Older man experiences trauma after IOL implantation
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A 70-year-old man presented with blurry vision after sustaining trauma 6 weeks after uncomplicated phacoemulsification and IOL implantation in the left eye.
He was carrying groceries when he tripped on the steps of his front porch, experiencing facial trauma and immediately noticing blurry vision in the left eye. He denied ocular pain, photophobia, discharge, flashes, floaters, curtains in his vision or scotomas. He had no significant ocular history other than cataract surgery of the right eye. Upon review of symptoms, he denied loss of consciousness, headaches, facial pain or focal neurological deficits.
Source: William Binotti, MD, and Amal Alwreikat, MD
The patient had a medical history of arthritis, alcoholic cirrhosis, suspicion for multifocal hepatocellular carcinoma, traumatic splenectomy as a child, left renal cell carcinoma resulting in nephrectomy, and melanoma in situ of the abdomen. He was a former smoker and alcohol drinker but denied illicit drug use.
Examination
On examination, visual acuity was 20/20 in the right eye and 20/50 in the left eye. IOP 12 mm Hg in the right eye and 24 mm Hg in the left eye. External exam showed left mild periorbital ecchymosis, 2-cm brow excoriation with no active bleeding, temporal and inferior subconjunctival hemorrhage, and clumps of small pigmented material on the lashes and in the tear lake (Figure 1a). There was no corneal or conjunctival leakage on fluorescein. Of note, the inferior subconjunctival hemorrhage was slightly more pronounced inferiorly, with a darker hue to the blood; however, no leakage was noted. There was also a 3.2-mm layered hyphema (Figure 1b), visible ciliary body superiorly with no iris identified as well as a strand of blood at the interior edge of the main cataract incision. The optic nerve head appeared healthy, and the retina was attached with a limited view to the inferior retina due to hyphema. No frank vitreous hemorrhage was noted.
Ancillary testing
Head and orbit CT without contrast showed no orbital wall fractures, no globe violation, no signs of retrobulbar hemorrhage, orbital compression and no acute intracranial changes. Ultrasound B-scan showed minimal vitreous debris but no vitreous hemorrhage or retinal detachment (Figure 2).
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Traumatic eye injury
This patient had a traumatic eye injury that appeared to be a closed-globe injury based on no visible rupture, no fluorescein leakage, formed anterior chamber, IOP of 24 mm Hg and relatively good vision. However, there was a suspicious area in the inferotemporal sclera with overlying dense subconjunctival hemorrhage that raised concerns for possible open-globe injury with temporary tamponade. There was also associated traumatic hyphema and iris avulsion or possibly traumatic aniridia. Exam and ancillary testing did not show posterior segment involvement.
Management
The patient underwent open-globe exploratory surgery of the left eye. Intraoperatively, a circumferential conjunctival peritomy was performed with no evidence of scleral laceration or fluorescein leakage. Because the IOP was only mildly elevated and given the patient’s thrombocytopenia and abnormal coagulation testing secondary to his underlying liver cirrhosis, an anterior chamber washout was not performed. Postoperatively, the patient’s IOP remained stable on prophylactic brimonidine twice daily in the left eye and prednisolone four times a day in the left eye. Once the hyphema resolved, total aniridia was confirmed with intact IOL and capsular bag (Figure 3). Visual acuity 1 month postoperatively was 20/60, IOP was 15 mm Hg off drops, and there was no photophobia. An anterior chamber lavage was offered to the patient to remove central coagulated blood and improve vision; however, the patient did not want to undergo any surgery while starting his hepatocellular carcinoma treatment.
Discussion
Ocular trauma is one of the leading causes of preventable visual impairment and blindness in the world. Closed-globe injuries usually have a better visual prognosis as compared with open-globe injuries. The estimated incidence is 4.4 per 100,000 person-years. Ocular trauma predominantly affects younger male patients, mainly related to work or sports injuries. In elderly patients, the most common cause is related to falls at home. In closed-globe injuries, more than 60% of cases present with a visual acuity of 20/40 or better. It is well known that the acuity at presentation is the most important prognostic factor in predicting visual outcomes in these patients. Findings such as globe rupture, endophthalmitis, perforating injury, retinal detachment and afferent pupillary defect decrease the chances of good visual functioning in the postoperative state.
Traumatic aniridia after phacoemulsification has been reported in the literature. The hypothesis postulates that with blunt trauma, the force exerted on the globe elevates IOP, causing the cataract incision to open, iris extrusion through the wound and avulsion of the iris root. Subsequent depressurization allows the cataract incision (corneal or scleral) to self-seal, preventing dislocation of the IOL, capsular bag and subsequently the posterior structures.
It is important to rule out secondary injuries that could impede visual recovery in patients with blunt ocular trauma. Reduced extraocular motility and/or positive forced duction testing can raise suspicion for impingement of the globe or rectus muscles when associated with orbital wall fractures. A CT scan is often an accessible and quick imaging modality to assess for such orbital wall fractures and possible rectus muscle entrapment. The retina and vitreous can be secondarily involved in a closed-globe injury, resulting in retinal tear/detachment, commotio retinae or vitreous hemorrhage. Ultrasound B-scan is a useful tool to help rule out retinal detachment in patients without a clear view of the retina. In contrast, ultrasound biomicroscopy can assist in confirming cyclodialysis or iridodialysis in suspected cases. Similarly, anterior segment OCT can identify injury to structures surrounding the iris.
Aniridia not only has cosmetic implications but can directly affect a patient’s visual acuity, contrast sensitivity and depth of focus, in addition to causing symptoms such as photophobia and glare. Treatment of aniridia includes sunglasses, tinted contact lenses with imprinted iris, keratopigmentation, prosthetic iris devices, iris-lens diaphragm and capsular tension ring-prosthetic iris devices. In cases of a partial iris defect with sufficient remaining iris tissue, different iris suturing techniques are available. It is important to highlight to patients that although the initial ocular injury may completely resolve with intact vision, these eyes can be at increased risk for developing retinal detachments, cataracts and glaucoma in the future. Therefore, annual eye exams and awareness of alarming ocular signs are key to prevent secondary morbidity.
- References:
- Chao J, et al. Am J Ophthalmol Case Rep. 2022;doi:10.1016/j.ajoc.2022.101577.
- Gius I, et al. J Cataract Refract Surg. 2023;doi:10.1097/j.jcrs.0000000000001147.
- Ichioka S, et al. BMC Ophthalmol. 2022;doi:10.1186/s12886-022-02615-4.
- Kuhn F, et al. Ophthalmol Clin North Am. 2002;doi:10.1016/s0896-1549(02)00007-x.
- Lee BWH, et al. Clin Exp Ophthalmol. 2023;doi:10.1111/ceo.14232.
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- Xie HN, et al. BMC Ophthalmol. 2023;doi:10.1186/s12886-023-03105-x.
- Yang HY, et al. BMC Ophthalmol. 2022;doi:10.1186/s12886-022-02266-5.
- For more information:
- Edited by Jonathan T. Caranfa, MD, PharmD, and Angell Shi, MD, of New England Eye Center, Tufts University School of Medicine. They can be reached at jcaranfa@tuftsmedicalcenter.org and ashi@tuftsmedicalcenter.org.
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