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Giant retinal tear and subretinal lens migration after complicated phacoemulsification
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CASE REPORT
Giant retinal tear and subretinal lens migration after complicated phacoemulsification Monica Lohchab, MD, FICO, Mayank Bansal, MD, FICO, Mahesh Kumar, MD
We report an unusual complication of phacoemulsification wherein an entire cataractous lens migrated through a giant retinal tear into the subretinal space. This case was managed successfully with pars plana vitrectomy and perfluorocarbon liquid–assisted
P
osterior migration of lens matter is one of the most dreaded intraoperative complications of phacoemulsification. Rarely, such cases are further complicated by giant retinal tear formation if aggressive attempts are made to retrieve the dropped fragments through the anterior route at the time of cataract surgery. We report an unusual case and surgical management of migration of a dropped nucleus through a giant retinal tear in the subretinal space after phacoemulsification.
phacofragmentation. To our knowledge, only a single case of a subretinal lens after phacoemulsification has been previously reported. JCRS Online Case Reports 2019; 7:53–54 © 2019 ASCRS and ESCRS
the subretinal space at the posterior pole, with evidence of an inferior giant retinal tear extending for nearly 4 clock hours with a total rhegmatogenous RD (Figure 1). After completion of the vitrectomy, perfluorocarbon liquid (PFCL) was injected over the optic nerve away from the lens to maneuverer it out of the subretinal space by gradually pushing it toward the edge of the break. The PFCL also served the purpose of unfolding the retinal flap caused by the giant retinal tear. After lens fragmentation, a 360-degree endolaser photocoagulation and silicone oil injection were performed. The patient was left aphakic. Postoperatively, the retina was attached. The CDVA was 20/200 at the most recent follow-up at 3 months.
CASE REPORT A 65-year-old woman presented with mild pain, redness, and poor gain of vision in the right eye 2 weeks after cataract surgery. According to the available records, phacoemulsification was complicated by a posterior capsule tear and nucleus drop. On presentation, the visual acuity in the affected right eye was hand motions close to face; the intraocular pressure was 12 mm Hg. Slitlamp examination showed dense cortical material in the pupillary area that prevented visualization of the fundus. A B-mode ultrasonography scan showed a total retinal detachment (RD) with an oval hyperechoic structure in the subretinal space suggestive of a cataractous lens. There was an immature senile cataract grade 2 in the left eye, which had a corrected distance visual acuity (CDVA) of 20/100. There was no evidence of pseudoexfoliation, phacodonesis, or posterior polar cataract, and the fundus was normal. The patient was scheduled for vitreoretinal surgery with an encircling band in the right eye. After the cataract wound was secured with a 10-0 monofilament nylon suture and the encircling band was passed, 3 standard 23-gauge par plana ports were made and cortical matter was cleared from the pupillary plane. On visualizing the fundus, the entire cataractous lens nucleus was seen in
DISCUSSION The reported incidence of posterior dislocation of the lens during phacoemulsification is 0.1% to 3.0%.1 Giant retinal tears can occur in such cases as a result of excessive vitreous traction caused by rigorous pursuit of the dropped lens fragments by the cataract surgeon.2 Subretinal lens migration is extremely rare and has been reported after blunt trauma3,4 and as a complication after pars plana lensectomy5 and phacoemulsification.6 In such cases, there are coexisting large retinal tears with a posteriorly displaced lens. In this case, after a posterior capsule tear and nucleus drop into the vitreous cavity, the cataract surgeon presumably attempted aggressive retrieval of the dropped nucleus. This might have led to excessive vitreous traction, giant retinal tear formation, and descent of the nucleus into the subretinal space through this large break.
Submitted: March 31, 2019 | Accepted: April 10, 2019 From Guru Nanak Eye Centre (Lohchab, Bansal), Maulana Azad Medical College, and the Dr. Rajendra Prasad Centre for Ophthalmic Sciences (Kumar), All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Dr. Atul Kumar provided guidance in clinical workup and management of the patient for this complicated case. Corresponding author: Monica Lohchab, MD, FICO, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi 110002, India. Email: monicalohchab@gmail. com. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
2214-1677/$ - see frontmatter https://doi.org/10.1016/j.jcro.2019.09.001
54
SUBRETINAL LENS MIGRATION AFTER COMPLICATED PHACOEMULSIFICATION
Subretinal lens migration after complicated cataract surgery is extremely unusual. To our knowledge, only one case of a subretinal lens after phacoemulsification has been previously reported.6 This case highlights the importance of abstaining from maneuvers to fish out the dropped nucleus by the primary surgeon through the anterior route and outlines a few surgical points for vitreoretinal surgeons to manage such cases. REFERENCES Figure 1. Lens in the subretinal space.
