Traumatic anterior dislocation of a cataractous lens: a treatable ophthalmic emergency

Description

Anterior dislocation of the lens is an infrequent occurrence,¹ with no study mentioning its incidence. According to Choi et al, approximately 50% of lens dislocations are attributed to trauma.² During blunt injury to the eye, the anteroposterior blunt force can cause equatorial expansion of the lens, leading to the rupture of zonular fibres and subsequent dislocation of the lens.^{3 4} Instances of anterior lens dislocation in hereditary conditions such as Wiell-Marchesani syndrome, homocystinuria and Marfan syndrome, are documented and often associated with systemic manifestations.⁵ An anteriorly dislocated lens can cause corneal endothelial injury leading to corneal decompensation, acute angle closure glaucoma secondary to pupillary block, and can also cause lens-induced uveitis if there is capsular break and/or leakage of lens proteins.⁶ Early surgical intervention has proven to significantly enhance postoperative vision and overall quality of life.²

A man in his early 40s presented to our emergency department after being hit in his right eye by the handlebar of his motorcycle in an accident. Following the trauma, he noticed a reduction in vision from his right eye, accompanied by a dull, aching pain. Notably, he did not report any flashes of light or floaters. Furthermore, there was no pertinent family history indicating inherited systemic disease.

The patient could count fingers at a distance of 1 m with his right eye, and the intraocular pressure was 30 mm Hg. There were no signs of ecchymosis, eyelid oedema or conjunctival congestion, and the cornea remained transparent. On examination of the anterior chamber, we noted a dislocated cataractous lens and lenticular-corneal contact (figure 1). Details of the iris and pupil were not visible. B-scan of the right eye showed an anechoic lenticular area with no vitreous echoes and an intact retina (figure 2). Left eye examination revealed no abnormality with the lens being transparent and in position. Serum homocysteine levels were 8 µmol/L—within the normal limits of 5–15 µmol/L.

Figure 1.

Preoperative slit-lamp images. (A) Cataractous lens dislocated to the anterior chamber (white arrow). (B) Cataractous lens in the anterior chamber (black arrow) with intact capsule (white arrow).

Figure 2.

B-scan image showing anechoic vitreous (red star) with intact retina (yellow arrow).

Choi et al ² described a closed-chamber technique for surgical removal of an anteriorly dislocated lens wherein they gently separated the lens capsule from the corneal endothelium with viscoelastic material, after which they performed bimanual lensectomy with a vitrectomy probe and a phacoemulsification microflow tip. This closed chamber technique reduces the chance of expulsive choroidal haemorrhage and endothelial damage but is suitable only for soft cataractous lens dislocated anteriorly.² Jaffe and Jaffe⁷ discussed an intracapsular cryoextraction of an anteriorly displaced lens through a limbal incision using a cryoprobe, but it has an increased risk of expulsive haemorrhage.⁷ Sahay et al ⁸ explained a novel technique involving microscope-integrated intraoperative optical coherence tomography-guided intralenticular aspiration of an anteriorly dislocated lens wherein they made two limbal entries at the 10 and 2 o’clock positions and two stab entries at the equator of the lens. They then performed bimanual irrigation and aspiration of lenticular matter in the bag, and the capsule was peeled from the corneal endothelium with the help of intravitreal forceps and then removed with a vitrectomy cutter. The advantages of this technique are that it can intraoperatively detect capsular adherence with endothelium so that it can be peeled before expressing out then so that damage to endothelium can be prevented, and since a small incision is used, there is less chance of postoperative astigmatism and expulsive haemorrhage. However, the disadvantage is that it is not easily available in all hospitals.⁸

In our case, we established a superior sclerocorneal tunnel and extracted the dislocated lens using a wire vectis. Additionally, we performed an anterior vitrectomy and implanted a scleral-fixated intraocular lens. Postprocedure, on the first day, evidence of epithelial and stromal oedema was observed (figure 3). However, at a follow-up of 1 month, visual acuity notably improved to 6/9.

Figure 3.

Postoperative slit lamp images. (A) Diffuse corneal oedema with an air bubble superiorly (white arrow. (B) Stromal and epithelial oedema and well-formed anterior chamber with an air bubble superiorly.

Patient’s perspective.

Before the trauma to my right eye, my vision was good, and I was not even using any glasses. But in that road traffic accident, I was hit in my right eye by the handle of my motorcycle. However, after being hit, there was no swelling, redness, or bleeding, but I suddenly developed a blurring of my vision so that I could not see anything through my right eye. My accompanying person observed that the black part of my eye had become white. I came to the hospital within one hour. In the hospital, an ophthalmologist attended me. After examination, he informed me that the lens of my right eye came in front of its original location, which is quite rare. He advised me to undergo surgery. After surgery, my vision improved. And I was prescribed glasses one month after surgery. I have returned to work, and I can do my day-to-day work well.

Learning points.

• Anterior dislocation of the lens is an infrequent occurrence. Trauma is the most common cause, followed by inherited connective tissue diseases.

• Corneal endothelial injury and pupillary block glaucoma are potential complications of anterior lens dislocation.

• Surgical extraction of an anteriorly dislocated lens should be performed as soon as possible, and timely intervention can substantially improve postoperative vision and quality of life.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).