From the Department of Ophthalmology (JNT), St. Louis University; and the Department of Ophthalmology (STC, AMB), Washington University School of Medicine, St. Louis, Missouri.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Rhonda Curtis for her assistance with the photographs.
Address correspondence to Anjali M. Bhorade, MD, MS, 660 S. Euclid Avenue, Campus Box 8096, St. Louis, MO 63110.
Cataract surgery is the gold standard treatment for relieving complications associated with hypermature cataracts, including Morgagnian cataracts. We report a case of a Morgagnian cataract that spontaneously ruptured into the anterior chamber and our unique, non-surgical management.
A 78-year-old man presented complaining of left eye pain. The patient also noticed total vision loss in the left eye 3 years prior to presentation. Ocular history was significant for cataract removal in the right eye. Relevant medical history included renal calculi.
Visual acuity was 20/30 in the right eye and no light perception in the left eye. Intraocular pressures (IOPs) were 21 and 62 mm Hg in the right and left eyes, respectively. Examination of the left eye revealed conjunctival injection, stromal and microcystic corneal edema, and significant iris neovascularization. A brunescent lens nucleus was located in the inferior angle with corneal touch (Fig. 1A). A rupture in the anterior capsule was noted (Fig. 1B) and the posterior capsule appeared thin. Gonioscopy of the left eye showed significant angle neovascularization. Funduscopic examination of the left eye revealed total optic nerve cupping and diffuse intraretinal hemorrhages consistent with a central retinal vein occlusion.
Figure 1. (A) Nucleus of Morgagnian Cataract Dislocated into the Anterior Chamber. (B) Tear in the Anterior Lens Capsule (arrow).
The patient was given maximum medical glaucoma treatment, except oral carbonic anhydrase inhibitors due to his history of kidney stones. At his next visit, the IOP in the left eye had decreased to 44 mm Hg. Surgical removal of the dislocated nucleus was offered to the patient. However, because this eye had visual acuity of no light perception, the patient refused surgery. He also refused panretinal photocoagulation for his neovascular glaucoma. Instead, the patient consented to diode laser cyclophotocoagulation, which reduced the IOP to 26 mm Hg. One month later, examination revealed bullous keratopathy in the left eye (Fig. 2A). He again refused surgery but agreed to a modified couching technique to reduce corneal decompensation and likely future ocular complications and pain.
Figure 2. (A) Nucleus of Morgagnian Cataract Causing Early Bullous Keratopathy. (B) Decreased Bullous Keratopathy After Non-Invasive Couching of the Nucleus into the Posterior Segment.
The patient was placed in the supine position after topical anesthetic and dilating medications were instilled in his left eye. Digital pressure was applied to the inferior cornea to push the nucleus superiorly, where it was directed through the pupil and into the posterior segment. The patient was given pilocarpine 0.5% four times a day in this eye. At his last follow-up examination, approximately 6 months after the procedure, the lens was no longer visible in the anterior chamber, the IOP was stable, the cornea was clear, the anterior chamber was quiet, and the patient was pain free (Fig. 2B). Unfortunately, the patient failed to follow up for his subsequent clinic visits and was unable to be contacted.
Morgagnian cataracts are hypermature cataracts that undergo liquefaction of the cortex, which allows the lens nucleus to displace in the capsular bag, typically inferiorly. Morgagnian cataracts are relatively uncommon in the United States, but can cause well-known complications including phacolytic or lens-particle glaucoma.1 Our patient likely had chronically elevated IOPs from these processes that may have led to a central retinal vein occlusion in this eye. In turn, the vein occlusion may have caused the anterior segment neovascularization, which further elevated the IOP.
