Posterior migration of lens matter is one of the most dreaded intraoperative complications of phacoemulsification. Rarely, such cases are further complicated by giant retinal tear formation if aggressive attempts are made to retrieve the dropped fragments through the anterior route at the time of cataract surgery. We report an unusual case and surgical management of migration of a dropped nucleus through a giant retinal tear in the subretinal space after phacoemulsification.
A 65-year-old woman presented with mild pain, redness, and poor gain of vision in the right eye 2 weeks after cataract surgery. According to the available records, phacoemulsification was complicated by a posterior capsule tear and nucleus drop. On presentation, the visual acuity in the affected right eye was hand motions close to face; the intraocular pressure was 12 mm Hg. Slitlamp examination showed dense cortical material in the pupillary area that prevented visualization of the fundus. A B-mode ultrasonography scan showed a total retinal detachment (RD) with an oval hyperechoic structure in the subretinal space suggestive of a cataractous lens.
There was an immature senile cataract grade 2 in the left eye, which had a corrected distance visual acuity (CDVA) of 20/100. There was no evidence of pseudoexfoliation, phacodonesis, or posterior polar cataract, and the fundus was normal.
The patient was scheduled for vitreoretinal surgery with an encircling band in the right eye. After the cataract wound was secured with a 10-0 monofilament nylon suture and the encircling band was passed, 3 standard 23-gauge par plana ports were made and cortical matter was cleared from the pupillary plane. On visualizing the fundus, the entire cataractous lens nucleus was seen in the subretinal space at the posterior pole, with evidence of an inferior giant retinal tear extending for nearly 4 clock hours with a total rhegmatogenous RD (Figure 1).
After completion of the vitrectomy, perfluorocarbon liquid (PFCL) was injected over the optic nerve away from the lens to maneuverer it out of the subretinal space by gradually pushing it toward the edge of the break. The PFCL also served the purpose of unfolding the retinal flap caused by the giant retinal tear. After lens fragmentation, a 360-degree endolaser photocoagulation and silicone oil injection were performed. The patient was left aphakic.
Postoperatively, the retina was attached. The CDVA was 20/200 at the most recent follow-up at 3 months.
The reported incidence of posterior dislocation of the lens during phacoemulsification is 0.1% to 3.0%.1 Giant retinal tears can occur in such cases as a result of excessive vitreous traction caused by rigorous pursuit of the dropped lens fragments by the cataract surgeon.2 Subretinal lens migration is extremely rare and has been reported after blunt trauma3,4 and as a complication after pars plana lensectomy5 and phacoemulsification.6 In such cases, there are coexisting large retinal tears with a posteriorly displaced lens.
In this case, after a posterior capsule tear and nucleus drop into the vitreous cavity, the cataract surgeon presumably attempted aggressive retrieval of the dropped nucleus. This might have led to excessive vitreous traction, giant retinal tear formation, and descent of the nucleus into the subretinal space through this large break.
Left untreated, retained lens fragments can cause glaucoma, corneal edema, uveitis, cystoid macular edema, retinal tears, and RD. Pars plana vitrectomy is the preferred surgery for a dropped nucleus.7 In contrast to usually good visual outcomes reported after pars plana vitrectomy for dislocated lens fragments, eyes with a coexisting giant retinal tear and RD have an unfavorable visual and anatomic prognosis.2
Phacofragmentation in an eye with a giant retinal tear and total RD is surgically challenging because of the excessive mobility of the detached retina and risk for reentry of smaller fragments through the break. Intraoperative use of PFCL simplifies the surgery and improves the outcome.8 In this case, however, the PFCL over the retina might have made the lens immobile, making it harder to remove. Therefore, we injected the PFCL over the optic nerve, away from the lens. While injecting the PFCL, we maneuvered the lens toward the giant retinal tear with the silicone-tipped cannula. We also recommend low vacuum and low infusion pressure for minimum turbulence of lens fragments. In addition, it is imperative to complete the peripheral vitrectomy before phacofragmentation to avoid traction over the vitreous and new retinal break formation.
Subretinal lens migration after complicated cataract surgery is extremely unusual. To our knowledge, only one case of a subretinal lens after phacoemulsification has been previously reported.6 This case highlights the importance of abstaining from maneuvers to fish out the dropped nucleus by the primary surgeon through the anterior route and outlines a few surgical points for vitreoretinal surgeons to manage such cases.
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None of the authors has a financial or proprietary interest in any material or method mentioned.