- Email: [email protected]
Unusual case of ruptured posterior lenticonus
870
CASE REPORT
Unusual case of ruptured posterior lenticonus Praveen Subudhi, MS, DNB, FRCS(G), Zahiruddin Khan, MS, Sweta Patro, MS, B. Nageswar Rao Subudhi, MS, Silla Sitaram, MS
A 14-year-old boy presented with a report of sudden-onset loss of vision in the right eye for the previous 10 days. The patient was diagnosed with a total cataract and ruptured posterior lenticonus. Lenticular aspiration was performed with an irrigation/aspiration probe. This was followed by anterior vitrectomy and implantation of 1-piece intraocular lens (IOL) in the capsular bag. Postoperatively, the patient had a good visual outcome with no evidence of
P
osterior lenticonus is a rare condition occurring in isolation or in association with a syndrome, specifically Alport syndrome.1 Many hypotheses regarding its pathogenesis have been proposed. An inflammatory irritant along the posterior surface of embryonic nucleus, hyaloid traction, thinning of the posterior capsule, and displacement of the nucleus are all to be causes of posterior protrusion of the lenticular pole.2–4 Rupture of the posterior capsule occurs as a result of pulling along the zonular fibers associated with biologic irritation over the posterior surface of the embryonic nucleus. Posterior proliferation of lenticular fibers from the embryonic nucleus and minor ocular trauma can also lead to rupture of the posterior capsule in these cases.5 Posterior capsule tear causes hydration of the lenticular fibers, leading to quick progression of opacification of the lenticular system and causing total cataract. We present a case of a 14-year-old boy who presented with total cataract in association with a ruptured posterior capsule. CASE REPORT
A 14-year-old boy reported defective vision in the right eye that had been present for 10 days. On examination, a white mature cataract was seen during the undilated pupil examination; however, with the pupil dilated, a slit-shaped posterior capsule tear could be seen. With a diagnosis of ruptured posterior lenticonus (Figure 1, A), the patient was scheduled for phacoemulsification with anterior vitrectomy and primary intraocular lens (IOL) implantation. A superior triplanar tunnel was constructed with a 2.8 mm keratome. After a side port was created, the capsule was stained with trypan
intraocular inflammation. Although ruptured posterior lenticonus is a rare condition, it can be encountered in day-to-day-practice. In such cases, implantation of a 1-piece IOL can be safely performed if the anterior vitreous is meticulously removed.
J Cataract Refract Surg 2019; 45:870–871 Q 2019 ASCRS and ESCRS
blue and a capsulorhexis was initiated with a 26-gauge cystotome (Figure 1, B). Although capsule extension occurred at the 11 o’clock position, the capsulorhexis was completed with a forceps. No hydrodissection was used so as to prevent dislocation of contents into the vitreous. Because the nucleus was soft, aspiration was performed with an irrigation/aspiration probe (Figure 1, C). After partial removal, the nucleus dislocated into the vitreous. An anterior vitrectomy was performed with a 23-gauge vitreous cutter at 2500 cuts per minute (Figure 1, D). Dislocated nucleus material came back into the anterior chamber with the prolapse of vitreous into the anterior chamber and was removed with a Simcoe cannula. Residual cortex was removed with a Simcoe cannula under slow flow. Intraoperative indirect ophthalmoscopy was performed to determine whether there was retention of nuclear material in the posterior vitreous. There was no evidence of this (Figure 1, E), and a 1-piece foldable IOL was implanted in the capsular bag. Intracameral pilocarpine was used to determine whether there were vitreous strands extending to the incision (Figure 1, F). A single suture was placed at the main incision port. Sixty days after surgery, examination showed a well-defined pupil with a stable IOL and no evidence of an inflammatory reaction (Figure 2). The patient had good visual recovery, with vision remaining stable thereafter.
