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Delayed Luxation of a Lens Nucleus After Vitrectomy
Arch Ophthalmol. 2002;120:1212-1213.
Accidental lens damage occurs less than 1% of the time during vitrectomy
for diabetic retinopathy and may necessitate concurrent lensectomy.1-2 We report an unusual late complication
of pars plana vitrectomy—delayed luxation of the lens nucleus.
Report of a Case
A 52-year-old man with a 20-year history of diabetes mellitus sought
treatment at the Parkland Memorial Hospital Ophthalmology Clinic, Dallas,
Tex, because of redness and photophobia in the left eye for 3 days. One year
previously, he underwent vitrectomy in the left eye for proliferative diabetic
retinopathy complicated by nonclearing vitreous hemorrhage and neovascular
glaucoma. Four months prior to the current development, he underwent a second
vitrectomy in the same eye for recurrent vitreous hemorrhage. The surgeon
noted no intraoperative complications, including lens touch with the instruments.
On the first day after the second vitrectomy, best-corrected visual acuity
was 20/400 OS, and a new posterior subcapsular cataract was noted.
On examination of the left eye, best-corrected visual acuity was hand
motion at 1 ft. Circumcorneal hyperemia and keratic precipitates were noted
on slitlamp biomicroscopy. The anterior chamber was deep, with a moderate
inflammatory reaction and visible lens particles. Neovascularization of the
iris was present at the pupillary margin but not in the angle of the anterior
chamber on gonioscopy. The anterior lens capsule was displaced posteriorly
and was wrinkled with an opacified anterior cortex, obstructing the view of
the fundus (Figure 1). The lens
nucleus and posterior lens capsule were not seen. Intraocular pressure was
12 mm Hg. B-scan ultrasonography revealed that the lens nucleus was resting
on the retina (Figure 2).
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Figure 1. A slitlamp photograph of the left
eye shows a wrinkled anterior lens capsule with an opacified white anterior
lens cortex.
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Figure 2. A B-scan ultrasonogram of the
left eye shows a lens nucleus that is dislocated into the posterior segment.
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The patient was treated with a topical corticosteroid and cycloplegia
for phacoantigenic uveitis and underwent pars plana lensectomy 5 days later.
At the time of the operation, the anterior capsule and zonules were intact,
but a large rent was found in the inferior posterior capsule.
Comment
After lens-sparing vitrectomy, the lens tends to fall slightly posteriorly,
making accidental lens touch more likely during repeat vitrectomy.3 Our patient likely had an iatrogenic defect in
the posterior capsule prior to luxation. The acute and persistent posterior
subcapsular cataract seen after the second vitrectomy in our patient was likely
due to direct trauma to the posterior lens. We theorize that increased intracapsular
volume secondary to lens hydration caused extension of the posterior capsule
defect and allowed the lens nucleus to fall into the posterior segment of
the eye.
Luxation of the lens nucleus is an unusual late complication of vitrectomy.
Cataract surgeons should be aware of the possibility of occult posterior capsule
damage when performing cataract extraction after vitrectomy.
AUTHOR INFORMATION
This study was supported in part by an unrestricted grant from Research
to Prevent Blindness, Inc, New York, NY.
The authors have no proprietary or financial interest in the material
discussed in this article.
David H. Ren, MD, PhD;
Preston H. Blomquist, MD;
Suri N. Appa, MD;
Kamel M. Itani, MD
Dallas, Tex
Corresponding author and reprints: Preston H. Blomquist, MD, Department
of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry
Hines Blvd, Dallas, TX 75390-9057 (e-mail: preston.blomquist{at}utsouthwestern.edu).
REFERENCES
1. Oyakawa RT, Schachat AP, Michels RG, Rice TA. Complications of vitreous surgery for diabetic retinopathy, I: intraoperative
complications. Ophthalmology. 1983;90:517-521.
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2. Novak MA, Rice TA, Michels RG, Auer C. The crystalline lens after vitrectomy for diabetic retinopathy. Ophthalmology. 1984;91:1480-1484.
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3. Faulborn J, Conway BP, Machemer R. Surgical complications of pars plana vitreous surgery. Ophthalmology. 1978;85:116-125.
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SECTION EDITOR: W. RICHARD GREEN, MD
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