127 SINGAPORE MEDICAL JOURNAL Vol. 4, No. 3. September, 1963. SPONTANEOUS RUPTURE OF THE ANTERIOR CAPSULE OF A HYPERMATURE

By Arthur Lim Siew Ming, F.R.C.S. (Eng.), D.O. (Lond.) (Department of Ophthalmology, General Hospital, Singapore)

As early as 1764, Morgagni, the famous She was admitted for removal of the nucleus, anatomist wrote in his book "The seats and and was given local steroids and i % pilocar- causes of disease" about hypermature cataracts pine drops to the left eye every 6 hours. in the elderly. This is a type of hypermature The eye was examined daily and no change cataract which is still known by his name-the or increased tension was seen. Morgagnian cataract. On 24th. January, the nucleus was removed In 1900, Gifford described four cases of hy- through a superior limbal section with a von permature cataract resulting in "spontaneous Greafe's cataract knife extending for about 3 cure". Of these, only one retained vision and of the circumference of the limbus, after a pre - the other three were blinded by secondary glau- placed suture was inserted. coma. Since this description there were scatter- A small peripheral iridotomy was done and ed reports in the ophthalmic literature of spon- the nucleus of the lens removed without diffi- taneous rupture of the anterior capsule of the culty with a vectis, which was inserted behind hypermature cataract, with expulsion of the the nucleus and lifted it gently against the pos- contents of the lens into the anterior chamber. terior surface of the in order to However, lens induced uveitis and secondary manoeuvre it out through the section. The pre - glaucoma due to hypermaturity gained some placed suture was tied and air was injected into prominence in recent reports. the anterior chamber. In 1948, Sugar reported three cases of glau- The post -operative period was uneventful. coma following rupture of the lens capsule. In On the 4th. February, a right simple intra - 1953 Hubbersty and Gourlay described 4 cases capsular extraction of the lens with peripheral of rupture of the anterior lens capsule, 3 of iridotomy and the use of alpha-chymotrypsin which presented as psuedo-hypopyon with was done without difficulty. Except for a mild raised intraocular tension as a result of the flow striate keratitis which persisted for three days, of liquified cortex into the anterior chamber, the post operative period was uneventful. She and one with the nucleus expelled into the bot- was discharged on the 15th. February. tom of the anterior chamber. On the 19th. March, a refraction was done and the findings were as follows : CASE REPORT right: +4.50 dioptres sphere = 6/9 B. B., a Malay female, age 50 years was first +4.00 dioptres cylinder, 165° seen at the Ophthalmic Department, General Hospital, on the 18th. January 1963 with a his- left : +7.00 dioptres sphere = count- tory of defective vision of her left eye associa- +2.50 dioptres cylinder, 175° ing ted with discomfort for 2 weeks. fingers at 3 On examination she had visual acuity of V. metres. R., hand movements V.L. perception of light. The cause of defective vision of her left eye Her right eye was normal with good projec- was found to be due to simple (primary) optic tion of light except for a dense almost matured atrophy of unknown etiology. cataract. DISCUSSION Her left eye was slightly congested and ten- Hypermaturity of cataracts will probably be- der. The anterior capsule of the lens was rup- come a progressively important problem be- tured and the nucleus was seen suspended at cause of our aging population. Although pre- the (figures I to iii). The tension was nor- ventable, it was not infrequently seen : often mal. Slit lamp microscopy showed a few cells it was due to neglect and sometimes the deli- in the anterior chamber and no other abnor- berate refusal by an elderly patient to have an mality. operation because the other eye is seeing well. SEPTEMBER, 1963 128

Hypermaturity leads to a variety of compli- to prevent the frequent refusal for further cations which are often severe and result in operation after the vision of one eye has been blindness. These include spontaneous disloca- restored. The author does not consider this the tion of the lens, glaucoma due to intumescence answer to the problem as simultaneous opera- of the lens, lens induced uveitis or phacolytic tions expose the patient to the danger of post- glaucoma due probably to minute leak of the operative complications occurring in both lens capsule, a definite anterior rupture of the together with possible disastrous results. lens capsule resulting in pseudo-hypopyon of Once cortical material or the nucleus being expelled the stage of hypermaturity is reached, ìt becomes into the anterior chamber. Rarely, such a hy- necessary to remove the lens as soon as permature cataract is cured spontaneously by possible. The author stresses that the time required gradual absorption without complications, pro- for a cataract to develop to hyperma- turity bably as a result of minute posterior capsular varies considerably and since the stage of ruptures. maturity merges into hypermaturity without any change in its symptoms, too often the pa- Anterior rupture of the capsule with expul- tient with hypermature lens presents only after sion of the lens matter is rare. Only a few cases complications have become established. It fol- have been reported in the ophthalmic literature. lows that the only effective way to prevent these The clinical picture after rupture depends large- complications is to anticipate the complications ly on the site and the size of the rupture, and and to remove the lens early. In fact, as early the contents of the lens. A rupture of the an- as 1900, Gifford stressed the importance of pre- terior capsule of a hypermature intumescent or vention of hypermaturity of cataracts by early Margognian cataract will result in the milky treatment. homogenous fluid cortical matter with nume- rous cholesterol crystals flowing into the ante- TREATMENT rior chamber often a causing secondary glau- Despite the knowledge of the dangers of hy- coma. It presents with the signs and symptoms permature cataracts, time and again this of acute im- congestive glaucoma, with pain, con- portant problem presents to the ophthalmolo- gestion, headache, and raised intraocular ten- gists. The treatment depends largely on whether sion. It also presents a pseudo-hypopyon. The there is an associated complication. diagnosis is generally not difficult, although it may appear superficially to be an intraocular 1. Hypermaturity without infection with hypopyon. A paracentesis is complication often useful not only for diagnostic purposes, The lens should be removed as soon as pos- but also for lowering the raised tension. sible. The method of extraction is usually intra - capsular, but is partly dependent on the type A rupture of the anterior capsule of a hyper - of hypermaturity. mature cataract where the liquified cortex has been absorbed leaving only a shrunken nucleus i. Intumescent cataract. This has to be dif- will result in expulsion of the nucleus into the ferentiated from intumescence due to a anterior chamber. In a report of four cases, maturing cataract. In both cases the an- Hubbersty and Gourlay (1953) described one terior chamber is narrowed as a result such case. of increase in size of the lens. In the former the cortex is a homogenous This case report is of particular interest not white fluid with no shadow, com- only because it is rare for hypermature catar- pared to the irregular radial opacities acts to present with rupture of the anterior cap- of the latter, usually with an iris sha- sule resulting in the expulsion of the nucleus dow. into the anterior chamber, but also because ii. Morgagnian cataract. The cortical there is no in sub- record the ophthalmic literature stance has liquified and the of an small nu- expelled nucleus being caught and sus- cleus has sunk to the bottom pended at the pupil! of the lens. Its appearance varies depending Since Hypermaturity of a cataract is often a on the amount of liquified cortex and cause of serious complications and is prevent- this in turn is probably related to the able by early operation, it is emphasised that degree of capsule permeability. it becomes the duty of ophthalmologists to take iii. The hypermature cataract with shrunken deliberate steps to prevent cataracts from reach- nucleus. This is due to absoption of the ing that stage. Duthie has advocated operating liquified cortex, leaving a hard shrunk- on both cataracts simultaneously in these cases, en disciform nucleus. I29 SINGAPORE MEDICAL JOURNAL

