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Evaluation and treatment of traumatic cataract and iris damage

Cases such as this can be highly challenging to surgically repair, but the results can be extremely rewarding.

Surgical repair of traumatic cataracts can be challenging due to the extent of damage to ocular structures. While the obvious deformity is the lens opacity, it can be accompanied by other issues such as capsule damage, zonular loss, vitreous prolapse, iris damage, induced glaucoma and more. A careful stepwise approach is best for these tough cases.

In the example shown here, a teenage boy was injured with a pellet gun a few weeks prior. Luckily, there was no rupture of the globe, and there was no intraocular or intraorbital foreign body. Still, the damage to the eye was extensive. At his initial presentation, the patient had a near total hyphema that was managed well with conservative therapy. Once the blood cleared from the anterior chamber, he was referred to our medical center for surgical repair. At our teaching hospital, we encounter many traumatic cases such as this, and I was fortunate to have James Sanchez, MD, our chief resident, spearhead the effort to help this child.

Clinical presentation

The presenting vision was light perception only due to a completely white cataract. Importantly, the anterior lens capsule appeared to have been ruptured and the crystalline lens swelled dramatically, shallowing the anterior chamber, further tearing the iris and inducing a strong glaucomatous response. The posterior segment was grossly normal using B-scan ultrasonography, and because the vision had only recently declined, there was no sensory exotropia. The fellow eye was normal.

We first assessed the extent of the damage, both visible and presumed. In this case, we saw that the iris was ripped through the superior part of the pupil, and it appeared that the posterior pressure from the swelling lens nucleus had caused the tear to extend toward the limbus. The remaining pupil structure was inferiorly displaced, and a superior iridodialysis existed from 12 o’clock to 2 o’clock as well as a separate smaller area from 10 o’clock to 11 o’clock. The lens capsule was certainly ruptured, but the site of this was not clearly seen. The central band of iris tissue was not healthy, as it appeared to be atrophic and fragile with a compromised blood supply. There might have been zonular damage as well, and there was a chance that the posterior capsule could be ruptured. Both of these issues could have led to vitreous prolapse during the lens extraction.

Top half, before: Traumatic cataract and iris damage caused by a pellet gun injury. The lens capsule was ruptured, and swollen lens material caused the iris to be pushed forward, further tearing it. Bottom half, after: The cataract was removed, and a sulcus IOL was placed. An attempted fix of the iris dialysis displaced the pupil, so it was left alone, and priority was given to restoring the pupil anatomy.

Top half, before: Traumatic cataract and iris damage caused by a pellet gun injury. The lens capsule was ruptured, and swollen lens material caused the iris to be pushed forward, further tearing it. Bottom half, after: The cataract was removed, and a sulcus IOL was placed. An attempted fix of the iris dialysis displaced the pupil, so it was left alone, and priority was given to restoring the pupil anatomy.

Source: Devgan U

With cataract removal, the goal is to have a sufficient degree of remaining capsule in order to implant a posterior chamber lens. In a young patient such as this, with a compromised iris, an anterior chamber lens could be problematic, particularly when considering that this eye will be pseudophakic for many decades to come. Lens calculations in this case were somewhat difficult, so we compared with the fellow eye and aimed for a mild degree of residual myopia. A three-piece monofocal acrylic IOL was our preference because it could be placed within the capsular bag if it was found to be reasonably intact or in the ciliary sulcus if needed.

Intraoperative considerations

General anesthesia was used due to the child’s age and the anticipated complexity and length of the surgery. A paracentesis was made into the anterior chamber, and the iris was freed from the synechiae, which were adhering it to the remaining lens capsule. Trypan blue dye was used to stain the anterior lens capsule, which was found to have multiple large ruptures, and then viscoelastic was used to deepen the anterior chamber and protect the corneal endothelium. We used a 23-gauge vitrector to aspirate the soft lens material and trim the anterior capsule remnants into a more suitable configuration. There was insufficient anterior capsule to place an IOL within the capsular bag, but fortunately, the posterior capsule was intact. This entire process was done via two small paracentesis incisions.

The temporal incision was enlarged to allow IOL insertion with care to ensure that the incision edge nicked limbal vessels to ensure long-term sealing. Some zonular weakness was noted superiorly, so the decision was made to place the three-piece acrylic IOL in the ciliary sulcus. With the eye still filled with viscoelastic, the iris defects were repaired using 10-0 Prolene on long needles. The first order was to restore the pupil anatomy with carefully placed suture passes using the Siepser technique to tie the knots. When it came time to repair the superior iridodialysis, the iris tissue was simply too fragile and friable to be reattached to the limbus. The decision was made to leave it alone because it was adequately covered by the upper eyelid. Antibiotics and steroids were injected at the end of the case, and a retrobulbar depot of bupivacaine was placed so that the child would be comfortable and pain-free overnight.

The next morning when the patch was removed, the child smiled and the parents cried. He recovered good vision, and he is expected to heal well and resume normal activities shortly. Surgically repairing traumatic cataracts can be highly challenging but also extremely rewarding.