DISCUSSION Posterior capsule integrity is crucial for the in-the-bag implantation of an IOL during phacoemulsification surgery. In eyes with a preexisting dehiscent posterior capsule, meticulous management of the nucleus is required to prevent posterior dislocation of the nucleus. Maximum retention of the capsule is the ultimate aim to allow placement of a posterior chamber IOL for maximum vision outcomes.6
Submitted: July 25, 2018 | Accepted: December 31, 2018 From Ruby Eye Hospital (P. Subudhi, Patro), Govinda Vihar, Hitech Medical College (P. Subudhi, Khan), Bhubaneswar, M.K.C.G. Medical College and Hospital (B.N.R. Subudhi), Berhampur, and the Ophthalmology Department (Sitaram), SDH Chatrapur, Odisha, India. Corresponding author: Praveen Subudhi, MS, DNB, FRCS(G), Ruby Eye Hospital, Govinda Vihar, Berhampur, Ganjam, Odisha, India. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.12.028
CASE REPORT: UNUSUAL CASE OF POSTERIOR RUPTURED LENTICONUS
871
Figure 2. Postoperative image of the eye shows a well-defined, round pupil and stable intraocular lens with no evidence of intracameral inflammation.
Figure 1. A: Appearance of posterior capsule split with near total cataract. B: A capsulorhexis is created with Utrata forceps. C: Cortical and nuclear material is aspirated with irrigation/aspiration probe. D: Vitrectomy is performed with a 23-gauge vitreous cutter at 2500 cuts per minute. E: Retroillumination of posterior capsular defect. F: Implantation of a 1-piece intraocular lens and aspiration of residual ophthalmic viscosurgical devices.
There are isolated reports of refractive lens exchange in cases of posterior lenticonus to maximize visual acuity and prevent rupture of the lens capsule.7 However, in the largest case series published to date,8 25% of cases had a posterior capsule defect, although this did not affect the final visual outcome after cataract surgery. Under ideal circumstances, a 3-piece IOL is appropriate for these cases; unfortunately, the required power of the IOL was not available at our center. Using a 1-piece IOL in cases of capsule extension is not recommended because the IOL might shift from the primary location; however, it was our only option. The published literature is not in favor of implanting a 1-piece IOL because it has maximum contact with the posterior surface of the iris, causing pigment dispersion that leads to uveitis–glaucoma–hyphema syndrome.9 This can be averted by performing a complete anterior vitrectomy without allowing anterior thrust of vitreous to the posterior surface of the IOL and iris. In our case, we ensured complete
anterior vitrectomy by using intracameral pilocarpine; a round pupil with no evidence of any vitreous strand extending to the wound site was considered as the endpoint. The patient had good visual outcomes that remained stable until the end of 12 months of observation, at which point the patient was lost to follow-up. This case is reported because it is rare in our clinical setting. REFERENCES 1. Butler TH. Lenticonus posterior; report of six cases. Arch Ophthalmol 1930; 3:425–436 2. Franceschetti A, Rickli H. Posterior (eccentric) lenticonus; report of first case with clinical and histopathological findings. AMA Arch Ophthalmol 1954; 51:499–508 3. Makley TA Jr. Posterior lenticonus; report of a case with histologic findings. Am J Ophthalmol 1955; 39:308–312 4. Khalil M, Saheb N. Posterior lenticonus. Ophthalmology 1984; 91:1429– 1430; 43A 5. Crouch ER Jr, Parks MM. Management of posterior lenticonus complicated by unilateral cataract. Am J Ophthalmol 1978; 85:503–508 6. Ryoo N-K, Park C, Kim T-W, Park KH, Lee JH, Woo SJ. Management of vitreal loss from posterior capsular rupture during cataract operation: Posterior versus anterior vitrectomy. Retina 2016; 36:819–825 7. Gupta A, Ramesh Babu K, Srinivasan R, Mohanty D. Clear lens extraction in Alport syndrome with combined anterior and posterior lenticonus or ruptured anterior lens capsule. J Cataract Refract Surg 2011; 37:2075–2078 8. Lee BJ, Kim JH, Yu YS. Surgical outcomes after intraocular lens implantation for posterior lenticonus–related cataract according to preoperative lens status. J Cataract Refract Surg 2014; 40:217–223 9. Mohebbi M, Bashiri SA, Mohammadi SF, Samet B, Ghassemi F, Ashrafi E, Bazvand F. Outcome of single-piece intraocular lens sulcus implantation following posterior capsular rupture during phacoemulsification. J Ophthalmic Vis Res 2017; 12:275–280
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.