SCLERA

SUSPENSORY LIGAMENT IRIS ANTERIOR CHAMBER CORNEA NUCLEUS OF LENS CAPSULE OF LENS

Fig. 1.

i

Fig. 2. Fig. 3.

Figures I 3 show the nucleus of the lens being suspended at the pupil. SEPTEMBER, 1963 130

Of these, the intumescent cataract is probably are best left alone and in anterior dislocations. the commonest. As already stated it is impor- there is no choice except to remove the lens. tant to exclude intumescence due to a maturing at once. cataract. In the latter, the suspensory ligament When i. often strong, as compared to the former the capsule is ruptured anteriorly and a pseudo-hypopyon liquified where it is weak and intracapsular extraction of cortical mate- rial floods the anterior chamber, a performed without difficulty. However, the paracentesis. sec- should be done urgently to lower the raised tion should be fully 180° and because of the tension and to remove the lens material. Alter- tenseness of the capsule, it is generally not pos- natively a small limbal section may be neces- sible to grip the capsule with intracupsular for- sary to enable the removal of the nucleus, ceps. Several techniques are used to overcome which is generally small in these cases. Similar- this difficulty. The author has found the fol- ly, if the nucleus is expelled anteriorly into the lowing very practical and easy : anterior chamber, it should be removed through a small section at the limbus. The author found i. The capsule can be punctured with a fine a small vectis very useful for scooping the lens needle at the site where the forceps will gently against the posterior surface of the cor- be applied later. The lens material will nea in order to manoeuvre it out of the flood the anterior chamber, which wound. The technique used in this case should be washed out before applica- presented no difficulty operation and there tion of the forceps. The intralenticular at were no post operative tension will be reduced and the capsule complications. can be grasped over the site of punc- ture to prevent further loss of lens ma- SUMMARY terial during extraction. I. An extremely rare case of anterior rupture ii. Another technique is to apply the eriso- of the capsule of a hypermature cataract phake over the site where the forceps resulting in the expulsion of the nucleus will be applied later. This will often which was caught and suspended at the eleviate a knuckle of capsule sufficient pupil was described. for it to be grasped by the forceps. 2. The types, complications and treatment of iii. Alternatively, the lens can be removed hypermature cataracts were briefly discuss- solely with the erisophake. The author ed with special reference to the case report. prefers this technique, but for ophthal- 3. The author stressed the importance of pre- mologists who do not use this instru- vention of hypermature cataracts by early ment it may be wise to avoid this removal when hypermaturity is anticipated technique. as the only definite method to prevent its.

serious complications : and if hypermaturi- Excellent results can also be attained with ty without complications presents to oph- extracapsular extraction, the main disadvan- thalmologists, the lens should be removed tage is the post possible -operative development as soon as possible. of a lens induced uveitis.

The Morgagnian cataract and the hyperma- R EFERENCES ture cataract with shrunken and hardened lens I. Casnell, G.W. (1958), Complications and treat- usually can be extracted intracapsularly with ment of the hypermature cataract, Transaction the erisophake without difficulty. of O.S.U.K., 98, 3. 2. Cook, C. (1958), Some pathological aspects of the complication associated with the hypermature 2. Hypermaturity with Complications lens, Transaction of O.S.U.K.. 98. 9. The most common complications are glau- 3. Hubbersty and Gourley (1953), Secondary glau- coma and uveitis. In both cases the complica- coma due to spontaneous rupture of the lens tions should be treated urgently by the usual capsule, B.J.O., 37, 432. methods of lowering the intraocular tension, 4. Gifford, H. (1900), The danger of the spontaneous with intravenous urea if necessary and the cure of senile cataract, A.J.O., 17, 289. uveitis controlled with steroid therapy. In 5. Stallard, H.B. (1957), Eye Surgery, 3rd. Edition. both Wright. cases, since the source of complication is the hypermaturity, the lens 6. Sugar, H.S. (1949), Acute Secondary Glaucoma should be removed as due to spontaneous rupture of the lens cap- soon as it is safe to do so. Posterior dislocations sule, A.J.O., 32, 1512.