Spontaneous Rupture of the Lens Capsule in Hypermature Cataract: Presentations and Outcomes Neha Goel, Meena Nagar

Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science Spontaneous rupture of the lens capsule in hypermature cataract: presentations and outcomes Neha Goel, Meena Nagar

ICARE Eye Hospital and ABSTRACT August 2012 to August 2014 was carried out and Postgraduate Institute, Noida, Aim To describe the occurrence of spontaneous rupture outcomes were assessed. All methods adhered to Uttar Pradesh, India of the lens capsule in patients with hypermature the tenets of the Declaration of Helsinki. The study Correspondence to cataract. was approved by the institutional ethics board. Dr Neha Goel, 57, Sadar Study design Consecutive case series. Ten patients were found to have presented with Apartments, Mayur Vihar Methods The records of patients with hypermature spontaneous capsule rupture in a HMSC. The fol- Phase 1 Extension, New Delhi cataract and spontaneous capsular dehiscence seen and lowing data were recorded from the clinical notes: 110091, India; [email protected] managed at a tertiary eye care centre between August age, gender, affected eye, duration of complaints 2012 and August 2014 were reviewed retrospectively. and history of trauma or any surgical intervention. Received 24 May 2015 Results 10 eyes of 10 patients were identified. Best- Detailed ophthalmic evaluation including measure- Revised 2 October 2015 corrected visual acuity (BCVA) was limited to light ment of best-corrected visual acuity (BCVA) using Accepted 25 October 2015 Published Online First perception in all patients. Three eyes had anterior Snellen chart, slit-lamp examination including bio- 13 November 2015 dislocation of the nucleus, two had posterior dislocation microscopy, measurement of intraocular pressure and in five the nucleus was presumed to have absorbed. (IOP) by Goldmann applanation tonometer and Eight eyes (80%) demonstrated both anterior and indirect ophthalmoscopy were noted. Each case posterior capsular tears and five eyes (50%) showed was examined for lens capsule rupture (anterior or calcification spots in the capsule remnants. Other features posterior or both), presence of calcification spots in at presentation included corneal oedema (two eyes), the capsular remnants, location of the nucleus and vitritis (four eyes), raised intraocular pressure (one eye) associated features, if any. and hypopyon (one eye). Removal of the nucleus through Relevant investigations that were carried out anterior (three eyes) or posterior route (two eyes) was such as B-scan ultrasonography (USG) and ultra- carried out in all patients with dislocated nucleus. sound biomicroscopy (UBM) were analysed. Intraocular lens could be implanted in seven eyes (70%) Treatment records were reviewed for details of and they had a final BCVA ranging from 6/18 to 6/36. medical and surgical management and intraopera- Conclusion Spontaneous lens capsule rupture can tive and postoperative complications, if any. All occur in hypermature senile cataract (HMSC) and result in ophthalmic parameters including BCVA, IOP and anterior or posterior dislocation of the nucleus or anterior and posterior segment details at each spontaneous resorption with or without an accompanying follow-up visit were noted. inflammatory reaction of varying severity. An acceptable visual outcome can be obtained, except in the presence RESULTS of associated glaucoma or corneal decompensation. This retrospective case series identified 10 eyes of 10 patients that presented with HMSC with spon- taneous capsular dehiscence, over a 2-year period. INTRODUCTION The age of the patients ranged from 75 to 85 years Mature and hypermature cataracts continue to con- with a median of 81 years. Seven patients were fi stitute a signi cant proportion of the cataract surgi- men with three were women. All patients presented 1 cal load in low/middle-income countries. with complaints of loss of vision in the affected eye A hypermature or Morgagnian cataract arises when since a period ranging from 2 to 12 months. This fi a cortical cataract progresses, lique es and is par- was painless in seven patients and associated with tially reabsorbed causing the solid nucleus to sink pain and redness in three patients (cases 1, 6 and 2 to the bottom. Hypermaturity may lead to a 7). All patients manifested unilateral disease; none variety of complications including lens-induced had history of trauma or surgical intervention. The uveitis, phacolytic glaucoma and dislocation of the fellow eyes were aphakic in two patients and pseu- 3 lens or nucleus. Spontaneous rupture of the anter- dophakic in eight patients following cataract ior or posterior lens capsule in hypermature senile surgery, with BCVA ranging from 6/12 to 6/24. 3–5 cataract (HMSC) resulting in anterior or poster- Systemic evaluation did not reveal any 6 ior dislocation of the nucleus has been described comorbidities. in few isolated case reports. We present a series of BCVA was limited to perception of light with 10 patients who presented with this complication accurate projection of rays (PR) in nine patients; one of HMSC and their subsequent management and patient had inaccurate PR (Case 7). Three patients clinical course. had anterior dislocation of the nucleus (figure 1), while two had posterior dislocation of the nucleus MATERIALS AND METHODS (figure 2). In five patients, the nucleus could not be To cite: Goel N, Nagar M. A retrospective review of records of patients diag- located on examination or investigations and was pre- Br J Ophthalmol nosed with HMSC and spontaneous dehiscence of sumed to have spontaneously absorbed (figures 3 and – 2016;100:1081 1086. the lens capsule at a tertiary eye care centre from 4). Two patients had an intact anterior lens capsule,

