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Isolated posterior capsular split limited by Weiger's ligament after blunt ocular trauma in a child mimicking posterior lenticonus
Volume 19 Number 6 / December 2015
Matalia et al
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Literature Search MEDLINE was searched on January 25, 2015, without language or date restriction, for the following terms: CHARGE, oculomotor nerve palsy, and third nerve palsy. References 1. Verloes A. Updated diagnostic criteria for CHARGE syndrome: a proposal. Am J Med Genet A 2005;133:306-8. 2. Zentner GE, Layman WS, Martin DM, Scacheri PC. Molecular and phenotypic aspects of CHD7 mutation in CHARGE syndrome. Am J Med Genet A 2010;52:674-86. 3. Blake KD, Hartshorne TS, Lawand C, Dailor AN, Thelin JW. Cranial nerve manifestations in CHARGE syndrome. Am J Med Genet A 2008;146:585-92. 4. McMain K, Blake K, Smith I, et al. Ocular features of CHARGE syndrome. J AAPOS 2008;12:460-65. 5. Song MH, Cho HJ, Lee HK, et al. CHD7 mutational analysis and clinical considerations for auditory rehabilitation in deaf patients with CHARGE syndrome. PLoS One 2011;6: e24511. 6. Kim JH, Hwang JM. Magnetic resonance imaging in three patients with congenital oculomotor nerve palsy. Br J Ophthalmol 2009;93: 1266-7. 7. Kim JH, Hwang JM. Congenital monocular elevation deficiency. Ophthalmology 2009;116:580-84. 8. Kee C, Cha DM, Ahn J, Hwang JM. Myasthenia mimicking monocular elevation deficiency. J Child Neurol 2013;28:108-10. 9. Kim JH, Hwang JM, Hwang YS, Kim KJ, Chae J. Childhood ocular myasthenia gravis. Ophthalmology 2003;110:1458-62. 10. Kim JH, Hwang JM. Simulated Brown syndrome in the contralateral eye in superior oblique palsy. Neurol Sci 2013;34:107-9.
Isolated posterior capsular split limited by Weiger’s ligament after blunt ocular trauma in a child mimicking posterior lenticonus Jyoti Matalia, DNB, Nirupama Kasturi, MS, Hemant Anaspure, MS, Bhujang K. Shetty, MS, and Himanshu Matalia, MS A 9-year-old boy presented with a posterior capsular split in the lens following a blunt ocular injury. This split was probably limited by the margins of the Weiger’s ligament with opacification of the anterior vitreous face along the patellar fossa producing an appearance of posterior lenticonus.
Author affiliations: Narayana Nethralaya, Bangalore, Karnataka, India Submitted February 27, 2015. Revision accepted May 12, 2015. Correspondence: Dr. Jyoti Matalia, DNB, Department of Pediatric Ophthalmology and Strabismus, Narayana Nethralaya-2, Narayana Health City, 258/A, Bommasandra, Hosur road, Bangalore-560099, India (email: [email protected]). J AAPOS 2015;19:557-558. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.05.022
Journal of AAPOS
FIG 1. Slit-lamp photograph. A, Diffuse illumination showing clear lens with posterior capsular split and opacification along the margins of the split (arrow) and the anterior vitreous face. B, Retroillumination showing the extent of the posterior capsular split.
Case Report
A
9-year-old boy presented at the Pediatric Ophthalmology Department of Narayana Nethralaya 2, Bangalore, India, with the history of injury to the right eye with a cricket ball 4 weeks earlier. On examination, visual acuity was 20/100 in the right eye and 20/20 in the left eye. Slit-lamp biomicroscopy of the right eye showed a clear cornea and iris sphincter tear at 9 o’clock, with traumatic mydriasis. The anterior chamber was deep and quiet. The lens showed an oval posterior capsular split of approximately 7–8 mm in width restricted to the center (Figure 1). The posterior capsule showed features of concentric opacification around the split, with early opacification of the anterior vitreous face just behind the patellar fossa, giving the appearance of a posterior lenticonus on oblique slit-lamp examination (Figure 2A). Intraocular pressure was 23 mm Hg in the right eye and 16 mm Hg in the left eye; there were signs of angle recession on
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FIG 2. A, Slit-lamp photograph with oblique slit illumination showing the posterior lenticonus appearance. B, Schematic diagram showing the retrolental structures: Weiger’s ligament (a), with attachment of the anterior hyaloid membrane to the posterior capsule; central hyaloideocapsular space (b), with central retrolental space in the patellar fossa between the posterior capsule of the lens and the anterior hyaloid membrane; Petit’s canal (c), with peripheral retrolental space between the posterior capsule of the lens, zonule, and the anterior hyaloid membrane; and anterior hyaloid membrane (d).
gonioscopy in the right eye. Dilated fundus examination revealed hazy optic disk and macula in the right eye while the fundus examination in the left eye appeared normal. Based on the above findings, cataract surgery with posterior capsular management and anterior vitrectomy with intraocular lens implantation in the left eye was advised, but patient was lost to follow-up.
