|Year : 2022 | Volume
| Issue : 2 | Page : 195-197
Traumatic phacocele – A rare case of lens dislocation
K Rajasekar, M Sangamithira, Rohini Krishnan, Sivakalai Ramakrishnan, Aswathi Vedalmaji
Department of Vitreo-Retina, Regional Institute of Ophthalmology and Govt. Ophthalmic Hospital (RIOGOH), Chennai, Tamil Nadu, India
|Date of Submission||20-Jan-2022|
|Date of Decision||06-Apr-2022|
|Date of Acceptance||11-Apr-2022|
|Date of Web Publication||30-Jun-2022|
Regional Institute of Ophthalmology and Govt. Ophthalmic Hospital (RIOGOH), Chennai- 600 008, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Traumatic phacocele is a rare case of lens dislocation following blunt trauma with only a few case reports in the literature. The risk of phacocele following blunt trauma is escalated in elderly patients due to increased scleral rigidity and hard nucleus. We report a case of a 70-year-old lady who sustained blunt trauma to her left eye with a wooden stick. On examination, a subconjunctival mass was noted with surrounding subconjunctival haemorrhage in the superonasal position in the left eye. The anterior segment showed left eye corneal oedema with total hyphaema and the fundus showed no view due to total hyphaema. B-scan ultrasonography of her left eye showed a vitreous haemorrhage with retinal detachment. Wound exploration was done and the lens was removed. Suturing of the scleral defect was also done. Postoperatively she had the perception of light. The visual outcome depends on timely management and associated ocular complication.
Keywords: Blunt trauma, phacocele, scleral rupture, subconjunctival mass
|How to cite this article:|
Rajasekar K, Sangamithira M, Krishnan R, Ramakrishnan S, Vedalmaji A. Traumatic phacocele – A rare case of lens dislocation. TNOA J Ophthalmic Sci Res 2022;60:195-7
|How to cite this URL:|
Rajasekar K, Sangamithira M, Krishnan R, Ramakrishnan S, Vedalmaji A. Traumatic phacocele – A rare case of lens dislocation. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Aug 12];60:195-7. Available from: https://www.tnoajosr.com/text.asp?2022/60/2/195/349505
| Introduction|| |
Phacocele is a rare consequence of severe trauma that involves the dislocation of the crystalline lens into the subconjunctival or subtenon region. The term phacocele comes from the Greek words phaco, which means lens, and kele, which means hernia. It occurs following indirect rupture of the sclera as a result of blunt trauma. Fejer reported the first case in 1928. Phacocele is an uncommon condition that accounts for less than 13% of all dislocations. Following blunt trauma, an elderly person with increased scleral rigidity along with a hard nucleus is more prone to develop phacocele. Previous ocular surgeries, scleritis and connective disuse disorders are other predisposing factors for the development of phacocele.
| Case Report|| |
A 70-year-old female had a history of pain and sudden loss of vision in her left eye since 20 days. She had a history of blunt trauma to the left eye with a wooden stick preceding the vision loss. She was initially treated conservatively in a private hospital for 15 days and later referred to our hospital for further management. She had no previous ocular surgery history.
On general examination, her vitals were stable. On ocular examination, right eye visual acuity was 6/18 due to immature senile cataract, and the left eye had the perception of light only. Right eye examination showed a normal anterior segment with a senile immature cataract. Left eye examination showed an oval subconjunctival mass of size 6 × 5 mm with a well-defined border and smooth surface at 10 to 12 'o' clock position with surrounding subconjunctival haemorrhage [Figure 1]. The anterior segment showed corneal oedema with total hyphaema in the anterior chamber. Fundus showed no view due to total hyphaema. Fundus examination of the right eye was normal. Her intraocular pressure (IOP) was 18 mmHg in the right eye and 10 mmHg in the left eye.