Goel N, Nagar M. Br J Ophthalmol 2016;100:1081–1086. doi:10.1136/bjophthalmol-2015-307184 1081 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science

Figure 1 Spontaneous lens capsule rupture with anterior dislocation of the nucleus in hypermature senile cataract. (A) Slit-lamp photograph of case 3 shows the nucleus in the pupillary area with calcification spots on the remnant capsular tags. Slit-lamp photographs of case 6 (B) and case 1 (C) show a small nucleus dislocated into the anterior chamber with inferior corneal oedema and Descemet’s folds. (D) Examination of case 1 at higher magnification revealed rupture of both the anterior and the posterior lens capsule with specks of calcification in the remaining anterior capsule.

with only posterior capsule opening (figure 3A). The remaining (figure 2A), and one of them (case 7) also had a hypopyon at pres- patients demonstrated tears in both the anterior and posterior lens entation (figure 4A). capsule (figures 1D and 2B). The presence of calcification spots UBM was performed in two eyes and showed an empty cap- in the anterior lens capsule could be observed in five eyes sular bag with anterior capsule discontinuity and partially (figures 1Dand3A, B). Two of the three patients with anterior absent zonules (figure 3D). USG B scan was carried out in all nucleus dislocation had lenticular-corneal touch, resulting in a patients, as the fundus was not visible clinically. In two eyes it hazy cornea with stromal oedema and Descemet’s folds especially located the presence of the nucleus in the vitreous cavity inferiorly (figure 1B, C). IOP was within normal limits in all (figure 2C). In the four eyes with vitreous cellular reaction patients except one (case 7), who had an IOP of 36 mm Hg at observed clinically, USG confirmed the presence of hyperecho- presentation. Four patients demonstrated significant vitritis genic vitreous opacities.

Figure 2 Spontaneous lens capsule rupture with posterior dislocation of the nucleus in hypermature senile cataract. (A) Slit-lamp photograph of case 2 shows aphakia with vitreous cellular reaction. (B) In inferior gaze, lens capsular remnants could be observed. (C) Ultrasound B scan revealed posterior dislocation of the nucleus. (D) Postoperative photograph following pars plana vitrectomy, phacofragmentation and implantation of anterior chamber intraocular lens. Best-corrected visual acuity at final follow-up was 6/18.

1082 Goel N, Nagar M. Br J Ophthalmol 2016;100:1081–1086. doi:10.1136/bjophthalmol-2015-307184 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science

Figure 3 Spontaneous lens capsule rupture with absorption of the nucleus in hypermature senile cataract. (A) Slit-lamp photograph of case 5 shows an intact anterior capsule with dense calcification. (B) The patient underwent anterior vitrectomy with capsulectomy and implantation of anterior chamber intraocular lens, resulting in a final best-corrected visual acuity of 6/18. (C) Anterior segment photograph of case 9 demonstrates lens capsule rupture with calcification and aphakia. (D) Ultrasound biomicroscopy revealed an empty capsular bag with anterior capsule rupture and partially absent zonules. Ultrasound B scan had failed to locate the nucleus in both these cases suggesting that it might have spontaneously absorbed.