Discussion Lens injury after blunt ocular trauma presents in various forms, including capsular rupture, cataract formation, subluxation, or dislocation of the crystalline lens. Isolated anterior and posterior capsular ruptures resulting in lens hydration and progression of cataract have also been reported.1,2 In young individuals the absence of a sclerotic nucleus and strong zonular fibers may allow the countercoup forces to be transmitted along the posterior lens surface, resulting in the rupture of the thinnest central portion of the posterior capsule.3 There are two potential spaces in the retrolental region (Figure 2B): the central hyaloideocapsular space, which is an interface between the anterior hyaloid membrane and posterior lens capsule, and the peripheral space called Petit’s canal. These two concentric spaces are separated by Weiger’s ligament, which is not a true ligament but a circular zone of adhesion of the anterior hyaloid membrane of the anterior vitreous cortex to the posterior capsule that is 8–9 mm in diameter and 1–2 mm in width. It may weaken with age or disappear completely.4
Volume 19 Number 6 / December 2015 Scanning electron microscopy has revealed that the posterior zonular fibers that originate from the ciliary body continue on their course toward the posterior lens capsule in the plane of the anterior hyaloidmembrane.5 As they reach the posterior capsule, they separate into loose fibrils that blend with the capsule and terminate at the Weiger’s ligament in a centripetal radial fashion. This anterior vitreous zonule not only helps to stabilize the anterior vitreous and lens position during accommodation6 but may contribute to the strength of the anterior hyaloid attachment. Previous reports of isolated posterior capsular rupture in nonpenetrating trauma have been described as large vertical or linear tears.4,7 These have been reported in children over 11 years of age, with the tears extending across the entire length of the posterior capsule. Our patient was younger, with the posterior capsular split being limited to the center, consistent with margins of Wieger’s ligament, probably indicating that this ligament was still strong. Normally, the central hyaloideocapsular space is not evident but becomes apparent in pathological conditions such as trauma.8 The opening up of the central hyaloideocapsular space into the patellar fossa, with opacification of the anterior vitreous cortex secondary to trauma due to migration of fibroblasts, gave the appearance of posterior lenticonus in the absence of a true lenticular bulge. References 1. Rao SK, Parikh S, Padhmanabhan P. Isolated posterior capsule rupture in blunt trauma: pathogenesis and management. Ophthalmic Surg Lasers 1998;29:338-42. 2. Wolff E. The vitreous. In: Bron AJ, Tripathi RC, Tripathi BJ, eds. Wolff’s Anatomy of the Eye and Orbit. 8th ed. London: Chapman & Hall Publications; 1997:443. 3. Wolter JR. Coup-Contrecoup mechanism of ocular injuries. Am J Ophthalmol 1963;56:785-96. 4. Pushkar N, Sony P, Khokhar S, Vardhan P. Implantation of foldable intraocular lens with anterior optic capture in isolated posterior capsular rupture. J Cataract Refract Surg 2005;31:1457-8. 5. Bernal A, Parel JM, Manns F. Evidence for posterior zonular fiber attachment on the anteriorhyaloidmembrane. Invest Ophthalmol Vis Sci 2006;47:4708-13. 6. L€ utjen-Drecoll E, Kaufman PL, Wasielewski R, Ting-Li L, Croft MA. Morphology and accommodative function of the vitreous zonule in human and monkey eyes. Invest Ophthalmol Vis Sci 2010;51:1554-64. 7. Li KK, Groenewald C, Wong D. Management of traumatic posterior capsular rupture: corneal approach with high speed vitrector. J Cataract Refract Surg 2005;31:1666-8. 8. Tolentino FI, Schepens CL, Freeman HM. Biomicroscopic appearance of the normal vitreous body. In: Tolentino FI, Schepens CL, Freeman HM, eds. Vitreoretinal Disorders: Diagnosis and Management. Philadephia: WB Saunders; 1976:110-14.
