid down, the lens increases in volume, leading to rupture of the capsule at its weakest point. Histopathologic examination of an anterior capsule from a patient with Alport syndrome revealed multiple capsule dehiscence containing fibrillar material and vacuoles.5,9 In our patient, the exact etiology could not be ascertained because the boy presented with ruptured anterior capsules in both eyes. He did not have other systemic abnormalities suggestive of Alport syndrome, a disorder frequently associated with anterior lenticonus. However, keeping in mind the age of the patient and the central location of the rupture, the 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.04.032
1413
1414
CASE REPORT: BILATERAL SPONTANEOUS RUPTURE OF ANTERIOR CAPSULE
Figure 1. Slitlamp photographs of the right eye showing partial rupture of the anterior capsule.
Figure 2. Slitlamp photographs of the left eye showing oblique rupture of the anterior capsule. J CATARACT REFRACT SURG - VOL 34, AUGUST 2008
CASE REPORT: BILATERAL SPONTANEOUS RUPTURE OF ANTERIOR CAPSULE
most likely etiology is anterior lenticonus. If the history of sudden onset of visual complaints in a child who had no previous visual problems were reliable, it would partly rule out this diagnosis. Absence of systemic abnormalities does not rule out anterior lenticonus because this can occur as an isolated entity without systemic association, and our patient may be such a case. Histopathology of the anterior capsule would probably have given us more information about this isolated entity. REFERENCES 1. Scott JG. Spontaneous rupture of the lens capsule. Br J Ophthalmol 1953; 37:58–60. Available at: http://www.pubmedcentral.nih. gov/picrender.fcgi?artidZ1324055&blobtypeZpdf. Accessed April 29, 2008 2. Sukhija J, Ram J, Brar GS, Bandhyopadhyaya S. Spontaneous rupture of the anterior lens capsule [letter]. Indian J Ophthalmol 2006; 54:216–217. Available at: http://www.ijo.in/temp/ IndianJOphthalmol543216_154845.pdf. AccessedApril 29, 2008 3. Gaviria JG, Johnson DA, Scribbick FW III, Gallardo MJ. Spontaneous anterior capsular rupture associated with anterior polar cataract. Arch Ophthalmol 2006; 124:134–135 4. Olitsky SE, Waz WR, Wilson ME. Rupture of anterior lens capsule in Alport syndrome. J AAPOS 1999; 3:381–382
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5. Streeten BW, Robinson MR, Wallace R, Jones DB. Lens capsule abnormalities in Alport’s syndrome. Arch Ophthalmol 1987; 105:1693–1697 6. Barnard K, Burgess SA, Carter DA, et al. Three-dimensional structure of type IV collagen in the mammalian lens capsule. J Struct Biol 1992; 108:6–13 7. Marshall GE, Konstas AGP, Bechrakis NE, Lee WR. An immunoelectron microscope study of the aged human lens capsule. Exp Eye Res 1992; 54:393–401 8. Kohno T, Sorgente N, Ishibashi T, Goodnight R, Ryan SJ. Immunofluorescent studies of fibronectin and laminin in the human eye. Invest Ophthalmol Vis Sci 1987; 28:506–514. Available at: http://www.iovs.org/cgi/reprint/28/3/506. Accessed April 29, 2008 9. Blaise P, Delanaye P, Martalo O, Pierard GE, Rorive G, Galand A. Le lenticoˆne ante´rieur: aide diagnostique au syndrome d’Alport. [Anterior lenticonus: diagnostic aid in Alport syndrome.] J Fr Ophtalmol 2003; 26:1075–1082
J CATARACT REFRACT SURG - VOL 34, AUGUST 2008
First author: Sunita Chaurasia, MS Cornea and Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, India