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Retained lens nuclear fragment presenting years after phacoemulsification
LETTERS
Retained lens nuclear fragment presenting years after phacoemulsification Mokhtarzadeh et al.1 report a case in which a retained lens nuclear fragment caused an inflammatory response and late-onset corneal edema 11 months after phacoemulsification. The authors cite a report by Braude et al.2 in which a nuclear fragment remained undetected for nearly as long and appear to conclude that 1 year is the longest duration reported “in which retained nuclear fragments were responsible for an inflammatory response and abrupt onset of corneal edema in an eye.” However, their review of the literature was incomplete and failed to cite our case in which a nuclear fragment was retained for 8.5 years after phacoemulsification prior to inducing symptoms.3 The patient was a 79-year-old woman who presented with a 1-week history of blurred vision, redness, photophobia, foreign-body sensation, and tearing in her right eye. The ocular history included sequential bilateral cataract surgery approximately 8.5 years prior to presentation. The patient had maintained biennial complete eye examinations afterward without any significant findings and did not have additional ocular procedures performed. Slitlamp examination revealed moderate central, paracentral, and inferior corneal edema along with trace anterior chamber reaction and moderate limbitis. Gonioscopy was performed, revealing the nuclear fragment in the inferior angle. We theorized that in our patient, extended periods of leaning forward to tighten a strap on her foot cast from recent surgery resulted in repeated Valsalva maneuvers that may have induced the small lens nuclear fragment to move anteriorly from behind the iris, where it presumably had resided. Anterior displacement of the nuclear fragment may cause direct mechanical trauma to the corneal endothelium, giving rise to edema,4 which is consistent with the fact that our patient's edema was out of proportion to the anterior chamber reaction. This is also consistent with the fact that our patient's corneal edema has, although improved, persisted over the past 3 years. Others have theorized that lens nuclear fragments may cross-react with corneal endothelial antigens, giving rise to edema.5 We further speculate that the fragment, when sequestered posterior to the iris in the ciliary sulcus, may be less mobile than when in the anterior chamber angle, thus inducing less local tissue trauma and thereby lack of iritis. The delay in inflammatory response from an undetected nuclear fragment in our patient is similar to that in the report by Mokhtarzadeh et al.1 Our case, however, demonstrates that an inflammatory response can be delayed for a significantly longer time than 1752
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
reported by these authors. Our case report, in which the lens nuclear fragment was retained for a period of 8.5 years prior to inducing symptoms, appears to be the longest duration reported in the peer-reviewed literature. It is important to consider this diagnosis even years after uneventful phacoemulsification surgery. We agree with the authors' emphasis on the value of gonioscopy in diagnosing such cases of sudden-onset corneal edema, especially when the edema extends to the inferior angle where a lens nuclear fragment may lie. Mitra Nair Houston, Texas, USA Rahul T. Pandit, MD Houston, Texas USA REFERENCES 1. Mokhtarzadeh A, Kaufman SC, Koozekanani DD, Meduri A. Delayed presentation of retained nuclear fragment following phacoemulsification cataract extraction. J Cataract Refract Surg 2014; 40:671–674 2. Braude LS, Schroeder RP. Retained nuclear fragment 1 year after uncomplicated phacoemulsification cataract extraction with posterior chamber intraocular lens implant [letter]. Arch Ophthalmol 1999; 117:847–848 3. Pandit RT, Coburn AG. Sudden corneal edema due to retained lens nuclear fragment presenting 8.5 years after cataract surgery. J Cataract Refract Surg 2011; 37:1165–1167 4. Bohigian GM, Wexler SA. Complications of retained nuclear fragments in the anterior chamber after phacoemulsification with posterior chamber lens implant. Am J Ophthalmol 1997; 123:546–547 5. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmology 2006; 113:1949–1953
Reply : We regret the omission of Drs. Pandit and Coburn's paper,1 which also documented the delayed presentation of a nuclear fragment after cataract surgery. These cases are important to cite because of the variable signs and symptoms associated with retained nuclear fragments. Our cases were similar in many ways: Both patients experienced acute corneal edema, minimal signs of intraocular inflammation, and reduced vision. However, differences between our cases also exist. In our case, the nuclear fragment was not initially present in the anterior chamber. Although mydriatics were used to dilate the pupil, the nuclear fragment was not identified, even after 2 dilated eye examinations. Ultimately, the lens fragment was identified 1 month after the patient's initial presentation, during a retinal examination with positioning maneuvers and scleral depression, when the large nuclear fragment slowly moved from its position 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.08.013
