CONSULTATION SECTION
Cataract Surgical Problem Edited by Rupert Menapace, MD
The right eye of a 70-year-old man suffered blunt trauma during a fist fight. Ten days later, the man presented to his local ophthalmologist with pain, particularly when reading and when lying face-down. The examination showed a residual hyphema, a very flat anterior chamber, a slightly decentered crystalline lens with anterior subcapsular freckles, and a central posterior subcapsular cataract. No lentodonesis was detected, even when knocking on the limbus. The pupil was somewhat dilated and reacted poorly to light. Retroillumination of the iris showed church-window pigment defects along the pupillary margin superiorly and nasally. The intraocular pressure (IOP) was 40 mm Hg, which prompted peripheral laser iridotomy. The IOP was controlled by applying full topical therapy and additional oral acetazolamide therapy. The corrected distance visual acuity (CDVA) in the right eye was 20/100. Refraction was +1.0 diopter (D) in both eyes, the axial length (AL) was 23.8 mm (ultrasound) in the right eye and 23.4mm (laser interferometry) in the left eye, and B-scan ultrasound and optical coherence tomography (OCT) showed an attached retina and a normal macula. The anterior chamber depth (ACD) in the right eye was only half of that in the left eye (Figures 1 and 2), 1.08 mm versus 2.16 mm, respectively, measured using anterior chamber OCT (Figure 3). What additional examination would you consider preoperatively, what adversities would you expect
Figure 1. The appearance of the right eye 2 weeks after blunt trauma.
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during surgery, and what surgical strategies and techniques might be needed to cope with these adversities?
- The clinical characteristics of the case, particularly the combination of a very flat anterior chamber and high IOP, are suggestive of ciliary block glaucoma, also known as malignant glaucoma. This situation is most frequently seen after trabeculectomy; although it is rare, posttraumatic malignant glaucoma also has been reported.1 The pathophysiology of ciliary block glaucoma is not fully understood. It is assumed to be caused by the misdirection of aqueous humor into the vitreous cavity, where it accumulates behind the iris and lens instead of following its normal pathway. The anterior rotation of the ciliary body is thought to cause the misdirection of the aqueous humor. The accumulation causes flattening of the anterior chamber and secondary angle closure. Ultrasound biomicroscopy (UBM) imaging has been used to confirm that in malignant glaucoma the ciliary body is rotated anteriorly,2 and it is needed in this case to confirm the diagnosis. The treatment of ciliary block glaucoma is controversial and challenging. As was done in this case, the first step is to lower the IOP. In a minority of cases, medical treatment, such as intravenous acetazolamide and hyperosmotic mannitol, can reduce aqueous humor production and reduce the vitreous volume, thus inducing posterior movement of the lens–iris diaphragm. Although laser iridotomy is generally performed, it is usually unsuccessful at releasing the aqueous humor trapped in the vitreous fluid. In this posttraumatic case, the classic treatment of ciliary block glaucoma is indicated, which is combined conventional transconjunctival sutureless vitrectomy and phacoemulsification.3 The surgery begins with placement of 23-gauge pars plana infusion and instrument cannulas. The anterior chamber then is filled with an ophthalmic viscosurgical device (OVD) through the side port for the phacoemulsification. Cataract surgery is then performed in a classic manner through a 2.2 mm clear corneal incision (CCI). Although this is a posttraumatic cataract, the risk for complications during phacoemulsification is not likely to be increased because no lentodonesis was observed http://dx.doi.org/10.1016/j.jcrs.2015.04.010 0886-3350
CONSULTATION SECTION
1115
Figure 2. The reduced ACD seen with oblique slitlamp illumination.
in the preoperative examination. A foldable hydrophobic acrylic intraocular lens (IOL) is placed in the capsular bag. A complete vitrectomy then is performed with 360-degree shaving of the vitreous base. If not already present, a posterior vitreous detachment is provoked by active aspiration using the vitrectome. The procedure can be considered successful not only if visual acuity is improved but also, and as importantly, if the IOP normalizes without the use of pressurelowering medication. Antoine P. Br ezin, MD, PhD Paris, France
Figure 3. The reduced ACD on anterior chamber OCT imaging.
