A 56-year-old woman with a history of trabeculectomy in both eyes sustained blunt trauma to the right eye at home. She initially presented with pain, loss of vision, total hyphema, and hypotony with no evidence of rupture or tissue prolapse. Prompt anterior chamber wash out revealed a partially subluxated crystalline lens behind the pupil, but the globe was intact. At 1 month postoperatively, subconjunctival displacement of the crystalline lens was detected. The patient gave a history of severe bouts of coughing and sneezing a few days earlier. During removal of phacocele, the trabeculectomy wound was intact with no evidence of leakage. A shallow concentric furrow was noticed across the flap approximately 3 mm from the limbus. It is believed that repeat trauma pushed the crystalline lens through the weakened trabeculectomy scleral flap. The wound later self-sealed.
From the Department of Ophthalmology (KSK, SZ), University of Texas Southwestern Medical Center; VA North Texas Health Care System (KSK, SZ), Dallas, Texas; and Retina Associates (SZ), New Orleans, Louisiana.
Supported in part by an unrestricted grant from the Research to Prevent Blindness, Inc., New York, New York.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Karanjit S. Kooner, MD, PhD, Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9057. E-mail: email@example.com
Received: January 24, 2012
Accepted: March 02, 2012
Posted Online: May 31, 2012
Traumatic phacocele is a rare manifestation of ocular trauma in which the entire crystalline lens is dislocated from its intraocular position into subconjunctival space.1–4 It has been reported in nearly 13% of all complete luxations.2 Because the eyeball is relatively incompressible, blunt trauma of sufficient force may rupture it.3 Other predisposing conditions include prior ocular trauma/surgery or inherent thinning of sclera.4 Although a clearly identifiable scleral laceration is typically detected,1–4 we describe a case of delayed traumatic phacocele without apparent globe rupture.
A 56-year-old woman with primary open-angle glaucoma sustained a fall and hit her right eye on a wooden sofa. She had undergone bilateral trabeculectomies with mitomycin C more than 18 years ago. Examination of the right eye revealed visual acuity of light perception, subconjunctival hemorrhage with blood under the bleb, hypotony of 2 mm Hg, clear cornea, total hyphema, and a deep anterior chamber.
The anterior chamber blood was washed out and the crystalline lens was clearly visible behind the dilated pupil. There was no visible intraocular tissue damage or prolapse. Postoperative examination revealed formed anterior chamber with few red blood cells, a partially subluxed crystalline lens behind the iris, and hypotony. The patient subsequently developed an upper respiratory tract infection resulting in violent coughing and sneezing, potentially causing additional stress on the eye.
At 1 month postoperatively, the hypotony had resolved and vision improved, but the subluxed lens disappeared. A soft cystic mass approximately 1 cm in diameter appeared under the superotemporal conjunctiva (Fig. 1). Anterior ocular coherence tomography was performed and showed a lenticular mass (Fig. 2). A second surgical exploration revealed a phacocele (Fig. 3), which was removed. Sclera in the trabeculectomy surgery area was explored and, except for a concentric shallow furrow (Fig. 4) across the flap, no laceration was found. Postoperatively, her vitreous hemorrhage gradually improved and indirect ophthalmoscopy confirmed the absence of choroidal rupture. The patient recovered her pretrauma vision after a glaucoma shunt procedure for uncontrolled glaucoma and a scleral fixated intraocular lens.
Figure 1. Photograph of a large cystic subconjunctival mass in the superotemporal quadrant.
Figure 2. Dimensions of the cystic mass revealed by anterior optical coherence tomography.
Figure 3. Intraoperative photograph of exposed intact but pliable crystalline lens.
Figure 4. Healed shallow groove across the trabeculectomy flap concentric to the limbus, 3 mm from the limbus (arrows).
Easily detectable scleral laceration is nearly universal in the reported cases of phacocele.1–4 It is typically concentric, between the limbus and spiral of Tillaux, in the superotemporal or superonasal quadrants.3
Both the absence of the identified scleral laceration and the delayed presentation of the phacocele make this case unusual. Our patient had trabeculectomy with mitomycin C in the past, presumably rendering her sclera more vulnerable to rupture. One report described a patient who developed dehiscence in her trabeculectomy flap with no scleral wall rupture after blunt trauma.5 The fact that the phacocele was found in the same quadrant as the bleb suggests that there was a self-sealing, temporary conduit between intraocular and subconjunctival spaces in that area. The patient’s coughing and sneezing (Valsalva maneuver) may have contributed to or caused positive vitreous pressure and further weakened the damaged sclera, most likely across the trabeculectomy flap (Fig. 4).
Hypotony on the initial visit may have been from traumatic ciliary body shutdown or undetected globe rupture. Concussive force was clearly strong enough to cause total hyphema and tears in the zonules resulting in partial displacement of the crystalline lens. We postulate the following sequence of events in our patient. She tolerated the first trauma well, except for partial disruption of zonules. Repeated Valsalva maneuver induced elevated vitreous pressure6 and was strong enough to push the weakly supported crystalline lens through the prior iridectomy; the sclerostomy in turn ruptured the trabeculectomy flap and pushed the lens under the conjunctiva.
It is important to remember that trabeculectomy wounds may rupture from both external and internal force of sufficient strength. Repeat trauma may further luxate the crystalline lens through the trabeculectomy–sclerostomy tract and push it under the conjunctiva. The wound may eventually self-seal under the right circumstances. Prompt recognition and intervention may restore useful vision.
- Bhattacharjee K, Bhattacharjee H, Deka A, Bhattacharyya P. Traumatic phacocele: review of eight cases. Indian J Ophthalmol. 2007;55:466–468. doi:10.4103/0301-4738.36487 [CrossRef]
- McDonald PR, Purnell JE. The dislocated lens. J Am Med Assoc. 1951;145:220–226. doi:10.1001/jama.1951.02920220028006 [CrossRef]
- Cherry PM. Indirect traumatic rupture of the globe. Arch Ophthalmol. 1978;96:252–256. doi:10.1001/archopht.1978.03910050120003 [CrossRef]
- Allen RC, Gupta RR, Poblete R, Oetting TA. Traumatic phacocele. J Cataract Refract Surg. 2001;27:1333–1334. doi:10.1016/S0886-3350(00)00760-4 [CrossRef]
- Rubinstein A, Salmon JF. Late traumatic scleral flap dehiscence following trabeculectomy. Eye (Lond). 2007;21:145–146. doi:10.1038/sj.eye.6702476 [CrossRef]
- Aykan U, Erdurmus M, Yilmaz B, Bilge AH. Intraocular pressure and ocular pulse amplitude variations during the Valsalva maneuver. Graefes Arch Clin Exp Ophthalmol. 2010;248:1183–1186. doi:10.1007/s00417-010-1359-0 [CrossRef]