Management of crystalline lens dislocation into the anterior chamber in a victim of domestic violence

Authors


Dr Ilias Georgalas, Consultant Vitreoretinal Surgeon, 59 Chrysanthemon St, 15452 Athens, GREECE. E-mail: igeorgalas@yahoo.com

Abstract

A 53-year-old woman presented with a right eye injury due to domestic violence. The crystalline lens in that eye was completely dislocated into the anterior chamber, fixated by the cornea and the iris. Fundoscopy showed a mild vitreous haemorrhage and a giant retinal tear. A modified lensectomy with a fragmatome was performed. During this procedure the capsule was preserved first to minimise the risk of corneal damage and second to reduce vitreous traction, which would repair the giant retinal tear.

A variety of anterior and posterior segment problems can result from blunt trauma to the globe. These include hyphaema, angle recession, secondary glaucoma, retinal detachment, macular hole formation, commotio retinae and choroidal rupture.1,2

Lens dislocation might occur spontaneously or after trauma.3,4 The lens is usually dislocated into the vitreous cavity and very rarely into the anterior chamber.

We report an unusual case of anterior dislocation of the crystalline lens into the anterior chamber in association with a giant retinal tear after blunt trauma and describe its management with a modified lensectomy and vitrectomy.

CASE REPORT

A 53-year-old woman with hypertension presented to our department complaining of pain in the right eye and blurred vision. She reported an eye injury due to domestic violence two days earlier. Visual acuity was 6/9 and the intraocular pressure (IOP) was 40 mmHg. Surprisingly, the crystalline lens in the right eye was completely dislocated into the anterior chamber, fixated by the cornea and the iris, which was semi-dilated (Figures 1 and 2). Fundoscopy showed a mild vitreous haemorrhage and a giant retinal tear. The patient was admitted to the ophthalmology department of ‘G.Gennimatas’ Hospital of Athens and received intravenous mannitol and oral acetazolamide to lower the IOP. Surgery was scheduled for the following morning.

Figure 1.

Colour photographs at presentation; the crystalline lens is dislocated into the anterior chamber, fixated by the pupil and cornea

Figure 2.

Image from the slitlamp. Note that the lens is in contact with the corneal endothelium.

A 20 g infusion cannula was sutured in the pars plana and subsequently two peripheral corneal incisions were performed. After filling the anterior chamber with a viscoelastic agent, an intracapsular modified lensectomy was performed with the aid of a hand-held infusion and a fragmatome (Figure 3A) using very low ultrasonic power, and cautiously to preserve the anterior and posterior capsule. Posterior vitreous detachment was present and a three-port pars plana vitrectomy was followed by a 360° circumferential retinopexy for treatment of the giant tear (Figure 3B). Perfluoropropane (C3F8) 14 per cent gas was used as tamponade and the patient was instructed to keep in a prone position for six days. Six weeks later the retina remained attached, IOP was 12 mmHg and the cornea was clear; however, there was a central area where the endothelium was damaged. Six months later the situation remained unchanged and visual acuity was 6/12 with a contact lens.

Figure 3.

Intraoperative image; (A) end stage of the modified intracapsular lensectomy through the corneal incisions (B) during vitrectomy of the giant tear with indentation

DISCUSSION

Ocular injuries in battered women are not unusual.5,6 They range from lacerations and contusions to more serious injuries such as globe ruptures.5 Traumatic crystalline lens dislocation is not rare but the lens is usually dislocated into the vitreous and very rarely into the anterior chamber. Most cases with anteriorly dislocated lenses had previously undergone laser iridotomy.7,8 It has been postulated that the zonular dehiscence secondary to laser iridotomy in combination with either aqueous misdirection8 or the shock wave secondary to trauma9 might cause the anterior dislocation and the corneal damage.7,8,10 Previous reports have recommended intracapsular lens extraction, cryoextraction with limbal incision and intracapsular phacoemulsification; however, most surgeons agree that the risk of intraoperative expulsive haemorrhage is quite high in such cases.7,8,10

In our patient, who did not have a laser iridotomy, the anterior dislocation of the lens occurred as a result of domestic trauma and was associated with a giant retinal tear. In addition to the risk of expulsive haemorrhage, the above surgical methods would also bear the risk of complicating the vitrectomy for the repair of the giant tear. Traction on the vitreous with phacoemulsification in the context of a giant retinal tear could be disastrous by extending the giant retinal tear, pulling the retina into the anterior segment or further detaching the retina. We decided to perform a modified technique, similar to that described by Choi, Kim and Song,10 but used a fragmatome rather than the sleeveless tip of the phacoemulsifier. During this procedure, we used very low ultrasonic power and tried to preserve the capsule first to minimise the risk of corneal damage and second to reduce vitreous traction and the risk of lens fragments falling into the vitreous cavity and complicating the rest of the surgery.

After this uneventful closed-chamber lensectomy, we were able to perform the vitrectomy and treat the giant tear. The patient's vision increased to 6/12, partially impaired due to the irreversible corneal endothelial damage.

We report an unusual case where dislocation of the crystalline lens was associated with a traumatic giant retinal tear. The case was challenging from both the diagnostic and treatment perspectives. We describe its successful management with intracapsular lensectomy and vitrectomy.

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