- Email: [email protected]
Nuclear fragment drop without posterior capsular tear in a patient with congenital choroidal coloboma
Correspondence Nuclear fragment drop without posterior capsular tear in a patient with congenital choroidal coloboma
C
ongenital colobomas result from incomplete closure of an embryonal fissure that may involve lens zonules and iris anteriorly, and choroid with the overlying retina posteriorly.1 As a result, cataract surgery in such patients has a higher rate of complications, such as poor pupillary dilatation, decentration of the intraocular lens (IOL), and vitreous prolapse into the anterior chamber through absent inferior zonules.2 We report a case of nuclear fragment drop through the inferior zonular dehiscence during phacoemulsification in a patient with choroidal coloboma. Successful management of the complication and surgical interventions to prevent a similar event in the patient’s other eye are also discussed. A 49-year-old male with a diagnosis of bilateral choroidal coloboma sparing the optic disc and macula presented with a gradual decrease in vision in both eyes over 6 months. Bestcorrected visual acuity (BCVA) was 6/60 OU. Anterior segment evaluation revealed bilateral, diffuse, cortical and posterior subcapsular cataract with inferior zonular deficiency corresponding to the inferonasal iris colobomas. Phacoemulsification surgery using low flow rate parameters was performed first in the right eye. Towards the end of surgery anterior vitrectomy was performed to tackle the vitreous prolapsing through the inferior zonular coloboma. As the phacoemusification probe was reinserted into the anterior chamber, the last remaining nuclear fragment prolapsed out of the capsular bag and entered the vitreous cavity through the inferior zonular defect (Fig. 1). Posterior segment surgery could not be performed at that time as the patient had been given only topical anaesthesia. Pars plana vitrectomy with phacofragmentation of the dropped nuclear piece and IOL placement in the bag was performed 3 days later. The left eye was operated on 1 week later using 2 disposable iris retractors inferiorly to support the capsular rim. Sethi et al.3 have documented a novel technique of placing iris hooks to engage the nondilating iris superiorly and the margin of the capsulorhexis inferiorly to mechanically dilate the pupil and provide support to the capsular bag in the region of absent zonules. We modified this technique by placing the inferior 2 iris hooks closer together so as to act like barricades preventing posterior migration of the nuclear fragments. The nuclear pieces did prolapse out of the bag but were caught by the iris hooks before they could dislocate posteriorly. Adequate distention of the capsular bag with viscoelastics was also maintained at all times during phacoemulsification, which helped prevent the prolapse of the nuclear pieces into the anterior chamber and pushed the prolapsing vitreous back. Surgery was uneventful in the left eye and lens implantation was done in the bag at the same sitting. Six months later, intraocular lenses were well centred, and BCVA was 6/12 OU.
644
CAN J OPHTHALMOL—VOL. 45, NO. 6, 2010
Fig 1—(A) Postoperative day 1 posterior segment photograph of patient’s right eye. The posteriorly dislocated nuclear fragment (black arrow heads) is seen settled within the choroidal coloboma margins (note presence of sclera in the background). (B) Anterior segment photograph of same eye showing the continuous anterior capsulorhexis margin (black arrow heads) and the folded inferior rim of the intact capsular bag (white arrow heads). (C) Pre-operative photograph of left eye of the same patient showing absence of zonular support along the inferior margin of the crystalline lens (black arrow heads).
Correspondence A literature review using MEDLINE failed to find a similar case of nuclear fragment drop in a case of congenital coloboma of the choroid. This report illustrates a new pitfall that might occur during otherwise uncomplicated cataract surgery in choroidal coloboma patients and modifications in existing surgical techniques that may be incorporated to prevent such a complication. REFERENCES 1. Jesberg DO, Schepens CL. Retinal detachment associated with coloboma of the choroid. Arch Ophthalmol 1961;65:163–73. 2. Nordlund ML, Sugar A, Moroi SE. Phacoemulsification and intraocular lens placement in eyes with cataract and congenital coloboma: visual acuity and complications. J Cataract Refract Surg 2000;26:1035–40.
3. Sethi HS, Sinha A, Pal N, Saxena R. Modified flexible iris retractor to retract superior iris and support inferior capsule in eyes with iris coloboma and inferior zonular deficiency. J Cataract Refract Surg 2006;32:715–6.
