Case report

New approach to management of traumatic phacocele with iris loss

Yong, Geng-Yi MB BS*; Ting, Xiao-Wei MB Bch BAO; Chau-Sim Yee, Alex MD; Pan, Shin-Wei MMed; Mohamed Noor, Jelinar MS; Zahari, Mimiwati FRCS

Author Information
Journal of Cataract and Refractive Surgery Online Case Reports: April 2018 - Volume 6 - Issue 2 - p 22-24
doi: 10.1016/j.jcro.2018.01.002
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Abstract

Traumatic phacocele is a rare complication of blunt trauma, either direct or indirect, in which rupture of the sclera results in dislocation of the crystalline lens into the subconjunctival space.1 A rigid sclera, hard crystalline lens, previous ocular trauma, and surgery (eg, trabeculectomy) might contribute to the development of a phacocele.1 Several studies have reported that an open-globe injury is associated with a poor visual outcome.2,3 Only a handful of traumatic phacocele cases have been reported to date, with emphasis on an appropriate surgical intervention being the key to obtaining a good visual outcome. We report a case of traumatic phacocele with extensive iris loss and scleral rupture after blunt trauma. This report highlights the successful surgical management with the use of a uniquely designed tripodal (3-haptic) anterior chamber intraocular lens (AC IOL).

CASE REPORT

A 77-year-old woman was referred to our institution a few hours after blunt trauma by a piece of wood to the left eye. The patient presented with pain in the left eye, acute blurring of vision, and headache. There was no history of eye surgery or trauma before this insult.

At presentation, her left vision was hand motion. An ocular examination revealed fullness of the left upper lid, a well-delineated superonasal subconjunctival cystic mass, and subconjunctival hemorrhage (Figure 1). The anterior chamber details were poorly visualized due to cornea edema and a hyphema of 4.0 mm height. Aphakia and iris loss from 10 o'clock to 1 o'clock was present. The intraocular pressure (IOP) was 4 mm Hg. There was no relative afferent pupillary defect in the affected eye. A clinical diagnosis of traumatic phacocele was made.

Figure 1.
Figure 1.:
Left: Preoperative photograph shows traumatic phacocele. Right: The CT scan showing dislocation of crystalline lens with discontinuation of sclera (CT = computed tomography).

A computed tomography (CT) scan showed an aphakic left eye with the crystalline lens situated at the superonasal subconjunctival area. There was no evidence of vitreous hemorrhage, retinal detachment, intraocular foreign body, or injury to the optic nerve. There was no orbital wall fracture (Figure 1).

Explorative surgery was performed under local anesthesia. A peritomy was made from 9 o'clock to 2 o'clock. A cataractous lens with an intact capsule was removed from the subconjunctival space. There was a 11.0 mm superonasal scleral wound with iris remnant (Figure 2). The scleral wound was repaired with 10-0 monofilament nylon interrupted sutures. An anterior vitrectomy was performed. The conjunctival wound was sutured with 8-0 polyglactin (Vicryl). Successful restoration of globe integrity was achieved. The eye was left primarily aphakic due to poor view of anterior chamber. She was prescribed oral ciprofloxacin 500 mg 2 times a day, topical ciprofloxacin 0.3% 1 drop every 2 hours, dexamethasone 1 drop every 2 hours, and homatropine sulphate 2.0% 3 times a day.

Figure 2.
Figure 2.:
Intraoperative photograph shows exposed crystalline lens after conjunctival peritomy, site of scleral rupture, and iris loss.

Two months after trauma, secondary IOL implantation was performed under local anesthesia. A uniquely designed tripodal AC IOL with 5.5 mm optic diameter and 14-degree angulated haptic was placed in the eye. The haptics were positioned at 2, 6, and 8 o'clock positions (Figure 3). Six months postoperatively, the patient's corrected distance visual acuity was 6/18, the cornea was clear, IOP was normal, and the AC IOL was stable (Figure 3).

Figure 3.
Figure 3.:
Left: Postoperative photograph shows successful secondary AC IOL implantation. Right: Photograph 3 months after trauma shows clear cornea and stable tripodal AC IOL (AC IOL = anterior chamber intraocular lens).

DISCUSSION

A phacocele is the dislocation of an intact crystalline lens into the subconjunctival space secondary to blunt trauma, resulting in scleral rupture.1,4,5

Traumatic phacocele occurs most commonly at the superior nasal region near the limbus. According to Cherry,5 the inferotemporal region of the globe is most susceptible to trauma, whereas other regions are protected by the brow, nose, and cheek. Hence, the line of impact from the inferotemporal direction will result in a contrecoup injury in the superior nasal aspect of the globe.5 Furthermore, the presence of Schlemm canal and perforating vessels near the limbus attribute to its inherent weakness.5 It is also the meridian of expansion where the tough inner scleral fibers transform into delicate lamellae of ligamentum pectinatum.4

Ultrasound biomicroscopy is superior to B-scan and anterior segment optical coherence tomography to diagnose phacocele.6 However, ocular ultrasound evaluation is contraindicated in suspected globe ruptured cases because pressure on the ocular surface might cause acute eye decompensation and prolapse of intraocular contents. Hence, CT scan was the choice of imaging in our case because it is the primary imaging modality in evaluating orbital trauma, lens dislocation, and orbital fractures.7

The initial management of phacocele includes wound exploration, crystalline lens extraction, vitrectomy, and scleral wound repair with or without IOL implantation. In our case, we decided not to implant the IOL as a primary procedure because the patient's cornea was hazy and visualizing the anterior chamber structures was difficult. Moreover, primary IOL implantation after globe repair might trigger further inflammation and increase the risk for infection. Furthermore, performing an accurate biometry to determine the IOL power is challenging. Cohen8 reported that a primary IOL implantation might result in a deviation of refraction of 4.0 diopters (D) by using the biometry of the nontraumatic eye. In comparison, Chuang and Lai9 concluded that there was only 1.0 D deviation of refraction in secondary IOL implantation. Thus, we decided on a secondary IOL implantation for the patient.

Currently, there are many surgical options for secondary IOL implantation, such as scleral-fixated IOL, iris-claw IOL, and AC IOL. A recent study10 showed that AC IOLs have visual outcomes comparable to iris- and scleral-fixated IOLs and less early postoperative complications (cystoid macular edema, escalation of glaucoma, corneal edema, hemorrhage, IOL subluxation, and other retinal pathology).

Choices of IOL implantation in phacocele cases was limited in this case because of its unique problem. Bhattacharjee et al.11 reported good visual outcomes in 2 patients with phacoceles with primary scleral fixation of the IOL. In view of the extensive scleral rupture and iris loss, we chose to implant a tripodal AC IOL in our case. The AC IOL has a 5.5 mm optic diameter, 14-degree angulated haptic, and a spherical equiconvex design that is more stable than a conventional 4-haptic AC IOL (Figure 4). Upon review, the patient was satisfied with her vision and no early postoperative complications were observed.

Figure 4.
Figure 4.:
Left: Illustration shows stability of tripodal AC IOL implantation in phacocele with iris loss. Right: Conventional 4-haptic AC IOL (AC IOL = anterior chamber intraocular lens).

In conclusion, good clinical judgment, timely medical and surgical intervention, and an appropriate IOL selection are instrumental in achieving good visual outcomes in cases of traumatic phacocele with extensive scleral rupture and iris loss.

Disclosures:

None of the authors has a financial or proprietary interest in any material or method mentioned.

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