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Delayed presentation of post-traumatic pseudo-phacocoele
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  1. Devesh Kumawat,
  2. Anusha Sachan,
  3. Pranita Sahay,
  4. Vinod Kumar
  1. All India Institute of Medical Sciences, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, Delhi, India
  1. Correspondence to Dr Pranita Sahay, drpranitasahay{at}gmail.com

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Description 

A 58-year-old man presented with complaint of sudden onset painless loss of vision in the left eye for the past one month. The patient had undergone small incision cataract surgery in the left eye 4 years ago. There was history of diminution of vision following closed globe injury with cow’s horn 6 months back, for which no ophthalmic intervention was obtained. The patient had complained of foreign body sensation in the left eye for the past few months. Currently, the visual acuity in left eye was finger counting close to face. The slit-lamp examination revealed superior limbal surgical scar, an opacified vitreous sheet in anterior chamber extending into the wound, superior iris defect with an up drawn pupil and aphakia with no visible capsular support (figure 1). To our surprise, a multipiece intraocular lens (IOL) was noted in the subconjunctival space superiorly with prolapse of one haptic over the conjunctiva (figure 2A, B). On fundus evaluation, inferior rhegmatogenous retinal detachment involving up to the macula was noted. No capsular remnant was observed around the IOL. Juxta-limbal conjunctival pigmentation was noted with no definite scleral wound dehiscence.

Figure 1

Slit-lamp photograph of the left eye of a 58-year-old man. Superior limbal scarring, up drawn pupil, vitreous in wound and aphakia can be noted.

Figure 2

Diffuse slit-lamp examination (A) in the inferior gaze shows a multipiece intraocular lens in the subconjunctival space superiorly with prolapse of one haptic on to the limbus. The second haptic lies in the subconjunctival space. Slit image (B) better demonstrates the subconjunctival location of the intraocular lens. Apart from the conjunctival pigmentation, no obvious scleral wound is visible.

A diagnosis of post-traumatic pseudo-phacocoele with rhegmatogenous retinal detachment was made. The patient had a self-sealed scleral wound, which was incidentally detected late after trauma due to associated retinal detachment. The patient underwent IOL removal after localised superior peritomy incision. No scleral dehiscence could be noted in the bed as posterior as the equator. In the same setting, vitrectomy was performed with silicone oil infusion for the retinal detachment. Postoperative best-corrected visual acuity of 20/200 was noted at 1-month follow-up with retina well attached. Silicone oil removal has been planned for the patient after 3 months of follow-up. Phacocoele or dislocation of crystalline lens into the subconjunctival or subtenon space after blunt ocular trauma is well reported in literature.1 It usually occurs in the superior quadrant in older patients with increased scleral rigidity and hardness of crystalline lens.1 The scleral rupture wound is often noted with associated uveal tissue prolapse.1 Pseudo-phacocoele or dislocation of IOL into the subconjunctival or subtenon space is a rare occurrence after blunt ocular trauma.2 3 It is usually detected immediately after trauma due to associated visual loss, hyphaema or subconjunctival haemorrhage. In our case, previous scleral wound from cataract surgery may have opened up and led to dislocation of IOL. Since it was 6 months after trauma at the time of presentation to us, the wound may have sealed spontaneously with time.

This case highlights a rare consequence of blunt ocular trauma. A high index of suspicion for crystalline lens or IOL dislocation into the subconjunctival space should be kept in mind while examining cases of post-traumatic aphakia.

Learning points

  • Pseudo-phacocoele should be suspected in cases of post-traumatic aphakia.

  • Previous scleral surgical scar or wound may be a risk factor for pseudo-phacocoele after ocular trauma.

References

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Footnotes

  • Contributors DK and VK: substantial contributions to the conception/design of work; acquisition, analysis, interpretation of data; drafting the work; final approval of the version; agreement to be accountable for all aspects of work. AS and PS: acquisition, analysis, interpretation of data; drafting the work; final approval of the version; agreement to be accountable for all aspects of work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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