Retained lens nuclear fragment presenting years after phacoemulsification Mokhtarzadeh et al.1 report a case in which a retained lens nuclear fragment caused an inflammatory response and late-onset corneal edema 11 months after phacoemulsification. The authors cite a report by Braude et al.2 in which a nuclear fragment remained undetected for nearly as long and appear to conclude that 1 year is the longest duration reported “in which retained nuclear fragments were responsible for an inflammatory response and abrupt onset of corneal edema in an eye.” However, their review of the literature was incomplete and failed to cite our case in which a nuclear fragment was retained for 8.5 years after phacoemulsification prior to inducing symptoms.3 The patient was a 79-year-old woman who presented with a 1-week history of blurred vision, redness, photophobia, foreign-body sensation, and tearing in her right eye. The ocular history included sequential bilateral cataract surgery approximately 8.5 years prior to presentation. The patient had maintained biennial complete eye examinations afterward without any significant findings and did not have additional ocular procedures performed. Slitlamp examination revealed moderate central, paracentral, and inferior corneal edema along with trace anterior chamber reaction and moderate limbitis. Gonioscopy was performed, revealing the nuclear fragment in the inferior angle. We theorized that in our patient, extended periods of leaning forward to tighten a strap on her foot cast from recent surgery resulted in repeated Valsalva maneuvers that may have induced the small lens nuclear fragment to move anteriorly from behind the iris, where it presumably had resided. Anterior displacement of the nuclear fragment may cause direct mechanical trauma to the corneal endothelium, giving rise to edema,4 which is consistent with the fact that our patient's edema was out of proportion to the anterior chamber reaction. This is also consistent with the fact that our patient's corneal edema has, although improved, persisted over the past 3 years. Others have theorized that lens nuclear fragments may cross-react with corneal endothelial antigens, giving rise to edema.5 We further speculate that the fragment, when sequestered posterior to the iris in the ciliary sulcus, may be less mobile than when in the anterior chamber angle, thus inducing less local tissue trauma and thereby lack of iritis. The delay in inflammatory response from an undetected nuclear fragment in our patient is similar to that in the report by Mokhtarzadeh et al.1 Our case, however, demonstrates that an inflammatory response can be delayed for a significantly longer time than 1752
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
reported by these authors. Our case report, in which the lens nuclear fragment was retained for a period of 8.5 years prior to inducing symptoms, appears to be the longest duration reported in the peer-reviewed literature. It is important to consider this diagnosis even years after uneventful phacoemulsification surgery. We agree with the authors' emphasis on the value of gonioscopy in diagnosing such cases of sudden-onset corneal edema, especially when the edema extends to the inferior angle where a lens nuclear fragment may lie. Mitra Nair Houston, Texas, USA Rahul T. Pandit, MD Houston, Texas USA REFERENCES 1. Mokhtarzadeh A, Kaufman SC, Koozekanani DD, Meduri A. Delayed presentation of retained nuclear fragment following phacoemulsification cataract extraction. J Cataract Refract Surg 2014; 40:671–674 2. Braude LS, Schroeder RP. Retained nuclear fragment 1 year after uncomplicated phacoemulsification cataract extraction with posterior chamber intraocular lens implant [letter]. Arch Ophthalmol 1999; 117:847–848 3. Pandit RT, Coburn AG. Sudden corneal edema due to retained lens nuclear fragment presenting 8.5 years after cataract surgery. J Cataract Refract Surg 2011; 37:1165–1167 4. Bohigian GM, Wexler SA. Complications of retained nuclear fragments in the anterior chamber after phacoemulsification with posterior chamber lens implant. Am J Ophthalmol 1997; 123:546–547 5. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmology 2006; 113:1949–1953
Reply : We regret the omission of Drs. Pandit and Coburn's paper,1 which also documented the delayed presentation of a nuclear fragment after cataract surgery. These cases are important to cite because of the variable signs and symptoms associated with retained nuclear fragments. Our cases were similar in many ways: Both patients experienced acute corneal edema, minimal signs of intraocular inflammation, and reduced vision. However, differences between our cases also exist. In our case, the nuclear fragment was not initially present in the anterior chamber. Although mydriatics were used to dilate the pupil, the nuclear fragment was not identified, even after 2 dilated eye examinations. Ultimately, the lens fragment was identified 1 month after the patient's initial presentation, during a retinal examination with positioning maneuvers and scleral depression, when the large nuclear fragment slowly moved from its position 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.08.013