Left untreated, retained lens fragments can cause glaucoma, corneal edema, uveitis, cystoid macular edema, retinal tears, and RD. Pars plana vitrectomy is the preferred surgery for a dropped nucleus.7 In contrast to usually good visual outcomes reported after pars plana vitrectomy for dislocated lens fragments, eyes with a coexisting giant retinal tear and RD have an unfavorable visual and anatomic prognosis.2 Phacofragmentation in an eye with a giant retinal tear and total RD is surgically challenging because of the excessive mobility of the detached retina and risk for reentry of smaller fragments through the break. Intraoperative use of PFCL simplifies the surgery and improves the outcome.8 In this case, however, the PFCL over the retina might have made the lens immobile, making it harder to remove. Therefore, we injected the PFCL over the optic nerve, away from the lens. While injecting the PFCL, we maneuvered the lens toward the giant retinal tear with the silicone-tipped cannula. We also recommend low vacuum and low infusion pressure for minimum turbulence of lens fragments. In addition, it is imperative to complete the peripheral vitrectomy before phacofragmentation to avoid traction over the vitreous and new retinal break formation.
Volume 7 Issue 4 October 2019
1. Aasuri MK, Kompella VB, Majji AB. Risk factors for and management of dropped nucleus during phacoemulsification. J Cataract Refract Surg 2001; 27:1428–1443 2. Aaberg TM Jr, Rubsamen PE, Flynn HW Jr, Chang S, Mieler WF, Smiddy WE. Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol 1997; 124:222–226 3. Nagaraj BN, Tirumale S, Sriprakash KS, Savitha CS, Jayadev C. Subretinal crystalline lens – an unusual complication of blunt trauma. Asian J Ophthalmol 2013; 13:68–70 4. Bawankar P, Das D, Agarwal B, Bhattacharjee K, Tayab S, Deka P, Singh A, Borah E, Dhar S. A rare case of traumatic subretinal migration of crystalline lens, corroborated histologically. Indian J Ophthalmol 2017; 65:1495–1497 5. Katzen LB, Rogell GD. Subretinal lens; an unusual complication of pars plana lensectomy. Arch Ophthalmol 1981; 99:1396–1397 6. Rani A, Pal N, Vohra R, Mandal S, Azad R. Subretinal dislocation of the crystalline lens: unusual complication of phacoemulsification. J Cataract Refract Surg 2005; 31:1843–1844 7. Rossetti A, Doro D. Retained intravitreal lens fragments after phacoemulsification: complications and visual outcome in vitrectomized and nonvitrectomized eyes. J Cataract Refract Surg 2002; 28:310–315 pez-Guajardo L, Benitez-Herreros J, Dapena I. Simple maneuver for un8. Lo folding giant retinal tear inverted flap trapped under perfluorocarbon bubble. Ophthalmic Surg Lasers Imaging 2010; 41:394–396
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.
First author: Monica Lohchab, MD, FICO Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
CASE REPORT
Giant retinal tear and subretinal lens migration after complicated phacoemulsification Monica Lohchab, MD, FICO, Mayank Bansal, MD, FICO, Mahesh Kumar, MD
We report an unusual complication of phacoemulsification wherein an entire cataractous lens migrated through a giant retinal tear into the subretinal space. This case was managed successfully with pars plana vitrectomy and perfluorocarbon liquid–assisted
P
osterior migration of lens matter is one of the most dreaded intraoperative complications of phacoemulsification. Rarely, such cases are further complicated by giant retinal tear formation if aggressive attempts are made to retrieve the dropped fragments through the anterior route at the time of cataract surgery. We report an unusual case and surgical management of migration of a dropped nucleus through a giant retinal tear in the subretinal space after phacoemulsification.
phacofragmentation. To our knowledge, only a single case of a subretinal lens after phacoemulsification has been previously reported. JCRS Online Case Reports 2019; 7:53–54 © 2019 ASCRS and ESCRS
the subretinal space at the posterior pole, with evidence of an inferior giant retinal tear extending for nearly 4 clock hours with a total rhegmatogenous RD (Figure 1). After completion of the vitrectomy, perfluorocarbon liquid (PFCL) was injected over the optic nerve away from the lens to maneuverer it out of the subretinal space by gradually pushing it toward the edge of the break. The PFCL also served the purpose of unfolding the retinal flap caused by the giant retinal tear. After lens fragmentation, a 360-degree endolaser photocoagulation and silicone oil injection were performed. The patient was left aphakic. Postoperatively, the retina was attached. The CDVA was 20/200 at the most recent follow-up at 3 months.