REFERENCES 1. Theelen T, Klevering BJ. Malignes Glaukom nach stumpfem Bulbustrauma [Malignant glaucoma following blunt trauma of the eye]. Ophthalmologe 2005; 102:77–81 2. Wang Z, Huang J, Lin J, Liang X, Cai X, Ge J. Quantitative measurements of the ciliary body in eyes with malignant glaucoma after trabeculectomy using ultrasound biomicroscopy. Ophthalmology 2014; 121:862–869 3. Debrouwere V, Stalmans P, Van Calster J, Spileers W, Zeyen T, Stalmans I. Outcomes of different management options for malignant glaucoma: a retrospective study. Graefes Arch Clin Exp Ophthalmol 2012; 250:131–141
- All ophthalmological findings in the right eye of this patient can be attributed to the coup–contrecoup trauma inflicted by the blow of the fist. The coup–contrecoup concept originally referred to acceleration– deceleration craniofacial trauma but has also been applied to the ophthalmic setting.1 In this case, the coup caused zonular stretching and possibly partial zonulysis and iris microruptures. The contrecoup caused a forward shift of the lens–iris diaphragm and thus dilation and blockage of the pupil by the lens. It is commonly known that blunt trauma speeds up cataract formation, especially posterior subcapsular cataract.2 The high IOP can be attributed to 2 factors. One is that the blockage of the pupil causes a vicious cycle in which the ciliary body continues to produce aqueous, pushing the lens against the posterior edge of the pupil and thus blocking the circulation even more by inducing a pupillary block. The other factor is that hyphema might also impede aqueous outflow by occlusion of the trabecular meshwork. The immobile and semidilated pupil is probably caused by traumatic microruptures in the sphincter and is
J CATARACT REFRACT SURG - VOL 41, MAY 2015
Cataract Surgical Problem Edited by Rupert Menapace, MD
The right eye of a 70-year-old man suffered blunt trauma during a fist fight. Ten days later, the man presented to his local ophthalmologist with pain, particularly when reading and when lying face-down. The examination showed a residual hyphema, a very flat anterior chamber, a slightly decentered crystalline lens with anterior subcapsular freckles, and a central posterior subcapsular cataract. No lentodonesis was detected, even when knocking on the limbus. The pupil was somewhat dilated and reacted poorly to light. Retroillumination of the iris showed church-window pigment defects along the pupillary margin superiorly and nasally. The intraocular pressure (IOP) was 40 mm Hg, which prompted peripheral laser iridotomy. The IOP was controlled by applying full topical therapy and additional oral acetazolamide therapy. The corrected distance visual acuity (CDVA) in the right eye was 20/100. Refraction was +1.0 diopter (D) in both eyes, the axial length (AL) was 23.8 mm (ultrasound) in the right eye and 23.4mm (laser interferometry) in the left eye, and B-scan ultrasound and optical coherence tomography (OCT) showed an attached retina and a normal macula. The anterior chamber depth (ACD) in the right eye was only half of that in the left eye (Figures 1 and 2), 1.08 mm versus 2.16 mm, respectively, measured using anterior chamber OCT (Figure 3). What additional examination would you consider preoperatively, what adversities would you expect
Figure 1. The appearance of the right eye 2 weeks after blunt trauma.
1114
during surgery, and what surgical strategies and techniques might be needed to cope with these adversities?