|Figure 1: Clinical picture on presentation showing superonasal subconjunctival mass|
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B-scan ultrasonography of the left eye showed vitreous haemorrhage with retinal detachment and absent lens echoes. The patient was diagnosed with left eye post-traumatic phacocele as she had sudden visual loss following blunt trauma with acute onset of subconjunctival mass. The patient was planned for wound exploration. Under peribulbar anaesthesia, conjunctival peritomy was done from 10 to 2 'o'clock position. A cataractous lens was found subconjunctivally [Figure 2] and extracted [Figure 3]. A scleral defect was detected at 11 to 12 'o' clock position 2 mm away from the limbus [Figure 4]. 8-0 ethylon johnson and johnson sutures is inserted [Figure 5]. Postoperatively she had the perception of light in her left eye. This was presumably due to associated hyphaema, vitreous haemorrhage and retinal detachment. The need for future vitrectomy and secondary intraocular lens (IOL) was elucidated to the patient.
|Figure 4: Lens removed from 11 'o' clock position followed by scleral defect noted|
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| Discussion|| |
Phacocele is a rare condition, resulting from indirect scleral rupture of the globe. Although uncommon, this symptom can be overlooked, particularly if the patient appears several days after the accident and the lid is not everted during the inspection. McDonald and Purnall reported that the incidence of phacocele was 13% among all lens dislocations in 1951. Bhupally et al. noted one case of phacocele among 76 cases of ocular trauma in 2015. Fejér et al. concluded that the supranasal quadrant was the most common site of phacocele following blunt trauma. While a thorough clinical examination is sufficient for diagnosis, imaging tools can be used to pinpoint the accurate location of the sclera rupture. Superonasal dislocations are the most common, followed by superotemporal and inferior dislocations. Goel et al. reported a case of phacocele following administration of peribulbar anaesthesia.
For diagnosing anteriorly situated lesions, ultrasound biomicroscopy (UBM), B-scan ultrasonography (B-scan) and anterior segment optical coherence tomography (AS-OCT) imaging are well-established methods. They are also useful for determining the extent of ocular trauma and assisting with surgical planning. Surgical correction of the sclera rupture, which is often identified only during surgery, is the treatment of choice. The phacocele can be removed from its subconjunctival position with ease. For vitreous haemorrhage, adjunctive surgery such as pars plana vitrectomy is frequently required.
| Conclusion|| |
Blunt trauma is common in younger individuals and phacocele is more frequent at a later age because of the increased crystalline lens and increased scleral rigidity. Our patient had appropriate surgical intervention, which helped to maintain the globe contour, and prevented the eye from going into phthisis bulbi. This case report also emphasizes that associated ocular complications can affect the final visual outcome of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Neupane S, Das D, Korgaonkar S. Migrated subconjunctival crystalline lens: A traumatic phacocele. BMJ Case Rep 2020;13:e237014. doi: 10.1136/bcr-2020-237014.
Sindal MD, Mourya D. A rare case of traumatic posterior phacocele with retinal detachment. Indian J Ophthalmol 2016;64:89–90.
Fejér J. Subconjunctival lens dislocation. Am J Ophthalmol 1928;11:354–6.
Mrudula PM, Jyothi PT, Prabhu PB, Babitha V. Phacocele presenting as localized hematoma in a suspected case of traumatic occult scleral rupture. Kerala J Ophthalmol 2018;30:51-3. [Full text]
Mcdonald PR, Purnell JE. The dislocated lens. J Am Med Assoc 1951;145:220–6.
Bhupally AK, Chigiri SS, Swathi M, Rohini M, Shruthi T. Ocular trauma. Int J Res Med Sci 2017;3:3714–9.
Cherry PM. Indirect traumatic rupture of the globe. Arch Ophthalmol 1978;96:252–6.
Goel N. Displacement of crystalline lens into the sub-conjunctival space following periocular anesthesia. Saudi J Ophthalmol 2018;32:257-60.
Vodapalli H, Murthy SI, Jalali S, Ali MJ, Rani PK. Comparison of immersion ultrasonography, ultrasound biomicroscopy and anterior segment optical coherence tomography in the evaluation of traumatic phacoceles. Indian J Ophthalmol 2012;60:63-5.
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