For more information:
Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.DevganEye.com.
Disclosure: Devgan reports no relevant financial disclosures.

Surgical repair of traumatic cataracts can be challenging due to the extent of damage to ocular structures. While the obvious deformity is the lens opacity, it can be accompanied by other issues such as capsule damage, zonular loss, vitreous prolapse, iris damage, induced glaucoma and more. A careful stepwise approach is best for these tough cases.

In the example shown here, a teenage boy was injured with a pellet gun a few weeks prior. Luckily, there was no rupture of the globe, and there was no intraocular or intraorbital foreign body. Still, the damage to the eye was extensive. At his initial presentation, the patient had a near total hyphema that was managed well with conservative therapy. Once the blood cleared from the anterior chamber, he was referred to our medical center for surgical repair. At our teaching hospital, we encounter many traumatic cases such as this, and I was fortunate to have James Sanchez, MD, our chief resident, spearhead the effort to help this child.

Clinical presentation

The presenting vision was light perception only due to a completely white cataract. Importantly, the anterior lens capsule appeared to have been ruptured and the crystalline lens swelled dramatically, shallowing the anterior chamber, further tearing the iris and inducing a strong glaucomatous response. The posterior segment was grossly normal using B-scan ultrasonography, and because the vision had only recently declined, there was no sensory exotropia. The fellow eye was normal.

We first assessed the extent of the damage, both visible and presumed. In this case, we saw that the iris was ripped through the superior part of the pupil, and it appeared that the posterior pressure from the swelling lens nucleus had caused the tear to extend toward the limbus. The remaining pupil structure was inferiorly displaced, and a superior iridodialysis existed from 12 o’clock to 2 o’clock as well as a separate smaller area from 10 o’clock to 11 o’clock. The lens capsule was certainly ruptured, but the site of this was not clearly seen. The central band of iris tissue was not healthy, as it appeared to be atrophic and fragile with a compromised blood supply. There might have been zonular damage as well, and there was a chance that the posterior capsule could be ruptured. Both of these issues could have led to vitreous prolapse during the lens extraction.

Top half, before: Traumatic cataract and iris damage caused by a pellet gun injury. The lens capsule was ruptured, and swollen lens material caused the iris to be pushed forward, further tearing it. Bottom half, after: The cataract was removed, and a sulcus IOL was placed. An attempted fix of the iris dialysis displaced the pupil, so it was left alone, and priority was given to restoring the pupil anatomy.

Top half, before: Traumatic cataract and iris damage caused by a pellet gun injury. The lens capsule was ruptured, and swollen lens material caused the iris to be pushed forward, further tearing it. Bottom half, after: The cataract was removed, and a sulcus IOL was placed. An attempted fix of the iris dialysis displaced the pupil, so it was left alone, and priority was given to restoring the pupil anatomy.

Source: Devgan U

With cataract removal, the goal is to have a sufficient degree of remaining capsule in order to implant a posterior chamber lens. In a young patient such as this, with a compromised iris, an anterior chamber lens could be problematic, particularly when considering that this eye will be pseudophakic for many decades to come. Lens calculations in this case were somewhat difficult, so we compared with the fellow eye and aimed for a mild degree of residual myopia. A three-piece monofocal acrylic IOL was our preference because it could be placed within the capsular bag if it was found to be reasonably intact or in the ciliary sulcus if needed.

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Intraoperative considerations

General anesthesia was used due to the child’s age and the anticipated complexity and length of the surgery. A paracentesis was made into the anterior chamber, and the iris was freed from the synechiae, which were adhering it to the remaining lens capsule. Trypan blue dye was used to stain the anterior lens capsule, which was found to have multiple large ruptures, and then viscoelastic was used to deepen the anterior chamber and protect the corneal endothelium. We used a 23-gauge vitrector to aspirate the soft lens material and trim the anterior capsule remnants into a more suitable configuration. There was insufficient anterior capsule to place an IOL within the capsular bag, but fortunately, the posterior capsule was intact. This entire process was done via two small paracentesis incisions.

The temporal incision was enlarged to allow IOL insertion with care to ensure that the incision edge nicked limbal vessels to ensure long-term sealing. Some zonular weakness was noted superiorly, so the decision was made to place the three-piece acrylic IOL in the ciliary sulcus. With the eye still filled with viscoelastic, the iris defects were repaired using 10-0 Prolene on long needles. The first order was to restore the pupil anatomy with carefully placed suture passes using the Siepser technique to tie the knots. When it came time to repair the superior iridodialysis, the iris tissue was simply too fragile and friable to be reattached to the limbus. The decision was made to leave it alone because it was adequately covered by the upper eyelid. Antibiotics and steroids were injected at the end of the case, and a retrobulbar depot of bupivacaine was placed so that the child would be comfortable and pain-free overnight.

The next morning when the patch was removed, the child smiled and the parents cried. He recovered good vision, and he is expected to heal well and resume normal activities shortly. Surgically repairing traumatic cataracts can be highly challenging but also extremely rewarding.

For more information:
Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.DevganEye.com.
Disclosure: Devgan reports no relevant financial disclosures.