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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 495-496

Fish-shaped anterior capsular rupture with anterior subcapsular cataract following blunt trauma in a young man: Case report


1 Cornea and Cataract Services, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India
2 Glaucoma and Cataract Services, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India
3 M & J Western Regional Institute of Ophthalmology, Ahmedabad, Gujarat, India

Date of Submission13-Sep-2020
Date of Acceptance04-Mar-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Nikunj Tank
Cornea and Cataract Services, Sitapur Eye Hospital, Sitapur - 261 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2938_20

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  Abstract 


A 20-year-old man presented with a history of blunt trauma by a rubber ball to his right eye. His visual acuity in the affected eye was 20/120 for distance and N36 for near. The lens showed anterior capsule tear with anterior subcapsular cataract, which did not progress to maturation even after 1 month. Following initial conservative management, phacoemulsification with a three-piece monofocal intraocular lens (IOL) implantation was performed and best-corrected visual acuity (BCVA) of 20/20 was achieved. This represents one of the few cases of blunt trauma presenting as an isolated anterior capsule rupture and anterior subcapsular cataract without mature cataract formation.

Keywords: Anterior capsule rupture, blunt ocular trauma, traumatic cataract


How to cite this article:
Tank N, Dixit S, Bhagat P. Fish-shaped anterior capsular rupture with anterior subcapsular cataract following blunt trauma in a young man: Case report. Indian J Ophthalmol Case Rep 2021;1:495-6

How to cite this URL:
Tank N, Dixit S, Bhagat P. Fish-shaped anterior capsular rupture with anterior subcapsular cataract following blunt trauma in a young man: Case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:495-6. Available from: https://www.ijoreports.in/text.asp?2021/1/3/495/320027



Anterior capsule rupture is commonly seen after penetrating ocular injuries due to direct damage to lens capsule by the object. After blunt trauma, posterior capsule rupture has been more frequently described in the literature.[1],[2],[3],[4] An isolated anterior capsule rupture after blunt trauma is a rare presentation. In this case report, we describe a case of blunt trauma with a rubber ball in a young man leading to a horizontally oval fish-shaped anterior capsule rupture with anterior subcapsular cataract.


  Case Report Top


A 20-year-old man suffered an injury to his right eye (RE) with a rubber ball while playing cricket and visited our hospital with complaints of diminution of vision for distance and near, associated with redness and mild pain. Best-corrected visual acuity (BCVA) in RE was 20/120 for distance and N36 for near. On slit-lamp biomicroscopy, the anterior chamber showed inflammation with cells 2 + and flare 1 +. A horizontally ruptured anterior lens capsule involving the visual axis was noted along with an isolated anterior subcapsular cataract and that was probably the reason of decreased vision for distance and near as changes were near to the nodal point of the lens [Figure 1]a and [Figure 1]b. The tear in the capsule was extending nasally under the pharmacologically dilated pupil. Extension into the posterior capsule was ruled out. On retro-illumination, the changes are visible clearly. There was no mature cataract formation at the presentation. The intraocular pressure (IOP) was 13 mm Hg by Goldmann applanation tonometry. The posterior segment was normal on indirect ophthalmoscopy and the left eye was also normal in all aspects. Anterior segment OCT was not available and ultrabiomicroscopy was not done due to fear of extension of the tear. After controlling anterior chamber inflammation with topical steroids, patient's vision was not improving, even with pinhole, as fibrosed anterior lens capsule was involving the visual axis. The patient underwent an uneventful phacoaspiration with a three-piece foldable monofocal intraocular lens (IOL) in-the-bag implantation under peribulbar anesthesia. The most challenging step was to convert the ruptured anterior capsule into a circular capsulorhexis avoiding its posterior extension. Using high-density ocular viscosurgical device (injection Aurogel, sodium hyaluronate 1.4% w/v, Aurolab, India) and microrhexis forceps, the fish-shaped opening was converted into a horizontally oval opening in the anterior capsule. After two tangential cuts on the edges of the ruptured capsule, the elevated flaps were pulled in a circumferential manner and an oval capsulorhexis was completed. After phacoemulsification using low parameters, a three-piece monofocal IOL was implanted in the bag. The haptics of the IOL were oriented at 3 and 9 o'clock position to give tamponade to the capsule in the area of extension of capsular tear. On the first postoperative day, the patient had a visual acuity of 20/30 improving to 20/20 with pinhole. The cornea was clear, anterior chamber was well formed with 0.5 cells, and IOP was 13 mm Hg. The IOL was well centered in the bag with the rhexis margins well covering the optic superiorly and inferiorly [Figure 2]a and [Figure 2]b. At 1 month postoperatively, the patient's BCVA was 20/20 for distance and N6 for near.
Figure 1: (a) Preoperative slit-lamp biomicroscopy showing good dilatation of pupil with ruptured anterior lens capsule with fibrosis (red arrows) (b) Retroillumination image showing fish-shaped ruptured anterior lens capsule (black arrow) with extension beyond dilated pupil under the iris (red arrow)

