- Email: [email protected]
Mature cataract and lens-induced glaucoma associated with an asymptomatic intralenticular foreign body
CASE REPORT
Mature cataract and lens-induced glaucoma associated with an asymptomatic intralenticular foreign body Woojin Lee, MD, Sung Yong Park, MD, Tae Kwann Park, MD, Hee Kyung Kim, MD, Young Hoon Ohn, MD, PhD
We report a case of mature cataract and lens-induced glaucoma associated with an asymptomatic intralenticular foreign body. At initial presentation, the patient had no definite history of ocular trauma. During cataract surgery, a metallic intralenticular foreign body was expressed with hydrodissection and easily removed with intraocular forceps. Postoperative visual acuity, ocular status, and electroretinographic findings indicated that the crystalline lens served as a natural barrier to irreversible intraocular toxicity. J Cataract Refract Surg 2007; 33:550–552 Q 2007 ASCRS and ESCRS
In cases of traumatic cataract caused by projectile objects, most patients present with a definite history of ocular trauma. However, asymptomatic penetrating ocular injuries do occur; these may be ignored or at least underappreciated by the patients and eventually forgotten. Retained ferrous metallic foreign bodies may cause secondary ocular damage, termed siderosis bulbi. Clinical findings of siderosis bulbi include iris heterochromia, pupillary mydriasis, cataract formation, chronic uveitis, secondary glaucoma, retinal degeneration, and optic nerve swelling. Prompt removal of the foreign body should be considered when ocular siderosis is expected to occur.1 However, in cases in which the foreign body is embedded in the crystalline lens and stable visual function is maintained, periodic observation is suggested because of a lower risk for ocular siderosis.2,3
Accepted for publication September 26, 2006. From the Department of Ophthalmology (Lee, S.Y. Park, T.K. Park, Ohn), and the Department of Pathology (Kim), Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Woojin Lee, MD, Department of Ophthalmology, Soonchunhyang University College of Medicine, #1174 Jung-dong, Wonmi-gu, Bucheon, Gyeonggi-do, 420-767, South Korea. E-mail: [email protected].
550
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 54-year-old man complained of decreased vision of insidious onset in the left eye. The medical history was unremarkable, and the patient had no definite history of ocular trauma. The best corrected visual acuity (BCVA) was hand motions in the left eye and 20/20 in the right eye. A paracentral corneal scar, 1.0 mm in length, was evident and a dense, mature cataract completely obscured the posterior segment. Anterior chamber flare was 2C. The anterior capsule appeared to be intact, including the area corresponding to the corneal scar. The intraocular pressure (IOP) was elevated to 58 mm Hg, and medical treatment to lower the IOP was started. Gonioscopy revealed an open angle of 360 degrees. Because the foreign body was not identified on routine examination, a computerized tomographic scan was done. An intralenticular foreign body was observed near the posterior pole of the cataractous lens (Figure 1). After the IOP was reduced, the patient had phacoemulsification and implantation of a foldable intraocular lens. Aqueous was collected for cytologic examination before surgery. The intralenticular foreign body was easily expressed with hydrodissection and eventually removed with intraocular forceps (Figure 2). Cytologic examination of the aqueous revealed macrophages with finely vacuolated cytoplasm in a proteinaceous background (Figure 3). Postoperatively, the IOP was normalized and the eye achieved a BCVA of 20/30. At 1 month, an electroretinogram showed no functional abnormality in the retina. 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.09.043
CASE REPORT: ASYMPTOMATIC INTRALENTICULAR FOREIGN BODY
Figure 1. Computerized tomographic finding of a metallic intralenticular foreign body (white arrow) near the posterior pole of the cataractous lens.
551
Figure 2. The intralenticular foreign body (white arrow) expressed at the time of surgery. With the aid of an ophthalmic viscosurgical device, it was moved to the center of the anterior chamber and eventually removed with an intraocular forceps.
DISCUSSION Intralenticular foreign bodies account for approximately 10% of all intraocular foreign bodies, and most patients seek medical care for ensuing cataract formation.1 However, stable visual function without significant cataract formation has been described in some cases.2,3 Although it has been suggested that the risk is low, a few cases of ocular siderosis in lens-embedded foreign bodies have been reported.2,4 If the risk of surgically removing the foreign body is less than the risk of leaving it undisturbed in the eye, early removal should be considered. Nonetheless, the decision to proceed to surgery should be based on various factors such as the size and chemical composition of the foreign body and the potential for infection.5 As shown in this case and previously reported cases,6,7 clinicians should consider the possibility of an asymptomatic intraocular foreign body even if patients have no definite history of ocular trauma. Intralenticular foreign bodies, even metallic ones, may remain inert for a long period of time.7,8 Even if the anterior capsule is intact, the possibility of an intraocular foreign body should not be excluded because the capsule may restore its continuity by subcapsular epithelial proliferation. Restoration of the anterior capsule breach can limit the free passage of ions and fluid that may have a part in cataractogenesis.9 In this case, the crystalline lens appears to have served as a natural barrier to irreversible intraocular toxicity. Macrophages and the proteinaceous background seem to be the major suspects in the IOP elevation in this case. Macrophages intermingled with amorphous lens material may lead to obstruction of the trabecular meshwork, and such cytologic findings in the
Figure 3. Light microscopic view of the aqueous sample. Macrophages with finely vacuolated cytoplasm in a proteinaceous background are observed. The nuclei, which vary in size and shape, are eccentrically placed (Papanicolaou, original magnification 400).