The presentation in case 7 was similar to endophthalmitis injected beneath the nucleus to fill the anterior chamber and with painful loss of vision, hypopyon, raised IOP and severe vit- raise the IOP so that the nucleus was pushed towards the reous reaction (figure 4A). The nucleus was not found by USG tunnel. Simultaneous posteriorly directed pressure over the and had likely been absorbed. Intensive therapy consisting of scleral incision caused the nucleus to engage in the tunnel. topical and systemic steroids, cycloplegics and IOP-lowering Continuous viscoelastic injection in the anterior chamber caused drugs resulted in alleviation of pain, normalisation of IOP, reso- the nucleus to be forced out of the incision. It was ensured that lution of hypopyon and vitritis (figure 4B). Subsequently both the tunnel was adequately sized for this manoeuvre to be suc- anterior and posterior lens capsule ruptures were observed cessful. Two eyes with posterior nucleus dislocation underwent (figure 4C) and fundus examination revealed glaucomatous standard 3 port pars plana vitrectomy with phacofragmentation. optic atrophy. After core vitrectomy, posterior vitreous detachment (PVD) was All patients underwent surgical management, except case 7 induced and the nucleus was removed by phacofragmentation in that was treated medically. The nucleus was removed by viscoex- the mid-vitreous cavity. The decision to implant an intraocular pression through a superior tunnelled scleral incision in the lens (IOL) was based on the visual potential, and the choice of three eyes with nucleus in the anterior chamber or pupil. IOL (anterior chamber IOL (ACIOL) or posterior chamber IOL Viscoelastic (2% hydroxypropyl methylcellulose) was first (PCIOL)) was governed by the status of the capsule. No IOL injected through the tunnel in the space between the nucleus was inserted in the two eyes with corneal decompensation and and the corneal endothelium. Subsequently the viscoelastic was in one eye with optic atrophy (case 7). A large polymethyl

Figure 4 Spontaneous lens capsule rupture with absorption of the nucleus in hypermature senile cataract presenting as endophthalmitis. (A) Circumcorneal congestion, hypopyon measuring 2.2 mm and exudates in the pupillary area seen in case 7 at presentation. Intraocular pressure (IOP) was raised to 37 mm Hg. Ultrasound B scan demonstrated hyperechogenic vitreous opacities but no nucleus. (B) Following intensive medical therapy with topical and systemic steroids, cycloplegics and IOP-lowering agents, the hypopyon resolved and IOP returned to normal. (C) Both the anterior and posterior lens capsules were ruptured. Fundus examination revealed optic atrophy. No intraocular lens was implanted.

