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 behind the iris and into the anterior chamber (see Figure 1 in our case report). The fragment then returned to its retro-iris position. Twenty minutes of head positioning was required in the operating room to bring the nuclear fragment back into the anterior chamber. Once it was visible, sodium hyaluronate was used to stabilize the large nuclear fragment, which was then removed with phacoemulsification.
At the heart of our cases lies the unexpected presentation of acute corneal edema and the question of how the lens fragment remained sequestered for such a prolonged period of time. We initially suspected a retained nuclear fragment but also entertained a diagnosis of viral endotheliitis or iritis when we could not identify a retained lens fragment. Oliveira et al.2 reported retained nuclear fragments after an iris elevation was observed in otherwise normal pseudophakic eyes. No signs or symptoms were present. The authors hypothesized that the posterior iris location of the nuclear fragment may have resulted in the absence of an inflammatory reaction or other findings. In our case, it is unclear whether the nuclear fragment remained sequestered in its posterior iris location or whether it intermittently moved into the anterior chamber, almost 1 year after cataract surgery.
These unusual cases highlight the potential difficulty and importance of identifying retained nuclear fragments immediately after cataract surgery and years later. However, when a nuclear fragment is identified, even in an asymptomatic individual, we believe that the fragment should be removed because of the unpredictable onset of complications.
1. Pandit RT, Coburn AG. Sudden corneal edema due to retained lens nuclear fragment presenting 8.5 years after cataract surgery. J Cataract Refract Surg
2. Oliveira C, Liebmann JM, Dodick JM, Topilow H, Cykiert R, Ritch R. Identification of retained nucleus fragment in the posterior chamber using ultrasound biomicroscopy. Am J Ophthalmol