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Posterior capsule rupture after blunt trauma
Posterior capsule rupture after blunt trauma Ravi Thomas, MD
osterior capsule rupture is a rare complication of blunt trauma that is usually discovered during surgery for the associated cataract. 1 The posterior capsule break typically has fibrosed edges. In the past 10 years, I have had the opportunity to manage several such cases. In two, the posterior capsule rupture was clearly visible and could be documented preoperatively.
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Case Reports Case 1 A 32-year-old man reported progressively decreasing vision in the left eye after blunt trauma to the eye with a fist 6 weeks previously. He had no history of poor vision before the trauma. Visual acuity in the involved eye was hand movement close to the face with accurate light projection. Examination of the anterior segment showed a mild cataract through which a posterior capsule break with fibrosed edges could be clearly identified (Figure 1). Some opacification was also present central to the margins of the break. Intraocular pressure was 18 mm Hg in this eye, and the angle was recessed in 3 clock hours superiorly. Examination of the fellow eye was normal. The patient had no systemic disorders. The patient had routine extracapsular cataract sutgety through a limbal incision. A vitrectomy was performed through the posterior capsule break, preserving the fibrosed edges, and a posterior chamber intraocular lens (10L) was implanted in the bag. Uncorrected visual acuity in the immediate postoperative period was 6/18 (6/6 with correction). Examination of the fundus at this time revealed no sequelae of blunt trauma. The patient was lost to follow-up. Reprint requests to Ravi Thomas, MD, Professor of Ophthalmology, Schell Eye Hospital, Christian Medical College, Ami Road, Vellore, Tamil Nadu 632001, India.
Case 2 A 10-year-old boy was brought to the hospital 2 months after injury to the right eye with a blunt stick. He had complained of decreased vision in that eye since the injury. Visual acuity in the involved eye was 6/36. Examination of the anterior segment showed an almost clear lens and a posterior capsule rupture with fibrosed edges; there was also opacification central to the edges (Figure 2). Intraocular pressure was 16 mm Hg; gonioscopy could not be performed. Examination of the fundus was normal, as was examination of the fellow eye. A pediatrician found no evidence of associated systemic disease. Extracapsular cataract surgery with posterior chamber IOL implantation was performed using an anterior chamber maintainer (ACM) and two 20 gauge paracenteses as described by Blumenthal and Assia. 2 Before IOL implantation, a partial anterior vitrectomy was done through the paracentesis openings without disrupting the fibrosed edges of the posterior capsule break. An endoilluminator was used to monitor the vitrectomy. Uncorrected visual acuity was 6/9 (6/6 with correction).
Discussion Anterior lens capsule rupture from blunt trauma caused by an air bag has been reported recently.3 To the best of my knowledge, there is only one report of preexisting posterior capsule break after blunt trauma to the eye. 1 This complication is usually discovered during surgery for the associated cataract. Our two cases are unusual as the typical fibrosed edges could be documented preoperatively and provided corroborative evidence that trauma was responsible for the "typical" break.
J CATARACT REFRACT SURG-VOL 24, FEBRUARY 1998
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CASE REPORTS: THOMAS
Figure 1. (Thomas) The fibrosed edges of the posterior capsule break are clearly seen. There is opacification central to the break.
Figure 2. (Thomas) The edges of the posterior capsule break are fibrosed and there is opacification central to the margins of the break.
Our patients' history did not suggest that the posterior capsule rupture antedated the trauma. The breaks were large and oval (in an oblique axis), with typical fibrosed edges. Both patients reported a history of good visual acuity before the trauma and recovered good acuity postoperatively; a congenital deformity such as posterior lenticonus would presumably have caused amblyopia. 4 Posterior polar cataracts predispose to intraoperative rupture of the posterior capsule. This may occur preoperatively with trauma. 5•6 The thickened and fibrosed margins of the posterior capsule break have been attributed to the migration of the hyperplastic epithelial cells that collect in this region.? The opacification central to the posterior capsule dehiscence could be explained by continued migration of these cells over the intact anterior vitreous face. The surgical management of these cases (including those in which the breaks are detected at surgery) has been described. 1 In my experience, these cases are easily managed with a closed-chamber technique using an ACM. Usually, the cataract can be removed using only aspiration through the paracentesis openings and the 10L implanted through a scleral tunnel incision. I was not using this technique in the late 1980s, when the first patient had surgery. I performed a partial anterior vitrectomy in view of the anterior vitreous face opacification. As the vitreous face may serve as a scaffold for migration of proliferating cells, an anterior vitrectomy may be desirable in younger patients even in the absence of such opacification. 8
Both patients recovered good visual acuity, as do most eyes in which the breaks have been discovered at surgery. The good visual prognosis suggests that the injury required to produce such breaks is not severe enough to produce vision-limiting changes at the macula. Postoperatively, the break functions as a capsulotomy to provide a clear visual axis.