CASE REPORT A 65-year-old woman presented with mild pain, redness, and poor gain of vision in the right eye 2 weeks after cataract surgery. According to the available records, phacoemulsification was complicated by a posterior capsule tear and nucleus drop. On presentation, the visual acuity in the affected right eye was hand motions close to face; the intraocular pressure was 12 mm Hg. Slitlamp examination showed dense cortical material in the pupillary area that prevented visualization of the fundus. A B-mode ultrasonography scan showed a total retinal detachment (RD) with an oval hyperechoic structure in the subretinal space suggestive of a cataractous lens. There was an immature senile cataract grade 2 in the left eye, which had a corrected distance visual acuity (CDVA) of 20/100. There was no evidence of pseudoexfoliation, phacodonesis, or posterior polar cataract, and the fundus was normal. The patient was scheduled for vitreoretinal surgery with an encircling band in the right eye. After the cataract wound was secured with a 10-0 monofilament nylon suture and the encircling band was passed, 3 standard 23-gauge par plana ports were made and cortical matter was cleared from the pupillary plane. On visualizing the fundus, the entire cataractous lens nucleus was seen in
DISCUSSION The reported incidence of posterior dislocation of the lens during phacoemulsification is 0.1% to 3.0%.1 Giant retinal tears can occur in such cases as a result of excessive vitreous traction caused by rigorous pursuit of the dropped lens fragments by the cataract surgeon.2 Subretinal lens migration is extremely rare and has been reported after blunt trauma3,4 and as a complication after pars plana lensectomy5 and phacoemulsification.6 In such cases, there are coexisting large retinal tears with a posteriorly displaced lens. In this case, after a posterior capsule tear and nucleus drop into the vitreous cavity, the cataract surgeon presumably attempted aggressive retrieval of the dropped nucleus. This might have led to excessive vitreous traction, giant retinal tear formation, and descent of the nucleus into the subretinal space through this large break.
Submitted: March 31, 2019 | Accepted: April 10, 2019 From Guru Nanak Eye Centre (Lohchab, Bansal), Maulana Azad Medical College, and the Dr. Rajendra Prasad Centre for Ophthalmic Sciences (Kumar), All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. Dr. Atul Kumar provided guidance in clinical workup and management of the patient for this complicated case. Corresponding author: Monica Lohchab, MD, FICO, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi 110002, India. Email: monicalohchab@gmail. com. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
2214-1677/$ - see frontmatter https://doi.org/10.1016/j.jcro.2019.09.001
54
SUBRETINAL LENS MIGRATION AFTER COMPLICATED PHACOEMULSIFICATION
Subretinal lens migration after complicated cataract surgery is extremely unusual. To our knowledge, only one case of a subretinal lens after phacoemulsification has been previously reported.6 This case highlights the importance of abstaining from maneuvers to fish out the dropped nucleus by the primary surgeon through the anterior route and outlines a few surgical points for vitreoretinal surgeons to manage such cases. REFERENCES Figure 1. Lens in the subretinal space.
Left untreated, retained lens fragments can cause glaucoma, corneal edema, uveitis, cystoid macular edema, retinal tears, and RD. Pars plana vitrectomy is the preferred surgery for a dropped nucleus.7 In contrast to usually good visual outcomes reported after pars plana vitrectomy for dislocated lens fragments, eyes with a coexisting giant retinal tear and RD have an unfavorable visual and anatomic prognosis.2 Phacofragmentation in an eye with a giant retinal tear and total RD is surgically challenging because of the excessive mobility of the detached retina and risk for reentry of smaller fragments through the break. Intraoperative use of PFCL simplifies the surgery and improves the outcome.8 In this case, however, the PFCL over the retina might have made the lens immobile, making it harder to remove. Therefore, we injected the PFCL over the optic nerve, away from the lens. While injecting the PFCL, we maneuvered the lens toward the giant retinal tear with the silicone-tipped cannula. We also recommend low vacuum and low infusion pressure for minimum turbulence of lens fragments. In addition, it is imperative to complete the peripheral vitrectomy before phacofragmentation to avoid traction over the vitreous and new retinal break formation.
Volume 7 Issue 4 October 2019
1. Aasuri MK, Kompella VB, Majji AB. Risk factors for and management of dropped nucleus during phacoemulsification. J Cataract Refract Surg 2001; 27:1428–1443 2. Aaberg TM Jr, Rubsamen PE, Flynn HW Jr, Chang S, Mieler WF, Smiddy WE. Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol 1997; 124:222–226 3. Nagaraj BN, Tirumale S, Sriprakash KS, Savitha CS, Jayadev C. Subretinal crystalline lens – an unusual complication of blunt trauma. Asian J Ophthalmol 2013; 13:68–70 4. Bawankar P, Das D, Agarwal B, Bhattacharjee K, Tayab S, Deka P, Singh A, Borah E, Dhar S. A rare case of traumatic subretinal migration of crystalline lens, corroborated histologically. Indian J Ophthalmol 2017; 65:1495–1497 5. Katzen LB, Rogell GD. Subretinal lens; an unusual complication of pars plana lensectomy. Arch Ophthalmol 1981; 99:1396–1397 6. Rani A, Pal N, Vohra R, Mandal S, Azad R. Subretinal dislocation of the crystalline lens: unusual complication of phacoemulsification. J Cataract Refract Surg 2005; 31:1843–1844 7. Rossetti A, Doro D. Retained intravitreal lens fragments after phacoemulsification: complications and visual outcome in vitrectomized and nonvitrectomized eyes. J Cataract Refract Surg 2002; 28:310–315 pez-Guajardo L, Benitez-Herreros J, Dapena I. Simple maneuver for un8. Lo folding giant retinal tear inverted flap trapped under perfluorocarbon bubble. Ophthalmic Surg Lasers Imaging 2010; 41:394–396
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.
First author: Monica Lohchab, MD, FICO Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India