aqueous may help establish a diagnosis of phacolytic glaucoma.10 REFERENCES 1. Hope-Ross M, Mahon GJ, Johnston PB. Ocular siderosis. Eye 1993; 7:419–425 2. Keeney AH. Intralenticular foreign bodies. Arch Ophthalmol 1971; 86:499–501 3. Pieramici DJ, Capone A Jr, Rubsamen PE, Roseman RL. Lens preservation after intraocular foreign body injuries. Ophthalmology 1996; 103:1563–1567 4. O’Duffy D, Salmon JF. Siderosis bulbi resulting from an intralenticular foreign body. Am J Ophthalmol 1999; 127:218–219
552
CASE REPORT: ASYMPTOMATIC INTRALENTICULAR FOREIGN BODY
5. Macken PL, Boyd SR, Feldman F, et al. Intralenticular foreign bodies: case reports and surgical review. Ophthalmic Surg 1995; 26:250–252 6. Taguri AH, Azuara-Blanco A. Traumatic cataract from asymptomatic nonmetallic foreign body [correspondence]. J Cataract Refract Surg 2002; 28:1889–1890 7. Cazabon S, Dabbs TR. Intralenticular metallic foreign body. J Cataract Refract Surg 2002; 28:2233–2234
8. Dhawahir-Scala FE, Kamal A. Intralenticular foreign body: a D-Day reminder [letter]. Clin Exp Ophthalmol 2005; 33:659–660 9. Fagerholm PP, Philipson BT. Human traumatic cataract. A quantitative microradiographic and electron microscopic study. Acta Ophthalmol (Copenh) 1979; 57:20–32 10. Goldberg MF. Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous. Br J Ophthalmol 1967; 51:847–853
Mature cataract and lens-induced glaucoma associated with an asymptomatic intralenticular foreign body Woojin Lee, MD, Sung Yong Park, MD, Tae Kwann Park, MD, Hee Kyung Kim, MD, Young Hoon Ohn, MD, PhD
We report a case of mature cataract and lens-induced glaucoma associated with an asymptomatic intralenticular foreign body. At initial presentation, the patient had no definite history of ocular trauma. During cataract surgery, a metallic intralenticular foreign body was expressed with hydrodissection and easily removed with intraocular forceps. Postoperative visual acuity, ocular status, and electroretinographic findings indicated that the crystalline lens served as a natural barrier to irreversible intraocular toxicity. J Cataract Refract Surg 2007; 33:550–552 Q 2007 ASCRS and ESCRS
In cases of traumatic cataract caused by projectile objects, most patients present with a definite history of ocular trauma. However, asymptomatic penetrating ocular injuries do occur; these may be ignored or at least underappreciated by the patients and eventually forgotten. Retained ferrous metallic foreign bodies may cause secondary ocular damage, termed siderosis bulbi. Clinical findings of siderosis bulbi include iris heterochromia, pupillary mydriasis, cataract formation, chronic uveitis, secondary glaucoma, retinal degeneration, and optic nerve swelling. Prompt removal of the foreign body should be considered when ocular siderosis is expected to occur.1 However, in cases in which the foreign body is embedded in the crystalline lens and stable visual function is maintained, periodic observation is suggested because of a lower risk for ocular siderosis.2,3
Accepted for publication September 26, 2006. From the Department of Ophthalmology (Lee, S.Y. Park, T.K. Park, Ohn), and the Department of Pathology (Kim), Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Woojin Lee, MD, Department of Ophthalmology, Soonchunhyang University College of Medicine, #1174 Jung-dong, Wonmi-gu, Bucheon, Gyeonggi-do, 420-767, South Korea. E-mail: [email protected].