Goel N, Nagar M. Br J Ophthalmol 2016;100:1081–1086. doi:10.1136/bjophthalmol-2015-307184 1083 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science methacrylate PCIOL was placed in the ciliary sulcus in one eye phacolytic glaucoma complicating HMSC in patients with good with an intact anterior lens capsule via a tunnelled scleral inci- vision in the opposite eye has been described earlier.7 sion (case 4). In the other eye with an intact anterior lens Anterior lens capsule rupture of a HMSC with expulsion of capsule, dense calcification was present that obstructed the the nucleus at the pupil has been described in isolated case visual axis (case 5). Hence, the capsule was excised, anterior reports.34Spontaneous anterior dislocation of the hypermature vitrectomy (AV) was performed and an ACIOL was placed nucleus has also been reported rarely.5 While no treatment (figure 3A, B). The remaining five eyes had both anterior and could be performed in one report,4 the other two described posterior capsule dehiscence and underwent AV followed by removal of the nucleus using a vectis.35In our series, one ACIOL implantation. No intraoperative complications were patient presented with the nucleus stuck in the pupillary plane, encountered. while two had anterior dislocation of the nucleus with corneal The follow-up period ranged from 3 to 8 weeks, with a mean endothelial touch. While the former had improvement in BCVA of 5.8 weeks. None of the patients were noted to have any com- following nucleus removal and ACIOL implantation, the latter plications during this period. The visual outcome was satisfac- two did not, due to corneal decompensation. Viscoexpression10 tory in seven patients who had a final BCVA ranging from 6/18 through a superior scleral tunnel was carried out to remove the to 6/36. Two eyes with corneal decompensation were left nucleus in all three cases; this has not been described previously. aphakic and had a BCVA of counting fingers close to face at the Since the nucleus was small and shrunken, it was ensured that final visit. They were advised penetrating keratoplasty with sec- the pupil was constricted intraoperatively to prevent posterior ondary IOL implantation; however, they declined. Only one eye dislocation into the vitreous cavity in the supine position. had inaccurate PR that was attributed to severe glaucomatous Documentation of dehiscence of the posterior lens capsule in optic nerve damage. The detailed demographic data, clinical fea- a HMSC with6 or without posterior dislocation of the nucleus11 tures, management and outcomes of all 10 patients has been is scarce. Two patients had posterior dislocation of the nucleus compiled in table 1. with posterior capsule rupture, which was picked up on USG B scan, with associated vitritis. Both patients underwent pars DISCUSSION plana vitrectomy with phacofragmentation and IOL implant- Cataract continues to be the leading cause of blindness in low/ ation with a good visual outcome. Intraoperatively, a small middle-income countries. Despite the cost-effectiveness of cata- ‘diminutive’ nucleus was found in the vitreous cavity. ract surgery, its delivery to a large part of the population is Spontaneous absorption of a hypermature lens can occur fraught with many issues and challenges.1 This has led to a sig- rarely9 and has been attributed to a rent in the posterior lens nificant proportion of patients still presenting with mature and capsule.12 Often, but not necessarily, this is associated with hypermature cataracts. HMSC are not as rare as literature lens-induced uveitis or glaucoma.9 Rupture of the lens capsule would imply. While they were encountered more frequently in exposes the cortex to the surrounding tissues as a powerful anti- previous years, cataracts of varying degrees of hypermaturity are genic stimulus and may produce a severe inflammatory response. still frequently seen in modern ophthalmic practice in low/ In half the patients in this series, the nucleus could not be middle-income countries. located on examination or investigations and was presumed to HMSC, also known as Morgagnian cataract, is a variety of have spontaneously absorbed. One patient presented with ‘pseu- cortico-nuclear cataract, in which the process of lens fibre dissol- dohypopyon’, vitritis and secondary glaucoma. This clinical ution by enzymatic degradation is accelerated, resulting in their picture has been described previously.713The patient was liquefaction, followed by resorption of the cortical fluid. The treated with intensive steroid therapy and IOP-lowering medica- nucleus being resistant to this process is left floating in the midst tions; however, severe visual impairment persisted owing to of a liquefied cortex in the capsular bag.2 Escape of lenticular optic atrophy. It has been suggested that intensive steroid contents into the anterior chamber can occur through an intact, therapy might delay absorption of the lens material. When the permeable lens capsule or through a minute dehiscence in the IOP fails to be controlled medically, surgical removal of the anterior lens capsule, resulting in uveitis and secondary glau- residual lens matter should be carried out.14 Rarely, a HMSC coma.37Spontaneous lens dislocation into the vitreous cavity may be cured spontaneously by gradual absorption without attributable to weak zonules8 and spontaneous absorption of the complications, probably as a result of minute posterior capsule lens material are other complications of HMSC.9 Spontaneous ruptures and slow release of the liquefied protein.3 Three lens capsule rupture in HMSC is extremely uncommon, espe- patients had this kind of presentation with no evidence of cially in the current era and has been documented rarely. The uveitis or glaucoma and were rehabilitated with IOL present study was done on 10 patients presenting with HMSC implantation. and spontaneous capsule rupture at a tertiary eye care centre The normal lens capsule consists of a three-dimensional catering to rural population over a 2-year period. A total of molecular meshwork consisting of type IV collagen with other 15 436 cataract surgeries were performed in this period. extracellular matrix constituents such a collaged type I, III, HMSC is a disease of advancing age as is evident by the age laminin and fibronectin, each of which contributes to the bio- of the patients in this series ranging between 75 and 85 years. mechanical properties of the capsule.15 A capsule rupture can About 70% of the patients were men. Patients with a history of be traumatic or spontaneous, due to intraocular tumours, sup- painful diminution of vision had a shorter duration of com- purative inflammation, HMSC or lenticoonus.16 In HMSC, as plaints. All patients had severe impairment of visual acuity at the lens fibres imbibe fluid and get increasingly hydrated, spon- presentation. Of note, the fellow eye of all 10 patients had taneous lens capsule rupture may occur. The subsequent clinical undergone cataract surgery with (eight eyes) or without (two picture depends on the site and size of rupture and the contents eyes) IOL implantation and had BCVA ranging from 6/12 to 6/ of the lens.3 Anterior capsule dehiscence in a HMSC with 24. This suggests that good visual acuity in one eye may lead to milky, fluid, cortical matter results in severe uveitis with second- delay in seeking medical attention for the other eye, especially ary glaucoma. If the cortex has already been absorbed leaving a in patients residing in rural areas, where they might not be ‘diminutive’ nucleus, it results in expulsion of the nucleus into having high visual demand. A similar preponderance of the anterior chamber. A large posterior capsule rupture can

1084 Goel N, Nagar M. Br J Ophthalmol 2016;100:1081–1086. doi:10.1136/bjophthalmol-2015-307184 olN aa M. Nagar N, Goel rJOphthalmol J Br

Table 1 Demographic data, clinical features, management and outcomes of 10 patients with spontaneous capsule rupture in hypermature senile cataract (HMSC) Fellow eye Calcification Location Downloaded from 2016; Case Age Duration lens status, Lens capsule of lens of Associated Final visual Follow-up no. (years) Sex Eye (months) BCVA BCVA rupture capsule nucleus features Investigations Treatment outcome (weeks) 100

