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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 602-604

A rare orbital cyst due to traumatic lens dislocation


Department of Ophthalmology, Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, China

Date of Submission20-Oct-2020
Date of Acceptance01-Mar-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Hongfei Liao
Department of Ophthalmology, Affiliated Eye Hospital of Nanchang University, 463 Bayi Road, Nanchang, Jiangxi - 330000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3241_20

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  Abstract 


Lens dislocation into the subconjunctival or subtenon's space is a rare but known complication of blunt eye trauma. However, lens dislocation into the orbital space has never been reported. Here, we describe a case of orbital cyst caused by traumatic lens dislocation. A 55-year-old man complained of persistent orbital edema and pain in the right eye after ocular evisceration and orbital implant surgery for severe scleral rupture. Computed tomography showed increased soft-tissue density in the infero-temporal orbital space. An orbitotomy and histological examination confirmed that the mass in the orbit was a cyst that formed from the dislocated lens.

Keywords: Computed tomography, lens dislocation, orbital cyst, scleral rupture, trauma


How to cite this article:
Wang A, Xu Q, Wang Y, Qiu W, Liao H. A rare orbital cyst due to traumatic lens dislocation. Indian J Ophthalmol Case Rep 2021;1:602-4

How to cite this URL:
Wang A, Xu Q, Wang Y, Qiu W, Liao H. A rare orbital cyst due to traumatic lens dislocation. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:602-4. Available from: https://www.ijoreports.in/text.asp?2021/1/3/602/320090



Ocular trauma could lead to lens luxation into the anterior chamber; vitreous cavity; or subretinal,[1] suprachoroidal,[2] subconjunctival,[3] or subtenon's spaces;[4] or the lens could go missing. Dislocation of the extraocular space is rare and difficult to diagnose. We report a lens luxation into orbital space and its management. To the best of our knowledge, this is the first case report of an orbital cyst caused by dislocation of the crystalline lens.


  Case Report Top


A 55-year-old man sustained a blunt injury to the right eye while chopping wood, following which, he had received immediate treatment at a local hospital. His medical records indicated visual acuity as no light perception (NLP); severe scleral rupture from below the lateral rectus insertion to the posterior pole in the right eye. The patient was managed with ocular evisceration and orbital implant placement immediately after injury, and administrated with systemic dexamethasone (10 mg every 24 h) and ceftazidime (2 g every 12 h), levofloxacin eye drops, tobramycin and dexamethasone eye ointment.

However, the patient was transferred to our hospital 10 days later for persistent ptosis, orbital edema and pain in the right eye, and the lower eyelid was more swollen and presented as a hard mass [Figure 1]a. The inserted conformer tended to slip. The conjunctiva was sutured and showed indications of chemosis. The left eye was normal (visual acuity 20/25). Computed tomography (CT) showed increased soft-tissue density in the infero-temporal orbital space and the appropriate location of the orbital implant in the right eye [Figure 2]a and [Figure 2]c. We reviewed the patient's medical history again; he denied history of ocular diseases and provided the CT images acquired at the time of his ocular injury. The images showed a smaller range, clearer boundary and higher density in the same orbital space [Figure 2]b and [Figure 2]d, and an absent intraocular crystalline lens. However, detailed information on ocular trauma and the last ocular surgery could not be obtained.
Figure 1: (a) Photograph showing ptosis and orbital swelling, the more swollen lower eyelid presented as a hard mass, with chemosis in the right eye. (b) Photograph showing satisfactory recovery and appearance with ocular prothesis at 6 months postoperatively

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Figure 2: (a and c) Computed tomography (CT) scan performed 10 days after injury showing a significantly increased density in the infero-temporal orbital space and the appropriate location of the orbital implant in the right eye. (b and d) CT image acquired after injury showing a clearer boundary and higher density in the infero-temporal orbital space, relative to the CT scan performed 10 days later

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Based on his history, clinical symptoms, and CT findings, we suspected that the mass was a dislocated lens or a foreign body and performed an orbitotomy on the second day after admission. We made an incision into the lower right eyelid margin to expose and remove the orbital mass [Figure 3]. Histological examination confirmed that the orbital mass was a cyst that formed from the dislocated lens [Figure 4]. The patient recovered rapidly and was discharged on the third postoperative day. The patient was satisfied with the results at the 6-month follow-up period [Figure 2]b.
Figure 3: (a) The exposed orbital mass on orbitotomy through an incision in the lower eyelid margin. (b) The mass was completely resected (length, 28 mm)

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Figure 4: (a) Histological findings of the orbital cyst showed fibroblasts, capillaries, and pigment deposition (H and E staining, Original magnification × 100). (b) Histological finding of the lens shows pink dyed homogeneous structureless matrix (H and E staining, Original magnification × 400)

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  Discussion Top


Owing to globe rupture, the lens may be dislocated into the extraocular space, which mostly occurs in people with a rigid sclera and hard crystalline lens.[5] Hence, predisposing factors for lens dislocation include old age, history of surgical or traumatic scleral scarring, other scleral disorders, cataract, and zonular weakness. In our case, this patient was a 55-year-old man with a well-formed crystalline lens and poor, elastic sclera. Scleral rupture occurred because of the blunt ocular trauma and the hard lens was extruded into the orbital tissue through the loose tenon's space.

