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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 399-400

Lights, camera, action: Sparkling and twinkling X-mass tree cataract through the eyes of a Scheimpflug imaging and anterior segment optical coherence tomography


1 Medical Officer, Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
2 Medical Officer, Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
3 Chief Medical Officer, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
4 Head of the Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India

Date of Submission01-Feb-2021
Date of Acceptance18-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Prasanna V Ramesh
Mahathma Eye Hospital Private Limited, No 6, Tennur, Seshapuram, Trichy - 620 017, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_266_21

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  Abstract 


Keywords: AS-OCT, Christmas tree cataract, Scheimpflug imaging


How to cite this article:
Ramesh PV, Ramesh SV, Rajasekaran R, Ramesh MK. Lights, camera, action: Sparkling and twinkling X-mass tree cataract through the eyes of a Scheimpflug imaging and anterior segment optical coherence tomography. Indian J Ophthalmol Case Rep 2021;1:399-400

How to cite this URL:
Ramesh PV, Ramesh SV, Rajasekaran R, Ramesh MK. Lights, camera, action: Sparkling and twinkling X-mass tree cataract through the eyes of a Scheimpflug imaging and anterior segment optical coherence tomography. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:399-400. Available from: https://www.ijoreports.in/text.asp?2021/1/3/399/320003



Christmas tree cataract is a rare type of lenticular opacity. The name explains its nomenclature; since the brightness and variety of colours refer to the ornaments that commonly decorate the Christmas tree.[1] It is characterised by polychromatic needle-shaped deposits in the deep cortex and nucleus, which may be isolated or associated with other opacities.[2] In this scenario, it is associated with cataractous changes with a unilateral presentation, though it can present asymmetrically bilateral too.[3]

An 80-year old gentleman, a known case of myotonic dystrophy, complained of low visual acuity in both eyes (OU). On examination, best-corrected visual acuity was 20/40 in OU. Slit-lamp examination revealed Christmas tree cataract with immature senile cataract [Figure 1] in OD, whereas OS examination revealed only cataractous features with posterior segment of OU being normal.
Figure 1: (a-c) Slit-lamp photography of the anterior segment in diffuse illumination showing highly reflective, polychromatic and needle-shaped opacities in OD

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There are still many unresolved controversies regarding the optical properties of the highly refringent multi-coloured needles. Hayes and Fisher state that the images formed are the result of light diffraction, whereas Pau and Förster suggested that the composition of the opacities would mostly be cholesterol.[4] Another literature suggested cystine as the substance related to the formation of these opacities which are typical of cataract.[5] Hence, the objective of this manuscript was to throw light to the lacunae in literature, by describing the Scheimpflug [Figure 2] and Anterior Segment Optical Coherence Tomography (AS-OCT) [Figure 3] imaging features of the Christmas tree cataract. To our knowledge, these features have not been reported in literature before.
Figure 2: (a-d) Scheimpflug imaging at different sections revealing the crystal deposits (red arrows) in various zones of the cataractous lens in OD

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Figure 3: (a) Infrared images of the anterior segment showing the sections (green arrows) of anterior segment OCT taken. (b-d) AS-OCT of the Christmas tree cataract showing hyper-reflective regions in various zones of the lens in OD

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As this is a novel method of visualising such rare scenarios, further additional biochemical analysis and workup of the Christmas tree cataract along with the crystals after extra-capsular extraction will be required with electron microscopy, energy-dispersive X-ray microanalysis and micro-spectroscopy.[5] The highly refractive multi-coloured needle material on slit-lamp examination is visualised as hyper-reflective spots within the lens matter on AS-OCT [Figure 3]. In the inverse colour of Scheimpflug imaging, the cataractous material is seen as dark spots with few crystals presenting with back shadows [Fig. 2a], whereas the remaining ones didn't, which suggests that each crystal optically behaves differently suggesting the possibility of different materials involved in their formation.


  Discussion Top


Though rare, Christmas tree cataract is known to throw surprises in clinical examination or during the time of surgery, significantly affecting the view of the surgeon. Hence, good pre-operative densitometry assessment of the Christmas tree cataract using Scheimpflug technology can effectively reduce phacoemulsification time and yield better outcomes.[6] Better understanding of the morphology and densitometry of these rarer cataracts by utilising these technologies will help optimise phacoemulsification settings, rather than necessitating intraoperative adjustments.

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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hayes BP, Fisher RF. Ultrastructural appearances of a lens with marked polychromatic lustre: Evidence for diffraction as a cause. Br J Ophthalmol 1984;68:850-8.  Back to cited text no. 1
    
2.
Brown NP, Bron AJ. Lens Disorders: A Clinical Manual of Cataract Diagnosis. 3rd ed. Oxford: Butterworth-Heinemann; 1996.  Back to cited text no. 2
    
3.
Kobayashi Y, Suzuki T. The aging lens: Ultrastructural changes in cataract. In: Bellows JG, editor. Cataract and Abnormalities of the Lens. New York: Grune & Stratton; 1975. p. 313-43.  Back to cited text no. 3
    
4.
Pau H, Förster H. Double refraction of crystals in the lens (spheroliths, “Christmas tree ornaments") and in the vitreous body (Scintillatio nivea). Graefes Arch Clin Exp Ophthalmol 1982;219:295-7. German.  Back to cited text no. 4
    
5.
Shun-Shin GA, Vrensen GF, Brown NP, Willekens B, Smeets MH, Bron AJ. Morphologic characteristics and chemical composition of Christmas tree cataract. Invest Ophthalmol Vis Sci 1993;34:3489-96.  Back to cited text no. 5
    
6.
Grewal DS, Grewal SP. Clinical applications of Scheimpflug imaging in cataract surgery. Saudi J Ophthalmol 2012;26:25-32.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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