:1081 1 80 F L 3 PL+PR acc Aphakic, 6/24 Anterior+posterior + AC Corneal USG WNL Nucleus removal FCCF (corneal 3 decompensation (anterior route), No IOL decompensation)

– −

06 o:013/jptaml21-0141085 doi:10.1136/bjophthalmol-2015-307184 1086. 2 80 M L 9 PL+PR acc Pseudophakic, Anterior+posterior VC Vitritis USG posterior PPV, 6/18 8 6/18 dislocated phacofragmentation, nucleus+vitreous ACIOL http://bjo.bmj.com/ opacities 3 75 M L 3 PL+PR acc Pseudophakic, Anterior+posterior + Pupil − USG WNL Nucleus removal 6/24 6 6/12 (anterior route), ACIOL 4 82 F R 6 PL+PR acc Pseudophakic, Posterior + VC Vitritis USG posterior PPV, 6/18 8 6/12 dislocated phacofragmentation, nucleus+vitreous PCIOL in sulcus onAugust30,2016-Publishedby opacities 5 85 M R 12 PL+PR acc Pseudophakic, Posterior + Not − USG WNL AV, removal of calcified 6/18 8 6/18 found? anterior capsule, ACIOL Absorbed 6 78 M L 3 PL+PR acc Pseudophakic, Anterior+posterior − AC Corneal USG WNL Nucleus removal FCCF (corneal 4 6/18 decompensation (anterior route), No IOL decompensation) 7 80 F R 2 PL+PR Aphakic, 6/18 Anterior+posterior − Not Hypopyon, USG vitreous Medical management, PL+PR inacc 8 inacc found? vitritis, raised opacities No IOL (optic atrophy) Absorbed IOP 8 85 M L 6 PL+PR acc Pseudophakic, Anterior+posterior − Not Vitritis USG vitreous Medical management 6/24 6 6/12 found? opacities (topical+systemic Absorbed steroids), AV, ACIOL 9 84 M L 9 PL+PR acc Pseudophakic, Anterior+posterior + Not − USG WNL, UBM AV, ACIOL 6/24 4 group.bmj.com 6/12 found? empty capsular Absorbed bag 10 78 M R 9 PL+PR acc Pseudophakic, Anterior+posterior − Not − USG WNL, UBM AV, ACIOL 6/36 3 6/18 found? empty capsular Absorbed bag AC, anterior chamber; Acc, accurate; ACIOL, anterior chamber intraocular lens; AV, anterior vitrectomy; BCVA, best-corrected visual acuity; F, female; FCCF, counting fingers close to face; inacc, inaccurate; IOL, intraocular lens; IOP, intraocular pressure; L, left; M, male; PCIOL, posterior chamber intraocular lens; PL, perception of light; PPV, pars plana vitrectomy; PR, projection of rays; R, right; UBM, ultrasound biomicroscopy; USG, Ultrasound B scan; VC, vitreous cavity; WNL, within normal limits. lnclscience Clinical Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com Clinical science cause posterior dislocation of the nucleus into the vitreous content. Both authors were involved in the final approval of the version to be cavity, especially if the opening is inferior. Smaller defects can published. lead to spontaneous lens absorption. Isolated posterior capsule Competing interests None declared. rupture with an intact anterior capsule has been reported Patient consent Obtained. 17 rarely and was observed in two patients in our series. This Provenance and peer review Not commissioned; externally peer reviewed. provided an opportunity to implant a PCIOL in the ciliary sulcus. Since one case had a calcified capsule, simultaneous limited capsulectomy was performed to clear the visual axis. REFERENCES The presence of multiple calcified spots in the capsular rem- 1 Khanna R, Pujari S, Sangwan V. Cataract surgery in developing countries. Curr Opin nants was visible in half the cases. High levels of calcium in the Ophthalmol 2011;22:10–14. capsule and nucleus in HMSC could be due to the precipitation 2 Bron AJ, Habgood JO. 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1086 Goel N, Nagar M. Br J Ophthalmol 2016;100:1081–1086. doi:10.1136/bjophthalmol-2015-307184 Downloaded from http://bjo.bmj.com/ on August 30, 2016 - Published by group.bmj.com

Spontaneous rupture of the lens capsule in hypermature cataract: presentations and outcomes Neha Goel and Meena Nagar

Br J Ophthalmol 2016 100: 1081-1086 originally published online November 13, 2015 doi: 10.1136/bjophthalmol-2015-307184

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Topic Articles on similar topics can be found in the following collections Collections Lens and zonules (801) Angle (997) Cornea (519) Glaucoma (979) Intraocular pressure (993) Ocular surface (613)

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