Complications Consult

Multistep management needed to treat pseudophacocele

The anterior chamber must be carefully examined preoperatively.

The term “pseudophacocele” is characterized by subconjunctival extrusion of an IOL. It is mostly traumatic in nature and commonly results due to opening or gaping of the surgical wound many years after the cataract surgery is performed. The surgical wound represents an inherent weakness in the contour of the globe and upon forceful trauma it leads to IOL extrusion. Due to an intact conjunctiva, the extruded IOL almost always becomes contained in the subconjunctival space. This prevents the globe from being directly exposed to the environment.

Preoperative examination

A careful slit lamp examination should be performed in all cases with a history of trauma. Slit lamp examination often leads to a clear assessment of the anterior chamber and the status of the cornea. Often other details might not be appreciated due to the presence of hyphema, but an attempt to visualize the iris structure should be made (Figure 1a). Anterior segment OCT often helps demarcate the presence of an IOL in the subconjunctival space. Although ultrasound biomicroscopy helps assess the eye in a better way, it is often difficult to perform due to the presence of the ruptured globe.

Figure 1. Traumatic pseudophacocele. Traumatic pseudophacocele with hyphema, corneal edema and limited intraoperative view of the eye (a). A trocar anterior chamber maintainer is introduced for fluid infusion inside the eye (b). Conjunctival peritomy is done, the ruptured scleral wound is explored, and the IOL is located (c). A broken one-piece IOL is removed, and the other broken haptic is searched for and removed (d). Anterior limbal vitrectomy is performed, and hyphema is cleared from the anterior chamber (e). Pars plana vitrectomy is performed (f).

Source: Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth

Figure 2. Traumatic pseudophacocele. Iris hooks are employed, and a three-piece foldable IOL is injected inside the anterior chamber for glued IOL fixation (a). Both haptics are externalized (b). Single-pass four-throw pupilloplasty is performed (c). The suture ends are cut with microscissors (d). Air is injected inside the anterior chamber, and fibrin glue is applied beneath the scleral flaps (e). Postoperative image of the case (f).
Figure 3. Preoperative and postoperative image. Ruptured globe with pseudophacocele (a). Postoperative 1 month image with 20/40 vision (b).

Management

The initial management consists of exploration of the wound. Fluid infusion is introduced inside the eye with either an anterior chamber maintainer or a trocar anterior chamber maintainer (Figure 1b). Conjunctival peritomy is done, and the extruded IOL is located and removed (Figures 1c and 1d). If the IOL is found to be broken, the remaining part of the IOL should also be located. The ruptured wound in the scleral wall is then assessed. In our experience with pseudophacocele, the surgical wound for cataract surgery gaped in all cases. The scleral wound is then sutured with 10-0 nylon to restore the integrity of the globe. A vitrectomy probe is introduced inside the anterior chamber, and vitreous along with hyphema is cleared from the anterior chamber (Figure 1e). Once the anterior chamber is cleared, pars plana vitrectomy is performed, the vitreous cavity is explored, and a thorough vitrectomy is performed (Figure 1f).

Iris hooks are often employed if the pupil is small or irregular in shape and size (Figure 2a) and if it is found to block the view of the posterior segment. Glued intrascleral fixation of an IOL is then performed, and a three-piece foldable IOL is injected followed by haptic externalization and haptic tucking (Figure 2b). Iris hooks are removed, and pupilloplasty is performed to restore the pupil integrity. The procedure of choice in our cases is single-pass four-throw technique because only a single pass is made into the anterior chamber in an already inflamed eye (Figures 2c and 2d). This indirectly translates into less inflammation in the postoperative period. The scleral flaps and conjunctival openings are then sealed with fibrin glue (Figures 2e and 2f).

This combination of procedures helps optimize the visual outcomes in these severely traumatized eyes (Figures 3a and 3b).

Disclosures: Agarwal and Narang report no relevant financial disclosures.

The term “pseudophacocele” is characterized by subconjunctival extrusion of an IOL. It is mostly traumatic in nature and commonly results due to opening or gaping of the surgical wound many years after the cataract surgery is performed. The surgical wound represents an inherent weakness in the contour of the globe and upon forceful trauma it leads to IOL extrusion. Due to an intact conjunctiva, the extruded IOL almost always becomes contained in the subconjunctival space. This prevents the globe from being directly exposed to the environment.

Preoperative examination

A careful slit lamp examination should be performed in all cases with a history of trauma. Slit lamp examination often leads to a clear assessment of the anterior chamber and the status of the cornea. Often other details might not be appreciated due to the presence of hyphema, but an attempt to visualize the iris structure should be made (Figure 1a). Anterior segment OCT often helps demarcate the presence of an IOL in the subconjunctival space. Although ultrasound biomicroscopy helps assess the eye in a better way, it is often difficult to perform due to the presence of the ruptured globe.

Figure 1. Traumatic pseudophacocele. Traumatic pseudophacocele with hyphema, corneal edema and limited intraoperative view of the eye (a). A trocar anterior chamber maintainer is introduced for fluid infusion inside the eye (b). Conjunctival peritomy is done, the ruptured scleral wound is explored, and the IOL is located (c). A broken one-piece IOL is removed, and the other broken haptic is searched for and removed (d). Anterior limbal vitrectomy is performed, and hyphema is cleared from the anterior chamber (e). Pars plana vitrectomy is performed (f).

Source: Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth

Figure 2. Traumatic pseudophacocele. Iris hooks are employed, and a three-piece foldable IOL is injected inside the anterior chamber for glued IOL fixation (a). Both haptics are externalized (b). Single-pass four-throw pupilloplasty is performed (c). The suture ends are cut with microscissors (d). Air is injected inside the anterior chamber, and fibrin glue is applied beneath the scleral flaps (e). Postoperative image of the case (f).
Figure 3. Preoperative and postoperative image. Ruptured globe with pseudophacocele (a). Postoperative 1 month image with 20/40 vision (b).

Management

The initial management consists of exploration of the wound. Fluid infusion is introduced inside the eye with either an anterior chamber maintainer or a trocar anterior chamber maintainer (Figure 1b). Conjunctival peritomy is done, and the extruded IOL is located and removed (Figures 1c and 1d). If the IOL is found to be broken, the remaining part of the IOL should also be located. The ruptured wound in the scleral wall is then assessed. In our experience with pseudophacocele, the surgical wound for cataract surgery gaped in all cases. The scleral wound is then sutured with 10-0 nylon to restore the integrity of the globe. A vitrectomy probe is introduced inside the anterior chamber, and vitreous along with hyphema is cleared from the anterior chamber (Figure 1e). Once the anterior chamber is cleared, pars plana vitrectomy is performed, the vitreous cavity is explored, and a thorough vitrectomy is performed (Figure 1f).

Iris hooks are often employed if the pupil is small or irregular in shape and size (Figure 2a) and if it is found to block the view of the posterior segment. Glued intrascleral fixation of an IOL is then performed, and a three-piece foldable IOL is injected followed by haptic externalization and haptic tucking (Figure 2b). Iris hooks are removed, and pupilloplasty is performed to restore the pupil integrity. The procedure of choice in our cases is single-pass four-throw technique because only a single pass is made into the anterior chamber in an already inflamed eye (Figures 2c and 2d). This indirectly translates into less inflammation in the postoperative period. The scleral flaps and conjunctival openings are then sealed with fibrin glue (Figures 2e and 2f).

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This combination of procedures helps optimize the visual outcomes in these severely traumatized eyes (Figures 3a and 3b).

Disclosures: Agarwal and Narang report no relevant financial disclosures.