Journal of AAPOS
Matalia et al
557
Literature Search MEDLINE was searched on January 25, 2015, without language or date restriction, for the following terms: CHARGE, oculomotor nerve palsy, and third nerve palsy. References 1. Verloes A. Updated diagnostic criteria for CHARGE syndrome: a proposal. Am J Med Genet A 2005;133:306-8. 2. Zentner GE, Layman WS, Martin DM, Scacheri PC. Molecular and phenotypic aspects of CHD7 mutation in CHARGE syndrome. Am J Med Genet A 2010;52:674-86. 3. Blake KD, Hartshorne TS, Lawand C, Dailor AN, Thelin JW. Cranial nerve manifestations in CHARGE syndrome. Am J Med Genet A 2008;146:585-92. 4. McMain K, Blake K, Smith I, et al. Ocular features of CHARGE syndrome. J AAPOS 2008;12:460-65. 5. Song MH, Cho HJ, Lee HK, et al. CHD7 mutational analysis and clinical considerations for auditory rehabilitation in deaf patients with CHARGE syndrome. PLoS One 2011;6: e24511. 6. Kim JH, Hwang JM. Magnetic resonance imaging in three patients with congenital oculomotor nerve palsy. Br J Ophthalmol 2009;93: 1266-7. 7. Kim JH, Hwang JM. Congenital monocular elevation deficiency. Ophthalmology 2009;116:580-84. 8. Kee C, Cha DM, Ahn J, Hwang JM. Myasthenia mimicking monocular elevation deficiency. J Child Neurol 2013;28:108-10. 9. Kim JH, Hwang JM, Hwang YS, Kim KJ, Chae J. Childhood ocular myasthenia gravis. Ophthalmology 2003;110:1458-62. 10. Kim JH, Hwang JM. Simulated Brown syndrome in the contralateral eye in superior oblique palsy. Neurol Sci 2013;34:107-9.
Isolated posterior capsular split limited by Weiger’s ligament after blunt ocular trauma in a child mimicking posterior lenticonus Jyoti Matalia, DNB, Nirupama Kasturi, MS, Hemant Anaspure, MS, Bhujang K. Shetty, MS, and Himanshu Matalia, MS A 9-year-old boy presented with a posterior capsular split in the lens following a blunt ocular injury. This split was probably limited by the margins of the Weiger’s ligament with opacification of the anterior vitreous face along the patellar fossa producing an appearance of posterior lenticonus.
Author affiliations: Narayana Nethralaya, Bangalore, Karnataka, India Submitted February 27, 2015. Revision accepted May 12, 2015. Correspondence: Dr. Jyoti Matalia, DNB, Department of Pediatric Ophthalmology and Strabismus, Narayana Nethralaya-2, Narayana Health City, 258/A, Bommasandra, Hosur road, Bangalore-560099, India (email: [email protected]). J AAPOS 2015;19:557-558. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.05.022
Journal of AAPOS
FIG 1. Slit-lamp photograph. A, Diffuse illumination showing clear lens with posterior capsular split and opacification along the margins of the split (arrow) and the anterior vitreous face. B, Retroillumination showing the extent of the posterior capsular split.
Case Report
A
9-year-old boy presented at the Pediatric Ophthalmology Department of Narayana Nethralaya 2, Bangalore, India, with the history of injury to the right eye with a cricket ball 4 weeks earlier. On examination, visual acuity was 20/100 in the right eye and 20/20 in the left eye. Slit-lamp biomicroscopy of the right eye showed a clear cornea and iris sphincter tear at 9 o’clock, with traumatic mydriasis. The anterior chamber was deep and quiet. The lens showed an oval posterior capsular split of approximately 7–8 mm in width restricted to the center (Figure 1). The posterior capsule showed features of concentric opacification around the split, with early opacification of the anterior vitreous face just behind the patellar fossa, giving the appearance of a posterior lenticonus on oblique slit-lamp examination (Figure 2A). Intraocular pressure was 23 mm Hg in the right eye and 16 mm Hg in the left eye; there were signs of angle recession on
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Matalia et al
FIG 2. A, Slit-lamp photograph with oblique slit illumination showing the posterior lenticonus appearance. B, Schematic diagram showing the retrolental structures: Weiger’s ligament (a), with attachment of the anterior hyaloid membrane to the posterior capsule; central hyaloideocapsular space (b), with central retrolental space in the patellar fossa between the posterior capsule of the lens and the anterior hyaloid membrane; Petit’s canal (c), with peripheral retrolental space between the posterior capsule of the lens, zonule, and the anterior hyaloid membrane; and anterior hyaloid membrane (d).
gonioscopy in the right eye. Dilated fundus examination revealed hazy optic disk and macula in the right eye while the fundus examination in the left eye appeared normal. Based on the above findings, cataract surgery with posterior capsular management and anterior vitrectomy with intraocular lens implantation in the left eye was advised, but patient was lost to follow-up.