550
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 54-year-old man complained of decreased vision of insidious onset in the left eye. The medical history was unremarkable, and the patient had no definite history of ocular trauma. The best corrected visual acuity (BCVA) was hand motions in the left eye and 20/20 in the right eye. A paracentral corneal scar, 1.0 mm in length, was evident and a dense, mature cataract completely obscured the posterior segment. Anterior chamber flare was 2C. The anterior capsule appeared to be intact, including the area corresponding to the corneal scar. The intraocular pressure (IOP) was elevated to 58 mm Hg, and medical treatment to lower the IOP was started. Gonioscopy revealed an open angle of 360 degrees. Because the foreign body was not identified on routine examination, a computerized tomographic scan was done. An intralenticular foreign body was observed near the posterior pole of the cataractous lens (Figure 1). After the IOP was reduced, the patient had phacoemulsification and implantation of a foldable intraocular lens. Aqueous was collected for cytologic examination before surgery. The intralenticular foreign body was easily expressed with hydrodissection and eventually removed with intraocular forceps (Figure 2). Cytologic examination of the aqueous revealed macrophages with finely vacuolated cytoplasm in a proteinaceous background (Figure 3). Postoperatively, the IOP was normalized and the eye achieved a BCVA of 20/30. At 1 month, an electroretinogram showed no functional abnormality in the retina. 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.09.043
CASE REPORT: ASYMPTOMATIC INTRALENTICULAR FOREIGN BODY
Figure 1. Computerized tomographic finding of a metallic intralenticular foreign body (white arrow) near the posterior pole of the cataractous lens.
551
Figure 2. The intralenticular foreign body (white arrow) expressed at the time of surgery. With the aid of an ophthalmic viscosurgical device, it was moved to the center of the anterior chamber and eventually removed with an intraocular forceps.
DISCUSSION Intralenticular foreign bodies account for approximately 10% of all intraocular foreign bodies, and most patients seek medical care for ensuing cataract formation.1 However, stable visual function without significant cataract formation has been described in some cases.2,3 Although it has been suggested that the risk is low, a few cases of ocular siderosis in lens-embedded foreign bodies have been reported.2,4 If the risk of surgically removing the foreign body is less than the risk of leaving it undisturbed in the eye, early removal should be considered. Nonetheless, the decision to proceed to surgery should be based on various factors such as the size and chemical composition of the foreign body and the potential for infection.5 As shown in this case and previously reported cases,6,7 clinicians should consider the possibility of an asymptomatic intraocular foreign body even if patients have no definite history of ocular trauma. Intralenticular foreign bodies, even metallic ones, may remain inert for a long period of time.7,8 Even if the anterior capsule is intact, the possibility of an intraocular foreign body should not be excluded because the capsule may restore its continuity by subcapsular epithelial proliferation. Restoration of the anterior capsule breach can limit the free passage of ions and fluid that may have a part in cataractogenesis.9 In this case, the crystalline lens appears to have served as a natural barrier to irreversible intraocular toxicity. Macrophages and the proteinaceous background seem to be the major suspects in the IOP elevation in this case. Macrophages intermingled with amorphous lens material may lead to obstruction of the trabecular meshwork, and such cytologic findings in the
Figure 3. Light microscopic view of the aqueous sample. Macrophages with finely vacuolated cytoplasm in a proteinaceous background are observed. The nuclei, which vary in size and shape, are eccentrically placed (Papanicolaou, original magnification 400).
aqueous may help establish a diagnosis of phacolytic glaucoma.10 REFERENCES 1. Hope-Ross M, Mahon GJ, Johnston PB. Ocular siderosis. Eye 1993; 7:419–425 2. Keeney AH. Intralenticular foreign bodies. Arch Ophthalmol 1971; 86:499–501 3. Pieramici DJ, Capone A Jr, Rubsamen PE, Roseman RL. Lens preservation after intraocular foreign body injuries. Ophthalmology 1996; 103:1563–1567 4. O’Duffy D, Salmon JF. Siderosis bulbi resulting from an intralenticular foreign body. Am J Ophthalmol 1999; 127:218–219
552
CASE REPORT: ASYMPTOMATIC INTRALENTICULAR FOREIGN BODY
5. Macken PL, Boyd SR, Feldman F, et al. Intralenticular foreign bodies: case reports and surgical review. Ophthalmic Surg 1995; 26:250–252 6. Taguri AH, Azuara-Blanco A. Traumatic cataract from asymptomatic nonmetallic foreign body [correspondence]. J Cataract Refract Surg 2002; 28:1889–1890 7. Cazabon S, Dabbs TR. Intralenticular metallic foreign body. J Cataract Refract Surg 2002; 28:2233–2234
8. Dhawahir-Scala FE, Kamal A. Intralenticular foreign body: a D-Day reminder [letter]. Clin Exp Ophthalmol 2005; 33:659–660 9. Fagerholm PP, Philipson BT. Human traumatic cataract. A quantitative microradiographic and electron microscopic study. Acta Ophthalmol (Copenh) 1979; 57:20–32 10. Goldberg MF. Cytological diagnosis of phacolytic glaucoma utilizing millipore filtration of the aqueous. Br J Ophthalmol 1967; 51:847–853