Volume 45 Issue 6 June 2019
CASE REPORT
Unusual case of ruptured posterior lenticonus Praveen Subudhi, MS, DNB, FRCS(G), Zahiruddin Khan, MS, Sweta Patro, MS, B. Nageswar Rao Subudhi, MS, Silla Sitaram, MS
A 14-year-old boy presented with a report of sudden-onset loss of vision in the right eye for the previous 10 days. The patient was diagnosed with a total cataract and ruptured posterior lenticonus. Lenticular aspiration was performed with an irrigation/aspiration probe. This was followed by anterior vitrectomy and implantation of 1-piece intraocular lens (IOL) in the capsular bag. Postoperatively, the patient had a good visual outcome with no evidence of
P
osterior lenticonus is a rare condition occurring in isolation or in association with a syndrome, specifically Alport syndrome.1 Many hypotheses regarding its pathogenesis have been proposed. An inflammatory irritant along the posterior surface of embryonic nucleus, hyaloid traction, thinning of the posterior capsule, and displacement of the nucleus are all to be causes of posterior protrusion of the lenticular pole.2–4 Rupture of the posterior capsule occurs as a result of pulling along the zonular fibers associated with biologic irritation over the posterior surface of the embryonic nucleus. Posterior proliferation of lenticular fibers from the embryonic nucleus and minor ocular trauma can also lead to rupture of the posterior capsule in these cases.5 Posterior capsule tear causes hydration of the lenticular fibers, leading to quick progression of opacification of the lenticular system and causing total cataract. We present a case of a 14-year-old boy who presented with total cataract in association with a ruptured posterior capsule. CASE REPORT
A 14-year-old boy reported defective vision in the right eye that had been present for 10 days. On examination, a white mature cataract was seen during the undilated pupil examination; however, with the pupil dilated, a slit-shaped posterior capsule tear could be seen. With a diagnosis of ruptured posterior lenticonus (Figure 1, A), the patient was scheduled for phacoemulsification with anterior vitrectomy and primary intraocular lens (IOL) implantation. A superior triplanar tunnel was constructed with a 2.8 mm keratome. After a side port was created, the capsule was stained with trypan
intraocular inflammation. Although ruptured posterior lenticonus is a rare condition, it can be encountered in day-to-day-practice. In such cases, implantation of a 1-piece IOL can be safely performed if the anterior vitreous is meticulously removed.
J Cataract Refract Surg 2019; 45:870–871 Q 2019 ASCRS and ESCRS
blue and a capsulorhexis was initiated with a 26-gauge cystotome (Figure 1, B). Although capsule extension occurred at the 11 o’clock position, the capsulorhexis was completed with a forceps. No hydrodissection was used so as to prevent dislocation of contents into the vitreous. Because the nucleus was soft, aspiration was performed with an irrigation/aspiration probe (Figure 1, C). After partial removal, the nucleus dislocated into the vitreous. An anterior vitrectomy was performed with a 23-gauge vitreous cutter at 2500 cuts per minute (Figure 1, D). Dislocated nucleus material came back into the anterior chamber with the prolapse of vitreous into the anterior chamber and was removed with a Simcoe cannula. Residual cortex was removed with a Simcoe cannula under slow flow. Intraoperative indirect ophthalmoscopy was performed to determine whether there was retention of nuclear material in the posterior vitreous. There was no evidence of this (Figure 1, E), and a 1-piece foldable IOL was implanted in the capsular bag. Intracameral pilocarpine was used to determine whether there were vitreous strands extending to the incision (Figure 1, F). A single suture was placed at the main incision port. Sixty days after surgery, examination showed a well-defined pupil with a stable IOL and no evidence of an inflammatory reaction (Figure 2). The patient had good visual recovery, with vision remaining stable thereafter.