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Figure 2: (a) Postoperative retroillumination image at 1 month showing three-piece IOL in the bag with temporal haptic orientation at 9 ofclock (red arrow) (b) Slit-lamp biomicroscopy image at 1 month showing oval-shaped anterior capsulorhexis margins (red arrows) covering the optic of IOL with early fibrotic changes in the capsule

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  Discussion Top


Blunt trauma to the eye causes damage to the external as well as internal ocular structures. Rupture of posterior capsule after blunt trauma has been frequently noted.[1],[2],[3],[4] In literature, reports of isolated anterior capsule rupture following blunt trauma are very few.[5],[6],[7],[8],[9] Ruptured anterior lens capsule has been reported following trauma by air bag deployment, trauma with stone, and trauma with a plastic toy.[5],[6],[8] In our case, the ruptured capsule is likely to be due to the theory proposed by Banitt et al.[9] Direct suppression effect toward the cornea may provide a rapid focal collapse over the lens (coup injury) or a quick rebound of the vitreous directed from posterior to anterior causing fluid-mechanical forces, which may lead to a rupture of the anterior capsule (contrecoup injury). We think the horizontal tear in the capsule could be due to expansion of the globe vertically when it may have got compressed from the front by the force of the rubber ball (coup injury), whereas the rebound fluid mechanical forces (contrecoupe injury) may have caused extension of tear up to the equator beyond the dilated pupillary margin. Similar supportive findings were proposed by Dezhgah et al. and Ilhan et al.[6],[8]

Interestingly in the case reported by Ilhan et al.[8] swollen mature cataract formation was noted 2 days after the injury and the in the report of Dezhgah et al.[6] patient had vision 20/125 despite ruptured capsule but developed a mature cataract after 4 months with visual acuity of hand motion. In our case, the patient had a visual acuity of 20/120 on presentation and it remained same until the time of surgery at 1 month. Fibrosis of the ruptured capsule margin with an isolated anterior subcapsular cataract was noted before the surgery. As visual axis was involved, surgery was advised. Reason for the cataract not progressing to maturation even after 1 month from presentation remains unclear.


  Conclusion Top


Blunt ocular trauma is quite common but isolated anterior capsule rupture without mature cataract development is rare. The most common reason for developing anterior capsule rupture is coup and contrecoup forces of trauma and strong zonules in young age. Early meticulous management can restore the vision of such patients without complications.

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.
Campanella PC, Aminlari A, DeMaio R. Traumatic cataract and Wieger's ligament. Ophthalmic Surg Lasers 1997;28:422-3.  Back to cited text no. 1
    
2.
Saika S, Kin K, Ohmi S, Ohnishi Y. Posterior capsule rupture by blunt ocular trauma. J Cataract Refract Surg 1997;23:139-40.  Back to cited text no. 2
    
3.
Yasukawa T, Kita M, Honda Y. Traumatic cataract with a ruptured posterior capsule from a nonpenetrating ocular injury. J Cataract Refract Surg 1998;24:868-9.  Back to cited text no. 3
    
4.
Lee SI, Song HC. A case of isolated posterior capsule rupture and traumatic cataract caused by blunt ocular trauma. Korean J Ophthalmol 2001;15:140-4.  Back to cited text no. 4
    
5.
Zabriskie NA, Hwang IP, Ramsey JF, Crandall AS. Anterior lens capsule rupture caused by air bag trauma. Am J Ophthalmol 1997;123:832-3.  Back to cited text no. 5
    
6.
Dezhagah H. Circular anterior lens capsule rupture caused by blunt ocular trauma. Middle East Afr J Ophthalmol 2010;17:103-5.  Back to cited text no. 6
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7.
Sugimoto M, Yagi T, Matsubara H, Uji Y. Anterior lens capsule rupture following non-penetrating ocular injury in elderly patients. Can J Ophthalmol 2010;45:13-4.  Back to cited text no. 7
    
8.
İlhan N, İlhan Á, Coşkun M, Ayıntap E, Tuzcu E, Keskin U, et al. Anterior lens capsule ruptureand traumatic cataract due to blunt ocular trauma. Turk J Ophthalmol 2013;43:477-8.  Back to cited text no. 8
    
9.
Banitt MR, Malta JB, Main SI, Soong HK. Rupture of anterior lens capsule from blunt ocular injury. J Cataract Refract Surg 2009;35:943-5.  Back to cited text no. 9
    


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