Discussion Lens injury after blunt ocular trauma presents in various forms, including capsular rupture, cataract formation, subluxation, or dislocation of the crystalline lens. Isolated anterior and posterior capsular ruptures resulting in lens hydration and progression of cataract have also been reported.1,2 In young individuals the absence of a sclerotic nucleus and strong zonular fibers may allow the countercoup forces to be transmitted along the posterior lens surface, resulting in the rupture of the thinnest central portion of the posterior capsule.3 There are two potential spaces in the retrolental region (Figure 2B): the central hyaloideocapsular space, which is an interface between the anterior hyaloid membrane and posterior lens capsule, and the peripheral space called Petit’s canal. These two concentric spaces are separated by Weiger’s ligament, which is not a true ligament but a circular zone of adhesion of the anterior hyaloid membrane of the anterior vitreous cortex to the posterior capsule that is 8–9 mm in diameter and 1–2 mm in width. It may weaken with age or disappear completely.4
Volume 19 Number 6 / December 2015 Scanning electron microscopy has revealed that the posterior zonular fibers that originate from the ciliary body continue on their course toward the posterior lens capsule in the plane of the anterior hyaloidmembrane.5 As they reach the posterior capsule, they separate into loose fibrils that blend with the capsule and terminate at the Weiger’s ligament in a centripetal radial fashion. This anterior vitreous zonule not only helps to stabilize the anterior vitreous and lens position during accommodation6 but may contribute to the strength of the anterior hyaloid attachment. Previous reports of isolated posterior capsular rupture in nonpenetrating trauma have been described as large vertical or linear tears.4,7 These have been reported in children over 11 years of age, with the tears extending across the entire length of the posterior capsule. Our patient was younger, with the posterior capsular split being limited to the center, consistent with margins of Wieger’s ligament, probably indicating that this ligament was still strong. Normally, the central hyaloideocapsular space is not evident but becomes apparent in pathological conditions such as trauma.8 The opening up of the central hyaloideocapsular space into the patellar fossa, with opacification of the anterior vitreous cortex secondary to trauma due to migration of fibroblasts, gave the appearance of posterior lenticonus in the absence of a true lenticular bulge. References 1. Rao SK, Parikh S, Padhmanabhan P. Isolated posterior capsule rupture in blunt trauma: pathogenesis and management. Ophthalmic Surg Lasers 1998;29:338-42. 2. Wolff E. The vitreous. In: Bron AJ, Tripathi RC, Tripathi BJ, eds. Wolff’s Anatomy of the Eye and Orbit. 8th ed. London: Chapman & Hall Publications; 1997:443. 3. Wolter JR. Coup-Contrecoup mechanism of ocular injuries. Am J Ophthalmol 1963;56:785-96. 4. Pushkar N, Sony P, Khokhar S, Vardhan P. Implantation of foldable intraocular lens with anterior optic capture in isolated posterior capsular rupture. J Cataract Refract Surg 2005;31:1457-8. 5. Bernal A, Parel JM, Manns F. Evidence for posterior zonular fiber attachment on the anteriorhyaloidmembrane. Invest Ophthalmol Vis Sci 2006;47:4708-13. 6. L€ utjen-Drecoll E, Kaufman PL, Wasielewski R, Ting-Li L, Croft MA. Morphology and accommodative function of the vitreous zonule in human and monkey eyes. Invest Ophthalmol Vis Sci 2010;51:1554-64. 7. Li KK, Groenewald C, Wong D. Management of traumatic posterior capsular rupture: corneal approach with high speed vitrector. J Cataract Refract Surg 2005;31:1666-8. 8. Tolentino FI, Schepens CL, Freeman HM. Biomicroscopic appearance of the normal vitreous body. In: Tolentino FI, Schepens CL, Freeman HM, eds. Vitreoretinal Disorders: Diagnosis and Management. Philadephia: WB Saunders; 1976:110-14.
Journal of AAPOS