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PHOTO ESSAY
Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 104-105

Traumatic subtle anterior subluxated lens with impending pupillary block


Department of Glaucoma, Aravind Eye Hospital and Postgraduate Research Institute, Madurai, Tamil Nadu, India

Date of Submission26-Sep-2021
Date of Decision15-Oct-2021
Date of Acceptance16-Oct-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Sharmila Rajendrababu
DNB, Glaucoma Consultant, Department of Glaucoma, Aravind Eye Hospital and Postgraduate institute of ophthalmology, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_145_20

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How to cite this article:
Rajendrababu S, Senthilkumar VA. Traumatic subtle anterior subluxated lens with impending pupillary block. TNOA J Ophthalmic Sci Res 2022;60:104-5

How to cite this URL:
Rajendrababu S, Senthilkumar VA. Traumatic subtle anterior subluxated lens with impending pupillary block. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Jun 29];60:104-5. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/104/340354



Subluxation of the lens is usually difficult to identify on routine examination unless obvious clinical signs are identified by meticulous ocular examination. Simple gonioscopic examination supplemented with anterior segment imaging techniques will help in earlier identification of subtle subluxation. We report an unusual presentation of a 30-year-old young male who presented with sudden-onset painless, defective vision in the right eye (oculus dextrus [OD]) for 72 h. He gave an alleged history of accidental injury with elbow of his 2-year-old son while playing. On examination, best-corrected visual acuity OD was 6/60, improving to 6/6 with -5D spherical correction and intraocular pressure (IOP) OD was 24 mmHg. Anterior segment evaluation revealed clear cornea, shallow chamber with variable depth (Van Herick grading, VH1-2), causing a near iridocorneal touch inferiorly [Figure 1]b. Pupil was 5 mm sluggishly reacting to light with traumatic sphincter atropy at 5–6'o clock position [Figure 1]a and with a slightly anteriorly subluxated lens causing total angle closure as seen on gonioscopy [Figure 1]c. No obvious phacodonesis was observed. Detailed posterior pole and peripheral retinal evaluation certainly excluded choroidal rupture, retinal tear in OD. Other eye findings were unremarkable. High-frequency ultrasound biomicroscopy (UBM) OD revealed shallow anterior chamber depth, anterior lens subluxation involving the inferior 4–6 clock hours associated with zonular damage and iridolenticular contact [Figure 1]d. The patient was diagnosed to have blunt trauma-induced anterior subluxated lens with impending pupillary block. Immediately, he underwent Nd:YAG laser peripheral iridotomy to avoid the occurrence of pupillary block and was started on ocular hypotensive drugs. However, in view of persistent high IOP and myopic shift of lens causing visual impairment an incisional surgery was planned.
Figure 1: (a) - Diffuse illumination image of the right eye showing traumatic sphincter atropy at 5–-6'o clock position (white arrowhead) and traumatic mydriasis,. (b)- slit- lamp image showing shallow anterior chamber with variable depth with anteriorly subluxated lens,. (c)- gonio image showing completely occludable angles with anteriorly subluxated lens,. (d)- ultrasound biomicroscopyUBM image anterior lens subluxation involving the inferior 4–-6 clock hours with associated zonular damageand iridolenticular contact (white arrow showing the areas of zonular damage) with impending pupillary block

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Ocular lens dislocation occurs most commonly due to trauma. Approximately 30% of serious eye injuries involve damage to the lens.[1] Blunt trauma compresses the eye in the anterior-posterior direction causing expansion of the eye laterally, superior, and inferiorly, stretching the zonules which hold the lens. Symptoms of lens dislocation include reduced visual acuity, poor near and distant vision, and monocular diplopia. Lens subluxation into the AC may lead to corneal edema, pupillary block glaucoma, or anterior uveitis.[1],[2]

Subtle subluxation of the lens is sometimes missed on routine examination when there is no obvious phacodonesis seen and may often cause intraoperative surprises during routine cataract surgery. Ocular imaging with anterior segment optical coherence tomography and UBM may help in early identification and also in planning the appropriate surgery. Extent of zonular laxity and anterior lens subluxation was assessed by UBM (4Sight Accutome by Keeler Plus, USA) in our patient. The high-resolution mode was used for detailed analysis, and gain was adjusted to obtain artifact-free images. Inbuilt tools such as calipers and A-scan mode were applied for further image analysis. A thorough evaluation of the lens position on axial sections was performed, and the presence of zonular tears and/or zonular stretching was noted.

While phacoemulsification and use of capsular support devices may be sufficient for partial subluxation, vitreoretinal surgery in the form of pars plana vitrectomy is necessary in cases of complete dislocation. Scleral or iris fixated IOLs may be a primary surgical option or as a secondary procedure depending on the complexity of the case.[3] Refractory glaucoma, persistent uveitis, or corneal damage is indications for urgent or emergent intervention.[4]

We present this case to highlight the plausibility of a trivial injury increasing the risk of lens subluxation ultimately leading to a vision-threatening pupillary block. Meticulous clinical examination with gonioscope and UBM is helpful in early identification of subtle signs of subluxation and prompt management to avoid needless blindness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Inatani M, Tanihara H, Honjo M, Kido N, Honda Y. Secondary glaucoma associated with crystalline lens subluxation. J Cataract Refract Surg 2000;26:1533-6.  Back to cited text no. 1
    
2.
Kawashima M, Kawakita T, Shimazaki J. Complete spontaneous crystalline lens dislocation into the anterior chamber with severe corneal endothelial cell loss. Cornea 2007;26:487-9.  Back to cited text no. 2
    
3.
Choi DY, Kim JG, Song BJ. Surgical management of crystalline lens dislocation into the anterior chamber with corneal touch and secondary glaucoma. J Cataract Refract Surg 2004;30:718-21.  Back to cited text no. 3
    
4.
Salehi-Had H, Turalba A. Management of traumatic crystalline lens subluxation and dislocation. Int Ophthalmol Clin 2010;50:167-79.  Back to cited text no. 4
    


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