- The clinical characteristics of the case, particularly the combination of a very flat anterior chamber and high IOP, are suggestive of ciliary block glaucoma, also known as malignant glaucoma. This situation is most frequently seen after trabeculectomy; although it is rare, posttraumatic malignant glaucoma also has been reported.1 The pathophysiology of ciliary block glaucoma is not fully understood. It is assumed to be caused by the misdirection of aqueous humor into the vitreous cavity, where it accumulates behind the iris and lens instead of following its normal pathway. The anterior rotation of the ciliary body is thought to cause the misdirection of the aqueous humor. The accumulation causes flattening of the anterior chamber and secondary angle closure. Ultrasound biomicroscopy (UBM) imaging has been used to confirm that in malignant glaucoma the ciliary body is rotated anteriorly,2 and it is needed in this case to confirm the diagnosis. The treatment of ciliary block glaucoma is controversial and challenging. As was done in this case, the first step is to lower the IOP. In a minority of cases, medical treatment, such as intravenous acetazolamide and hyperosmotic mannitol, can reduce aqueous humor production and reduce the vitreous volume, thus inducing posterior movement of the lens–iris diaphragm. Although laser iridotomy is generally performed, it is usually unsuccessful at releasing the aqueous humor trapped in the vitreous fluid. In this posttraumatic case, the classic treatment of ciliary block glaucoma is indicated, which is combined conventional transconjunctival sutureless vitrectomy and phacoemulsification.3 The surgery begins with placement of 23-gauge pars plana infusion and instrument cannulas. The anterior chamber then is filled with an ophthalmic viscosurgical device (OVD) through the side port for the phacoemulsification. Cataract surgery is then performed in a classic manner through a 2.2 mm clear corneal incision (CCI). Although this is a posttraumatic cataract, the risk for complications during phacoemulsification is not likely to be increased because no lentodonesis was observed http://dx.doi.org/10.1016/j.jcrs.2015.04.010 0886-3350
CONSULTATION SECTION
1115
Figure 2. The reduced ACD seen with oblique slitlamp illumination.
in the preoperative examination. A foldable hydrophobic acrylic intraocular lens (IOL) is placed in the capsular bag. A complete vitrectomy then is performed with 360-degree shaving of the vitreous base. If not already present, a posterior vitreous detachment is provoked by active aspiration using the vitrectome. The procedure can be considered successful not only if visual acuity is improved but also, and as importantly, if the IOP normalizes without the use of pressurelowering medication. Antoine P. Br ezin, MD, PhD Paris, France
Figure 3. The reduced ACD on anterior chamber OCT imaging.
REFERENCES 1. Theelen T, Klevering BJ. Malignes Glaukom nach stumpfem Bulbustrauma [Malignant glaucoma following blunt trauma of the eye]. Ophthalmologe 2005; 102:77–81 2. Wang Z, Huang J, Lin J, Liang X, Cai X, Ge J. Quantitative measurements of the ciliary body in eyes with malignant glaucoma after trabeculectomy using ultrasound biomicroscopy. Ophthalmology 2014; 121:862–869 3. Debrouwere V, Stalmans P, Van Calster J, Spileers W, Zeyen T, Stalmans I. Outcomes of different management options for malignant glaucoma: a retrospective study. Graefes Arch Clin Exp Ophthalmol 2012; 250:131–141
- All ophthalmological findings in the right eye of this patient can be attributed to the coup–contrecoup trauma inflicted by the blow of the fist. The coup–contrecoup concept originally referred to acceleration– deceleration craniofacial trauma but has also been applied to the ophthalmic setting.1 In this case, the coup caused zonular stretching and possibly partial zonulysis and iris microruptures. The contrecoup caused a forward shift of the lens–iris diaphragm and thus dilation and blockage of the pupil by the lens. It is commonly known that blunt trauma speeds up cataract formation, especially posterior subcapsular cataract.2 The high IOP can be attributed to 2 factors. One is that the blockage of the pupil causes a vicious cycle in which the ciliary body continues to produce aqueous, pushing the lens against the posterior edge of the pupil and thus blocking the circulation even more by inducing a pupillary block. The other factor is that hyphema might also impede aqueous outflow by occlusion of the trabecular meshwork. The immobile and semidilated pupil is probably caused by traumatic microruptures in the sphincter and is
J CATARACT REFRACT SURG - VOL 41, MAY 2015