284
References 1. Angra SK, Vajpayee RB, Titiyal JS, et al. Types of posterior capsular breaks and their surgical implications. Ophthalmic Surg 1991; 22:388-391 2. Blumenthal M, Assia EI. Extracapsular cataract extraction. In: Nordan LT, Maxwell WA, Davison JA, eds, The Surgical Rehabilitation of Vision; an Integrated Approach to Anterior Segment Surgery. New York, NY, Gower Medical Publishing, 1992; chap 10 3. Zabriskie NA, Hwang IP, Ramsey JF, Crandell AS. Anterior lens capsule rupture caused by air bag trauma. Am J Ophthalmol 1997; 123:832-833 4. Wright KW, Kolin T, Matsumoto E. Lens abnormalities. In: Wright KW, ed, Pediatric Ophthalmology and Strabismus. St Louis, MO, Mosby, 1995; 370 5. Osher RH, Yu BC-Y, Koch DO. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg 1990; 16:157-162 6. Skalka HW. Ultrasonic diagnosis of posterior lens rupture. Ophthalmic Surg 1977; 8(6):72-76 7. Vajpayee RB, Angra SK, Honavar SG, et al. Pre-existing posterior capsule breaks from perforating ocular injuries. J Cataract Refract Surg 1994; 20:291-294 8. Atkinson CS, Hiles DA. Treatment of secondary posterior capsular membranes with the Nd:YAG laser in a pediatric population. Am J Ophthalmol 1994; 118:496-501
J CATARACT REFRACT SURG-VOL24. FEBRUARY 1998
osterior capsule rupture is a rare complication of blunt trauma that is usually discovered during surgery for the associated cataract. 1 The posterior capsule break typically has fibrosed edges. In the past 10 years, I have had the opportunity to manage several such cases. In two, the posterior capsule rupture was clearly visible and could be documented preoperatively.
P
Case Reports Case 1 A 32-year-old man reported progressively decreasing vision in the left eye after blunt trauma to the eye with a fist 6 weeks previously. He had no history of poor vision before the trauma. Visual acuity in the involved eye was hand movement close to the face with accurate light projection. Examination of the anterior segment showed a mild cataract through which a posterior capsule break with fibrosed edges could be clearly identified (Figure 1). Some opacification was also present central to the margins of the break. Intraocular pressure was 18 mm Hg in this eye, and the angle was recessed in 3 clock hours superiorly. Examination of the fellow eye was normal. The patient had no systemic disorders. The patient had routine extracapsular cataract sutgety through a limbal incision. A vitrectomy was performed through the posterior capsule break, preserving the fibrosed edges, and a posterior chamber intraocular lens (10L) was implanted in the bag. Uncorrected visual acuity in the immediate postoperative period was 6/18 (6/6 with correction). Examination of the fundus at this time revealed no sequelae of blunt trauma. The patient was lost to follow-up. Reprint requests to Ravi Thomas, MD, Professor of Ophthalmology, Schell Eye Hospital, Christian Medical College, Ami Road, Vellore, Tamil Nadu 632001, India.
Case 2 A 10-year-old boy was brought to the hospital 2 months after injury to the right eye with a blunt stick. He had complained of decreased vision in that eye since the injury. Visual acuity in the involved eye was 6/36. Examination of the anterior segment showed an almost clear lens and a posterior capsule rupture with fibrosed edges; there was also opacification central to the edges (Figure 2). Intraocular pressure was 16 mm Hg; gonioscopy could not be performed. Examination of the fundus was normal, as was examination of the fellow eye. A pediatrician found no evidence of associated systemic disease. Extracapsular cataract surgery with posterior chamber IOL implantation was performed using an anterior chamber maintainer (ACM) and two 20 gauge paracenteses as described by Blumenthal and Assia. 2 Before IOL implantation, a partial anterior vitrectomy was done through the paracentesis openings without disrupting the fibrosed edges of the posterior capsule break. An endoilluminator was used to monitor the vitrectomy. Uncorrected visual acuity was 6/9 (6/6 with correction).
