Optometry Dx: Something In The Way

Slideshow

  • Figure 1. This slit lamp image shows the right eye of a 77-year-old patient with anterior uveitis and a history of glaucoma and cataract surgery. Can anything in his history or the photo explain the likely reason for his late anterior uveitis events?

  • Figure 2. This gonioscopic image shows the patient’s presentation.

A 77-year-old man presented to the clinic 2 years after undergoing bilateral cataract surgery. His medical history included type 1 diabetes and bilateral primary open-angle glaucoma. During the past 2 years, his glaucoma has progressed in both eyes, but more so in the right. He’s also experienced cystoid macular edema (CME) in the right eye and 2 episodes of recurrent anterior uveitis — each a year apart, and both in the right eye. He has had 2 ophthalmologic consultations about the anterior uveitis in the right eye, with findings presented from the most recent consult (Figures 1 and 2). 

Retained lens fragments in the anterior chamber are rare, but can present problems even years after cataract surgery. The complication can lead to corneal edema or iritis, or both. Nuclear fragments are usually more problematic than cortical fragments.1 In a...

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Retained lens fragments in the anterior chamber are rare, but can present problems even years after cataract surgery. The complication can lead to corneal edema or iritis, or both. Nuclear fragments are usually more problematic than cortical fragments.1 In a large 1000-patient 3-year study performed by a single surgeon, a total of 65 nuclear fragments were found; some after phacoemulsification but before aspiration of the viscoelastic material. During irrigation and aspiration, 17 eyes still had fragments, and following irrigation and aspiration, only 5 eyes still had fragments.2 

A Duke University study shows 54 patients who retained lens fragments in the anterior chamber. The lens fragments were primarily located inferiorly and, in 13% of cases, required gonioscopy for diagnosis.3 This demonstrates that lens fragments may remain hidden in the posterior chamber for years, and can eventually migrate into the anterior chamber causing corneal edema or an iritis.3 The patient in this case was diagnosed with migrating lens fragments. 

Another study looked at 16 patients at Bascom Palmer who had nuclear fragments. A third of them had fragments that were not seen at all on slit lamp examinations.4 Gonioscopies were required to identify these fragments. The researchers there suggested gonioscopy for any patient with unresolved iritis or corneal edema that occurs postoperatively — even in the case of iritis or corneal edema that occurs years after cataract surgery. Researchers suggest these events are likely due to migration of trapped lens particles from the posterior chamber to the anterior chamber.4-6

Matthew Garston, OD, is an adjunct professor at the New England College of Optometry and was a senior staff optometrist in the medical department at MIT for 43 years.

References

1. Moisseiev E, Kinori M, Glovinsky Y, Loewenstein A, Moisseiev J, Barak A. Retained lens fragments: nucleus fragments are associated with worse prognosis than cortex or epinucleus fragments. Eur J Ophthalmol. 2011;21(6):741-7. doi:10.5301/EJO.2011.6483

2. Dada VK, Sharma N. Dada T. Retained nuclear fragments (letter). J Cataract Refract Surg. 2000:26:1106-7. doi:10.1007/s10792-008-9279-2

3. Zadovni Z, Meyer J. Kim T. Clinical features and outcomes of retained lens fragments in the anterior chamber after phacoemulsification Am J Ophthalmol. 2015;160(6):1171-1175.e1. doi:10.1016/ajo2015.08.019.

4. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmol. 2006;113(11):1949-1953. doi:10.1016/j.ophtha.2006.03.066

5. Norton J, Goyal S. Patient characteristics and outcomes of retained lens fragments in the anterior chamber after uneventful phacoemulsification. J Cataract Refract Surg. 2018;44:848-855. doi:10.1016/j.jcrs.2018.03.034

6. Kang HM, Park JW,Chung EJ. A retained lens fragment induced anterior uveitis and corneal edema 15 years after cataract surgery. Korean J Ophthalmol. 2011;25(1):60-62. doi:10.3341/kjo.2011.25.1.60

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