DISCUSSION Posterior capsule integrity is crucial for the in-the-bag implantation of an IOL during phacoemulsification surgery. In eyes with a preexisting dehiscent posterior capsule, meticulous management of the nucleus is required to prevent posterior dislocation of the nucleus. Maximum retention of the capsule is the ultimate aim to allow placement of a posterior chamber IOL for maximum vision outcomes.6
Submitted: July 25, 2018 | Accepted: December 31, 2018 From Ruby Eye Hospital (P. Subudhi, Patro), Govinda Vihar, Hitech Medical College (P. Subudhi, Khan), Bhubaneswar, M.K.C.G. Medical College and Hospital (B.N.R. Subudhi), Berhampur, and the Ophthalmology Department (Sitaram), SDH Chatrapur, Odisha, India. Corresponding author: Praveen Subudhi, MS, DNB, FRCS(G), Ruby Eye Hospital, Govinda Vihar, Berhampur, Ganjam, Odisha, India. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.12.028
CASE REPORT: UNUSUAL CASE OF POSTERIOR RUPTURED LENTICONUS
871
Figure 2. Postoperative image of the eye shows a well-defined, round pupil and stable intraocular lens with no evidence of intracameral inflammation.
Figure 1. A: Appearance of posterior capsule split with near total cataract. B: A capsulorhexis is created with Utrata forceps. C: Cortical and nuclear material is aspirated with irrigation/aspiration probe. D: Vitrectomy is performed with a 23-gauge vitreous cutter at 2500 cuts per minute. E: Retroillumination of posterior capsular defect. F: Implantation of a 1-piece intraocular lens and aspiration of residual ophthalmic viscosurgical devices.
There are isolated reports of refractive lens exchange in cases of posterior lenticonus to maximize visual acuity and prevent rupture of the lens capsule.7 However, in the largest case series published to date,8 25% of cases had a posterior capsule defect, although this did not affect the final visual outcome after cataract surgery. Under ideal circumstances, a 3-piece IOL is appropriate for these cases; unfortunately, the required power of the IOL was not available at our center. Using a 1-piece IOL in cases of capsule extension is not recommended because the IOL might shift from the primary location; however, it was our only option. The published literature is not in favor of implanting a 1-piece IOL because it has maximum contact with the posterior surface of the iris, causing pigment dispersion that leads to uveitis–glaucoma–hyphema syndrome.9 This can be averted by performing a complete anterior vitrectomy without allowing anterior thrust of vitreous to the posterior surface of the IOL and iris. In our case, we ensured complete
anterior vitrectomy by using intracameral pilocarpine; a round pupil with no evidence of any vitreous strand extending to the wound site was considered as the endpoint. The patient had good visual outcomes that remained stable until the end of 12 months of observation, at which point the patient was lost to follow-up. This case is reported because it is rare in our clinical setting. REFERENCES 1. Butler TH. Lenticonus posterior; report of six cases. Arch Ophthalmol 1930; 3:425–436 2. Franceschetti A, Rickli H. Posterior (eccentric) lenticonus; report of first case with clinical and histopathological findings. AMA Arch Ophthalmol 1954; 51:499–508 3. Makley TA Jr. Posterior lenticonus; report of a case with histologic findings. Am J Ophthalmol 1955; 39:308–312 4. Khalil M, Saheb N. Posterior lenticonus. Ophthalmology 1984; 91:1429– 1430; 43A 5. Crouch ER Jr, Parks MM. Management of posterior lenticonus complicated by unilateral cataract. Am J Ophthalmol 1978; 85:503–508 6. Ryoo N-K, Park C, Kim T-W, Park KH, Lee JH, Woo SJ. Management of vitreal loss from posterior capsular rupture during cataract operation: Posterior versus anterior vitrectomy. Retina 2016; 36:819–825 7. Gupta A, Ramesh Babu K, Srinivasan R, Mohanty D. Clear lens extraction in Alport syndrome with combined anterior and posterior lenticonus or ruptured anterior lens capsule. J Cataract Refract Surg 2011; 37:2075–2078 8. Lee BJ, Kim JH, Yu YS. Surgical outcomes after intraocular lens implantation for posterior lenticonus–related cataract according to preoperative lens status. J Cataract Refract Surg 2014; 40:217–223 9. Mohebbi M, Bashiri SA, Mohammadi SF, Samet B, Ghassemi F, Ashrafi E, Bazvand F. Outcome of single-piece intraocular lens sulcus implantation following posterior capsular rupture during phacoemulsification. J Ophthalmic Vis Res 2017; 12:275–280
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.
Volume 45 Issue 6 June 2019