Morgagnian cataracts have been described in association with spontaneous ruptures of both the anterior and posterior lens capsules in the absence of trauma.2,3 However, these past cases have described only small breaks in the anterior capsule that allowed only the liquefied cortex to escape into the anterior chamber. In contrast, the anterior capsular break in our patient was large enough to allow dislocation of the entire nucleus into the anterior chamber. It is also interesting that the posterior capsule was sufficiently weakened to allow passage of the nucleus into the vitreous during the couching procedure. It is unknown why the nucleus did not dislocate spontaneously into the posterior segment, as has been described in other cataract types.4
Our patient’s ocular pain was probably due to increased IOP and corneal decompensation. Our ideal treatment for this patient would have included panretinal photocoagulation and intravitreal bevacizumab injection for his neovascular glaucoma and cataract extraction for his phacogenic glaucoma, uveitis, and corneal decompensation. However, anti-vascular endothelial growth factor agents were not readily available during the time the patient presented and because he refused the other treatment modalities, our challenge was to eliminate his eye pain in a non-surgical manner. Although a retrobulbar injection of ethanol or chlorpromazine may have relieved his ocular pain, these treatments would not have prevented progressive corneal decompensation, which may lead to corneal infection, phthisis bulbi, and possible enucleation of the eye. Our modified couching procedure decreased the risk of these less favorable scenarios.
We used pilocarpine in the period immediately following the procedure to prevent migration of the lens back into the anterior chamber. The retention of the nuclear lens in the eye and the use of pilocarpine may cause increased intraocular inflammation. Our patient tolerated the procedure and pilocarpine well and remained comfortable with a quiet eye for 6 months. Unfortunately, long-term follow-up was not attainable.
The technique of couching traditionally involves using a needle-like tool to pierce the eye and displace the cataract into the vitreous and out of the visual axis. It was a popular technique for relieving blindness due to cataracts until approximately 1850 and is still practiced in certain areas where modern cataract surgical services are not accessible.5,6 Traditional couching has many complications, including retinal detachment, persistent intraocular inflammation, endophthalmitis, and sympathetic ophthalmia in the fellow eye.7 As expected, this procedure is associated with poor visual outcomes, with only approximately 10% of patients achieving best-corrected visual acuities of 20/60 or better.6,8
In our patient, the affected eye had no vision so we were not concerned about inducing further vision loss. After controlling his IOP and inflammation, our main goal was to reduce corneal decompensation from lens–cornea touch to prevent further ocular complications and pain. This was accomplished with a modified couching procedure, which used a non-penetrating technique to avoid patient discomfort and future risk of sympathetic ophthalmia. Any corneal endothelial dysfunction that may have occurred from the brief lens–corneal contact during the procedure likely outweighs the risk of sympathetic ophthalmia from invasive procedures.
Cataract surgery is the recommended method of relieving the complications associated with hypermature (including Morgagnian) cataracts. However, when surgical intervention is not feasible, our non-invasive couching procedure is a viable alternative to reduce corneal decompensation, ocular pain, and complications that may require enucleation of the eye.
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- Ballen PH, Hughes WL. Spontaneous rupture of lens capsule in hypermature (morgagnian type) cataract. Am J Ophthalmol. 1955;39:403–405.
- Takamura Y, Oishi N, Kubo E, Tsuzuki S, Akagi Y. Morgagnian cataract with an isolated posterior capsular opening. Arch Ophthalmol. 2003;121:1487–1488. doi:10.1001/archopht.121.10.1487 [CrossRef]
- Ho SF, Ahmed S, Zaman AG. Spontaneous dislocation of posterior polar cataract. J Cataract Refract Surg. 2007;33:1471–1473. doi:10.1016/j.jcrs.2007.05.007 [CrossRef]
- Brown P. Couching a cataract. Med Instrum. 1982;16:123.
- Rabiu MM, Muhammed N. Rapid assessment of cataract surgical services in Birnin-Kebbi local government area of Kebbi State, Nigeria. Ophthalmic Epidemiol. 2008;15:359–365. doi:10.1080/09286580802399078 [CrossRef]
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- Mpyet C, Dineen BP, Solomon AW. Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria. Br J Ophthalmol. 2005;89:936–938. doi:10.1136/bjo.2004.062455 [CrossRef]