Furious Eyes: Chronic Intraocular Inflammation as Post-Couching Sequelae: A Rare Case Report

Abstract

Couching, an ancient technique of cataract management where cataractous lens is manually dislocated from its anatomical position into vitreous cavity. A 85-year-old female was referred complaining of diminished vision, redness and photophobia in both eyes for 2 weeks. A history of similar episodes in the past for which she used topical medication from local doctor. She underwent cataract surgery 25 years back, without intraocular lens implantation and has been using thick spectacles since then. Best-corrected visual acuity in both eyes was hand movements close to face. Bilateral circumcilliary congestion, diffuse corneal edema, anterior chamber reaction, iridodonesis, sluggish pupillary reaction and aphakia were noted. Intraocular pressures were raised. After medical treatment, bilateral cornea cleared. Fundus examination revealed vitritis and vitreous degeneration with optic atrophy in both eyes. B-scan revealed dislocated crystalline lens in the vitreous cavity inferiorly near the posterior pole. Due to the presence of optic atrophy, conservative management was done and inflammation was successfully controlled.

INTRODUCTION

Posterior dislocation of the lens is a form of ectopia lentis, a hereditary or acquired condition in which the human crystalline lens gets dislocated into the posterior chamber. It is often associated with acquired causes such as trauma, inflammation and hypermature cataracts.[1]

Couching is an ancient and early documented method of cataract treatment where the cataractous lens is manually dislocated into the posterior segment.[2] Various instruments were used to dislocate the opaque crystalline lens into vitreous cavities such as thorns and solid-type needles made up of copper, iron, silver and gold.[3,4] However, couching was largely unsuccessful, was done for mature cataracts and had dangerous outcomes due to the presence of retained cataractous lens matter intraocularly and also lack of aseptic conditions, often resulting in blindness post-procedure. Several reported complications include corneal edema, iritis, secondary glaucoma, optic atrophy, vitreous hemorrhage, cystoid macular edema, retinal detachment and in most deleterious cases endophthalmitis and phthisis bulbi eventually.[5]

CASE REPORT

An 85-year-old female, with no comorbidity, presented with chief complaints of diminished vision, redness and photophobia in both eyes for the past 2 weeks. There was a history of similar episodes in the past for which she used to take topical medications from a local doctor and the symptoms used to subside. She had undergone cataract surgery in both eyes 25 years back. After further questioning about the method of the surgery, she revealed that the procedure was done at home by local medical personnel. Some eye drops were put first. The procedure was carried out in a sitting position. During the surgery, she felt a needle-like pricking sensation in her eye and after a few minutes, procedure was completed. This same procedure was done for the other eye within a gap of 1 year. However, there was no history of intraocular lens (IOL) implantation.

On ocular examination, the best-corrected visual acuity in both eyes was hand movement close to the face. Slit-lamp biomicroscopy showed bilateral conjunctival and circumcilliary congestion, corneal edema, iridodonesis, anterior chamber 1+ flare and 3+ reaction and aphakia. Pupillary reactions were sluggish bilaterally. Bilateral intraocular pressure was digitally high. B-scan OU [Figures 1 and 2] revealed a solitary, well-circumscribed, oval and hyperechoic mass in a vitreous cavity near the posterior pole suggestive of a dislocated crystalline lens probably still surrounded by its capsule, mostly likely secondary to the couching procedure done as assessed from the given history. The diagnosis of OU intraocular inflammation secondary to chronically retained human crystalline cataractous lens was made. Inflammation was treated with oral prednisolone 1 mg/kg OD, topical eye drops gatifloxacin (0.5%) with prednisolone (1%) QID, atropine (1%) TID, and timolol maleate (1%) BD. After 3 days of treatment, conjunctival congestion and corneal edema were reduced [Figures 3 and 4]. With a + 10D lens visual acuity did not improve in both eyes. Intraocular pressure was 28 mmHg and 26 mmHg in OD and OS, respectively, with Goldmann applanation tonometer. A dilated fundus examination was done which showed Grade 2 vitritis and vitreous degeneration with optic atrophy bilaterally. Systemic examination and blood investigations such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, random blood sugar, and viral markers were unremarkable to rule out any cause of uveitis. The case was conservatively managed and the inflammation was controlled. Pars plana vitrectomy with secondary IOLs implantation was not planned as there was nil visual prognosis due to the presence of optic atrophy bilaterally.

Figure 1.

B-scan images of right eye showing well-circumscribed hyperechoic mass (red arrow) suggestive of crystalline lens with vitreous degeneration

Figure 2.

B-scan images of left eye showing well-circumscribed hyperechoic mass (red arrow) suggestive of crystalline lens with vitreous degeneration

Figure 3.

Right eye slit-lamp images: (a) diffuse illumination (b) Indirect illumination showing anterior chamber reaction

Figure 4.

Left eye slit-lamp images: (a) diffuse illumination (b) indirect illumination showing anterior chamber reaction

DISCUSSION

Posterior dislocation of crystalline lens results from high-energy trauma which occurs in couching.[1] Sequelae of retained lens material in the vitreous cavity result in persistent uveitis, secondary glaucoma, corneal edema, cystoid macular edema, retinal tears and detachment and even endophthalmitis can be present which eventually results in permanent vision loss.[6]

The management of our case was a challenge as the patient had long-term bilateral intraocular inflammation and inflammatory glaucoma because of retained lens material due to couching, which eventually resulted in permanent vision loss. In case of vitreous present in the anterior chamber, anterior vitrectomy should be performed before lens material removal. After the removal of larger nuclear fragments, the main wound should be sutured to stabilize the anterior chamber.[6]

As in our case, as any capsular support is absent, IOL options would have been iris-sutured IOLs scleral-sutured IOLs, sutureless scleral-fixated IOLs, and open-loop anterior chamber IOLs. IOL should be implanted after a thorough vitrectomy. Depending upon the status of ocular inflammation, corneal edema, the need for vitreoretinal intervention and its operative time, IOL implantation can be delayed.[6] Hydrophobic IOL material is preferred in aphakics.[7] Consideration of choice of IOL, lens power calculation formula and IOL design/material and expertise should be done.[8] Hence, in such cases as our case, customized management should be carried out after weighing the risks and benefits of the procedure and IOL to be used. As the visual acuity of our patient was not improving with high hypermetropic correction, pars plana vitrectomy with secondary IOL implantation was deffered.

Hence, the lesson learned in today’s time is that couching as cataract treatment is not acceptable due to its deleterious long-term sequelae resulting in permanent loss of vision.[9]

CONCLUSION

Couching illustrates long-term sight-threatening sequelae of posterior lens dislocation, including chronic intraocular inflammation, secondary glaucoma, vitreous degeneration and irreversible optic atrophy. Although medical therapy can control inflammation, visual rehabilitation is often limited, especially when significant optic nerve damage is present. Early identification of couching-related complications and timely referral is essential to prevent permanent vision loss. Strengthening public awareness, improving access to safe cataract surgery and discouraging harmful traditional practices are the critical steps toward reducing avoidable blindness associated with couching.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.