A scleral rupture could occur at the impact site (direct rupture) or in a remote area, away from the impact site (indirect rupture).[6] In our case, scleral rupture was infero-temporal, close to the lateral rectus insertion. The infero-temporal quadrant of the eye is particularly vulnerable to trauma as it has no relevant neighboring tissues for protection to cushion the impact.[6] However, other lens dislocations more commonly present with an indirect scleral rupture and the predominant sites are the superonasal and superotemporal quadrants, between the limbus and the spiral of the Tillaux.[5]

Traumatic lens dislocation is always associated with other ocular diseases. The slit-lamp examination and ultrasound B-scan has limited usefulness for media opacity and open globe injuries, respectively. However, CT examination is valuable for the diagnosis of these conditions.[3] In our case, a CT scan performed after the injury showed signs of lens dislocation. However, these findings were overlooked, and intraocular tissues were not assessed intraoperatively during the initial management.

Primary management of lens luxation cases includes removal of the dislocated lens and restoration of globe integrity, additional vitrectomy, and retinal detachment repair, if necessary.[4],[5] Existing literature suggests that the displaced lens would be absorbed.[7] However, many reports have shown that the dislocated lens remains intact for several months until surgical intervention.[7],[8] Patients may experience inflammation, pain, edema, or discomfort during the process of lens absorption. When the CT findings in our case were compared, the dislocated lens in the orbit showed a larger range, unclear boundary, and reduced density, which may indicate that the lens were absorbed slightly in the 10 days; however, the patient complained of pain and swelling. Hence, we proposed to extract the dislocated lens along with ocular debridement to relieve the patient's discomfort. Moreover, controversy exists over whether eyes with NLP should be enucleated to prevent sympathetic ophthalmia.[9] The incidence of sympathetic ophthalmia after trauma is very low,[9] and eyes with NLP may benefit from vitrectomy.[10] We recommend that the scleral wound should be meticulously explored and repaired in cases of ocular rupture, even in cases with NLP. Enucleation or evisceration can be performed when all methods to salvage the eye have been considered.


  Conclusion Top


This case highlights the importance of careful examination for lens dislocation in cases of ocular rupture. CT examination is valuable in cases where lens dislocation is not visible by routine examinations. The management of cases of lens luxation is complex, and includes removal of the lens, repair of the scleral tear, followed by vitrectomy surgery, even in eyes with NLP.

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.
Bawankar P, Das D, Agarwal B, Bhattacharjee K, Tayab S, Deka P, et al. A rare case of traumatic subretinal migration of crystalline lens, corroborated histologically. Indian J Ophthalmol 2017;65:1495-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Shanmugam MP, Shah P, Rajesh R, Mishra DK, Sagar P, Sheemar A. Post-traumatic suprachoroidal dislocation of crystalline lens and its management. Indian J Ophthalmol 2019;67:1469-70.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Neupane S, Das D, Korgaonkar S. Migrated subconjunctival crystalline lens: A traumatic phacocele. BMJ Case Rep 2020;13:e237014.  Back to cited text no. 3
    
4.
Sindal MD, Mourya D. A rare case of traumatic posterior phacocele with retinal detachment. Indian J Ophthalmol 2016;64:89-90.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Bhattacharjee K, Bhattacharjee H, Deka A, Bhattacharyya P. Traumatic phacocele: Review of eight cases. Indian J Ophthalmol 2007;55:466-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Andonegui J, Ferro J. Subconjunctival cataract after trauma. Arch Ophthalmol 2002;120:1102.  Back to cited text no. 6
    
7.
Yurdakul NS, Uğurlu S, Yilmaz A, Maden A. Traumatic subconjunctival crystalline lens dislocation. J Cataract Refract Surg 2003;29:2407-10.  Back to cited text no. 7
    
8.
Gaur A, Sharma YR, Sudan R. Subconjunctival lens dislocation. J Cataract Refract Surg 2005;31:13-4.  Back to cited text no. 8
    
9.
Savar A, Andreoli MT, Kloek CE, Andreoli CM. Enucleation for open globe injury. Am J Ophthalmol 2009;147:595-600.e1.  Back to cited text no. 9
    
10.
Heidari E, Taheri N. Surgical treatment of severely traumatized eyes with no light perception. Retina 2010;30:294-9.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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