Description
A 65-year-old systemically healthy woman presented with painless gradual diminution of vision not associated with floaters, redness or ocular trauma in the left eye for 2 years. The patient noted mild sudden visual improvement 6 months back with minimal change thereafter. Visual acuity was counting fingers improving to 6/24 with +10 DS. Slit-lamp examination revealed absent crystalline lens in patellar fossa and deep and quiet anterior chamber. Intraocular pressure and posterior segment were normal. Ultrasound B-scan was anechoic. The crystalline lens, lenticular material or empty capsular bag (ECB) were not appreciated on anterior segment optical coherence tomography (ASOCT) and ultrasound biomicroscopy (UBM). A diagnosis of left eye spontaneous lens absorption (SLA) with indetectable ECB was made. The right eye had visual acuity of 20/20 along with a stable in-the-bag foldable posterior chamber intraocular lens (PC-IOL). Endothelial cell count, axial length, anterior chamber depth and white-to-white diameter of left eye were 2390 cells/mm2, 23.56 mm, 3.36 mm and 11.72 mm, respectively. The patient was planned for anterior chamber IOL implantation in the left eye under intraoperative optical coherence tomography integrated microscope (i-OCT; RESCAN 700, Carl Zeiss, Germany) under peribulbar anaesthesia under aseptic conditions. At the onset of surgery, a thin free-floating membrane, presumed to be retained ECB, was noted intracamerally (figure 1). Its presence was better appreciated after accidental blood staining and confirmed as retained ECB on i-OCT (figure 2). The retained ECB was removed piecemeal with a microvitrectomy cutter followed by anterior chamber IOL implantation. Postoperatively, visual acuity was 20/30 and intraocular pressure was normal and an antibiotic-steroid-cycloplegic combination was prescribed for 1 month.
Figure 1.
Clinically barely visible empty capsular bag (ECB) in the anterior chamber (A) well visualised on accidental blood staining (B, red arrow); followed by anterior chamber intraocular lens implantation (C, D).
Figure 2.
Retained ECB visualised on i-OCT (A), inwardly rolled anterior margins of ECB (B, yellow arrow).
SLA is a rare phenomenon occurring in eyes with pre-existing weak zonules such as hypermature/traumatic/uveitic cataract or pseudoexfoliative syndrome.1 2 Retained ECBs in these cases are usually located in and around the patellar fossa. Rarely, these may be found in the anterior chamber or vitreous cavity.1–3 Every effort should be made to locate them as they can lead to visual disturbances and corneal decompensation later on.3 We believe that the ECB in our case was very thin and present behind the iris and therefore missed on preoperative imaging. We presume that this retained ECB was free-floating and could have surfaced to the anterior chamber during surgery due to positional changes (sitting to supine). Another possibility is that it had weak zonular support that gave away either naturally or due to surgical manipulations (peribulbar block, placing speculum) causing it to float to the anterior chamber during surgery.
i-OCT not only confirmed the presence of retained ECB and guided its removal in our case but also provided an insight into its pathogenesis by determining its configuration.4 An anterior opening with inwardly rolled margins suggested an ignored hypermature cataract with rupture of anterior capsule or anterior rotation of a ruptured posterior capsule, a finding usually seen in unilaterally pseudophakic women as they tend to ignore their fellow cataractous eye.5
To conclude, rarely, thin ECB present behind the iris that is missed preoperatively may be detected intraoperatively and i-OCT may play a role in confirming its presence.
Learning points.
Thin empty capsular bag (ECB) present behind the iris may be missed preoperatively.
Such ECBs may float to anterior chamber intraoperatively due to positional changes or alterations in zonular support.
i-OCT helps in confirming the intracameral presence of such membranes during surgery.
Footnotes
Contributors: RA: patient care, manuscript writing and editing. NS: manuscript review and editing. JST: manuscript review and editing.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Consent obtained directly from patient(s).
References
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