Discussion Anterior lens capsule rupture from blunt trauma caused by an air bag has been reported recently.3 To the best of my knowledge, there is only one report of preexisting posterior capsule break after blunt trauma to the eye. 1 This complication is usually discovered during surgery for the associated cataract. Our two cases are unusual as the typical fibrosed edges could be documented preoperatively and provided corroborative evidence that trauma was responsible for the "typical" break.
J CATARACT REFRACT SURG-VOL 24, FEBRUARY 1998
283
CASE REPORTS: THOMAS
Figure 1. (Thomas) The fibrosed edges of the posterior capsule break are clearly seen. There is opacification central to the break.
Figure 2. (Thomas) The edges of the posterior capsule break are fibrosed and there is opacification central to the margins of the break.
Our patients' history did not suggest that the posterior capsule rupture antedated the trauma. The breaks were large and oval (in an oblique axis), with typical fibrosed edges. Both patients reported a history of good visual acuity before the trauma and recovered good acuity postoperatively; a congenital deformity such as posterior lenticonus would presumably have caused amblyopia. 4 Posterior polar cataracts predispose to intraoperative rupture of the posterior capsule. This may occur preoperatively with trauma. 5•6 The thickened and fibrosed margins of the posterior capsule break have been attributed to the migration of the hyperplastic epithelial cells that collect in this region.? The opacification central to the posterior capsule dehiscence could be explained by continued migration of these cells over the intact anterior vitreous face. The surgical management of these cases (including those in which the breaks are detected at surgery) has been described. 1 In my experience, these cases are easily managed with a closed-chamber technique using an ACM. Usually, the cataract can be removed using only aspiration through the paracentesis openings and the 10L implanted through a scleral tunnel incision. I was not using this technique in the late 1980s, when the first patient had surgery. I performed a partial anterior vitrectomy in view of the anterior vitreous face opacification. As the vitreous face may serve as a scaffold for migration of proliferating cells, an anterior vitrectomy may be desirable in younger patients even in the absence of such opacification. 8
Both patients recovered good visual acuity, as do most eyes in which the breaks have been discovered at surgery. The good visual prognosis suggests that the injury required to produce such breaks is not severe enough to produce vision-limiting changes at the macula. Postoperatively, the break functions as a capsulotomy to provide a clear visual axis.
284
References 1. Angra SK, Vajpayee RB, Titiyal JS, et al. Types of posterior capsular breaks and their surgical implications. Ophthalmic Surg 1991; 22:388-391 2. Blumenthal M, Assia EI. Extracapsular cataract extraction. In: Nordan LT, Maxwell WA, Davison JA, eds, The Surgical Rehabilitation of Vision; an Integrated Approach to Anterior Segment Surgery. New York, NY, Gower Medical Publishing, 1992; chap 10 3. Zabriskie NA, Hwang IP, Ramsey JF, Crandell AS. Anterior lens capsule rupture caused by air bag trauma. Am J Ophthalmol 1997; 123:832-833 4. Wright KW, Kolin T, Matsumoto E. Lens abnormalities. In: Wright KW, ed, Pediatric Ophthalmology and Strabismus. St Louis, MO, Mosby, 1995; 370 5. Osher RH, Yu BC-Y, Koch DO. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg 1990; 16:157-162 6. Skalka HW. Ultrasonic diagnosis of posterior lens rupture. Ophthalmic Surg 1977; 8(6):72-76 7. Vajpayee RB, Angra SK, Honavar SG, et al. Pre-existing posterior capsule breaks from perforating ocular injuries. J Cataract Refract Surg 1994; 20:291-294 8. Atkinson CS, Hiles DA. Treatment of secondary posterior capsular membranes with the Nd:YAG laser in a pediatric population. Am J Ophthalmol 1994; 118:496-501
J CATARACT REFRACT SURG-VOL24. FEBRUARY 1998