A 66-year-old male presented in eye outpatient department for insidious onset-colored halos for a month. He, being a known case of Parkinsonism, was on treatment with Syndopa for the past 5 years. His visual acuity was OU 6/18–6/12. His anterior segment showed multiple polychromatic needle-shaped crystals traversing in all directions, located in the anterior nucleus of the lens in the right eye [Figure 1], the same being minimally visible in the left eye lens [Figure 2].
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Figure 1: Right eye showing several polychromatic needle crystals occupying anterior nucleus of inferior part of lens giving it a decorated Christmas tree pattern
Figure 2: Left eye shows very few needle crystals in the center of lens
It was diagnosed as Christmas tree cataract (CTC), though an appropriate systemic association could not be demonstrated. From a review of such CTCs, mechanisms postulated for its occurrence vary from study to study.[1] While few studies suggest the opacities to be cholesterol crystals,[2] few say that they were most likely made of cystine crystals due to an age-related aberrant breakdown of crystallins induced by elevated Ca++ levels.[3] One study postulated the diffraction of light from parallel-sided stacks of fused cell membranes to be the cause for the striking polychromatic luster.[4]
CTC is very well associated with myotonic dystrophy (DM), wherein premature cataract (<55 years) with polychromatic crystals of the CTC in posterior lens capsule.[5] CTC has been identified as the first sign of DM, developing into full-blown symptoms of myotonia after 7–14 years.[6] An exhaustive search of PubMed literature did not show any association between CTCs and Parkinsonism or Syndopa usage. As noted, in the reported patient, the presence of CTC in anterior nucleus and in elderly age of 66 years does not fit into DM.
CONCLUSION
The Christmas tree cataract in this patient is probably age related. Had it been diagnosed in a young patient, the Ophthalmologist should take up the responsibility to refer promptly to a Neurophysician to rule out the possibility of DM.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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3. Shun-Shin GA, Vrensen GF, Brown NP, Willekens B, Smeets MH, Bron AJ. Morphologic characteristics and chemical composition of Christmas tree cataract Invest Ophthalmol Vis Sci. 1993;34:3489–96
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5. Thornton CA. Myotonic dystrophy Neurol Clin. 2014;32:705–19 viii.
6. Pagoulatos D, Kapsala Z, Makri OE, Georgakopoulos CD. Christmas tree cataract and myotonic dystrophy type 1 Eye (Lond). 2018;32:1794–5