Prashant Naithani, Naginder Vashisht, Preeti Sankaran, Subrata Mandal, Satpal Garg Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to Prashant Naithani, MD: [email protected] Can J Ophthalmol 2010;45:644–5 doi:10.3129/i10-057
CAN J OPHTHALMOL—VOL. 45, NO. 6, 2010
645
C
ongenital colobomas result from incomplete closure of an embryonal fissure that may involve lens zonules and iris anteriorly, and choroid with the overlying retina posteriorly.1 As a result, cataract surgery in such patients has a higher rate of complications, such as poor pupillary dilatation, decentration of the intraocular lens (IOL), and vitreous prolapse into the anterior chamber through absent inferior zonules.2 We report a case of nuclear fragment drop through the inferior zonular dehiscence during phacoemulsification in a patient with choroidal coloboma. Successful management of the complication and surgical interventions to prevent a similar event in the patient’s other eye are also discussed. A 49-year-old male with a diagnosis of bilateral choroidal coloboma sparing the optic disc and macula presented with a gradual decrease in vision in both eyes over 6 months. Bestcorrected visual acuity (BCVA) was 6/60 OU. Anterior segment evaluation revealed bilateral, diffuse, cortical and posterior subcapsular cataract with inferior zonular deficiency corresponding to the inferonasal iris colobomas. Phacoemulsification surgery using low flow rate parameters was performed first in the right eye. Towards the end of surgery anterior vitrectomy was performed to tackle the vitreous prolapsing through the inferior zonular coloboma. As the phacoemusification probe was reinserted into the anterior chamber, the last remaining nuclear fragment prolapsed out of the capsular bag and entered the vitreous cavity through the inferior zonular defect (Fig. 1). Posterior segment surgery could not be performed at that time as the patient had been given only topical anaesthesia. Pars plana vitrectomy with phacofragmentation of the dropped nuclear piece and IOL placement in the bag was performed 3 days later. The left eye was operated on 1 week later using 2 disposable iris retractors inferiorly to support the capsular rim. Sethi et al.3 have documented a novel technique of placing iris hooks to engage the nondilating iris superiorly and the margin of the capsulorhexis inferiorly to mechanically dilate the pupil and provide support to the capsular bag in the region of absent zonules. We modified this technique by placing the inferior 2 iris hooks closer together so as to act like barricades preventing posterior migration of the nuclear fragments. The nuclear pieces did prolapse out of the bag but were caught by the iris hooks before they could dislocate posteriorly. Adequate distention of the capsular bag with viscoelastics was also maintained at all times during phacoemulsification, which helped prevent the prolapse of the nuclear pieces into the anterior chamber and pushed the prolapsing vitreous back. Surgery was uneventful in the left eye and lens implantation was done in the bag at the same sitting. Six months later, intraocular lenses were well centred, and BCVA was 6/12 OU.
644
CAN J OPHTHALMOL—VOL. 45, NO. 6, 2010
Fig 1—(A) Postoperative day 1 posterior segment photograph of patient’s right eye. The posteriorly dislocated nuclear fragment (black arrow heads) is seen settled within the choroidal coloboma margins (note presence of sclera in the background). (B) Anterior segment photograph of same eye showing the continuous anterior capsulorhexis margin (black arrow heads) and the folded inferior rim of the intact capsular bag (white arrow heads). (C) Pre-operative photograph of left eye of the same patient showing absence of zonular support along the inferior margin of the crystalline lens (black arrow heads).
Correspondence A literature review using MEDLINE failed to find a similar case of nuclear fragment drop in a case of congenital coloboma of the choroid. This report illustrates a new pitfall that might occur during otherwise uncomplicated cataract surgery in choroidal coloboma patients and modifications in existing surgical techniques that may be incorporated to prevent such a complication. REFERENCES 1. Jesberg DO, Schepens CL. Retinal detachment associated with coloboma of the choroid. Arch Ophthalmol 1961;65:163–73. 2. Nordlund ML, Sugar A, Moroi SE. Phacoemulsification and intraocular lens placement in eyes with cataract and congenital coloboma: visual acuity and complications. J Cataract Refract Surg 2000;26:1035–40.
3. Sethi HS, Sinha A, Pal N, Saxena R. Modified flexible iris retractor to retract superior iris and support inferior capsule in eyes with iris coloboma and inferior zonular deficiency. J Cataract Refract Surg 2006;32:715–6.
Prashant Naithani, Naginder Vashisht, Preeti Sankaran, Subrata Mandal, Satpal Garg Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to Prashant Naithani, MD: [email protected] Can J Ophthalmol 2010;45:644–5 doi:10.3129/i10-057
CAN J OPHTHALMOL—VOL. 45, NO. 6, 2010
645