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Consultation section

May consultation #3

Joosse, Maurits V. MD, PhD

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Journal of Cataract & Refractive Surgery: May 2015 - Volume 41 - Issue 5 - p 1115-1116
doi: 10.1016/j.jcrs.2015.04.012
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All ophthalmological findings in the right eye of this patient can be attributed to the coup–contrecoup trauma inflicted by the blow of the fist. The coup–contrecoup concept originally referred to acceleration–deceleration craniofacial trauma but has also been applied to the ophthalmic setting.1 In this case, the coup caused zonular stretching and possibly partial zonulysis and iris microruptures. The contrecoup caused a forward shift of the lens–iris diaphragm and thus dilation and blockage of the pupil by the lens.

It is commonly known that blunt trauma speeds up cataract formation, especially posterior subcapsular cataract.2 The high IOP can be attributed to 2 factors. One is that the blockage of the pupil causes a vicious cycle in which the ciliary body continues to produce aqueous, pushing the lens against the posterior edge of the pupil and thus blocking the circulation even more by inducing a pupillary block. The other factor is that hyphema might also impede aqueous outflow by occlusion of the trabecular meshwork. The immobile and semidilated pupil is probably caused by traumatic microruptures in the sphincter and is exacerbated by anterior shifting of the swollen crystalline lens.

The OCT image shows that the crystalline lens pushes against almost the complete posterior side of the iris. Thus, neodymium:YAG (Nd:YAG) laser iridectomy might not be effective in restoring aqueous flow. In this case, performing prompt biometry and phacoemulsification is the best option for interrupting the pressure build-up cycle and the inevitable glaucomatous nerve damage and cataract progression. Also, the pressure should be controlled to reduce the risk for intraoperative subchoroidal bleeding. A capsulorhexis and standard phacoemulsification should be attempted. During capsulorhexis, the extent of zonular weakness can be estimated. If there is significant nuclear instability, the bag can be fixated using 2 to 4 disposable iris hooks. In case of zonular dehiscence of more than 4 clock hours, a capsular tension ring (CTR) with an eyelet for scleral fixation or a capsular anchor can be used.3,4 These devices can be fixated using a 10-0 polypropylene suture under a Hoffman scleral pocket.5 In case of subtotal zonular dehiscence, the bag should be removed after phacoemulsification, and then an anterior vitrectomy performed and an iris-fixated IOL implanted. In a case involving persistent symptomatic (traumatic) mydriasis, either pilocarpine 0.125% or thymoxamine 0.5% could be prescribed.

References

1. Wolter JR. Coup-contrecoup mechanism of ocular injuries. Am J Ophthalmol. 1963;56:785-796.
2. Wong TY, Klein BEK, Klein R, Tomany SC. Relation of ocular trauma to cortical, nuclear, and posterior subcapsular cataract: the Beaver Dam Eye Study. Br J Ophthalmol. 86, 2002, p. 152-155, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770991/pdf/bjo08600152.pdf. Accessed March 9, 2015.
3. Cionni RJ, Osher RH. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. J Cataract Refract Surg. 1998;24:1299-1306.
4. Assia EI, Ton Y, Michaeli A. Capsule anchor to manage subluxated lenses: initial clinical experience. J Cataract Refract Surg. 2009;35:1372-1379.
5. Hoffman RS, Fine IH, Packer M. Rozenberg I: Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg. 32, 2006, p. 1259-1263, Available at: http://www.finemd.com/reprints/Scleral%20Fixation%20Using%20suture%20Retrieval%20Through%20a%20Scleral%20Tu.pdf. Accessed March 9, 2015.
© 2015 by Lippincott Williams & Wilkins, Inc.