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CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 704-706

Management of pediatric traumatic cataract with fibrovascular downgrowth over the posterior capsule


1 Department of Pediatric Ophthalmology and Strabismus, Narayana Nethralaya, Bangalore, Karnataka, India
2 Department of Vitreoretina Services, Narayana Nethralaya, Bangalore, Karnataka, India

Date of Submission06-Jan-2021
Date of Acceptance06-Apr-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Jyoti Matalia
Narayana Nethralaya-2, Narayana Health City, 258/A, Bommasandra, Hosur Road, Bangalore - 560 099, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_29_21

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  Abstract 


Penetrating injury in children resulting in a corneal tear with associated complicated cataract can present in different ways. The presence of fibrovascular downgrowth on the posterior capsule is very unusual and has never been reported before with pediatric traumatic cataract. In this study, we describe surgical management of such a case along with its postoperative course to help achieve good visual outcome.

Keywords: Fibrovascular downgrowth, penetrating trauma, traumatic cataract


How to cite this article:
Matalia J, Basavaraj TM, Shah N, Panmand P. Management of pediatric traumatic cataract with fibrovascular downgrowth over the posterior capsule. Indian J Ophthalmol Case Rep 2021;1:704-6

How to cite this URL:
Matalia J, Basavaraj TM, Shah N, Panmand P. Management of pediatric traumatic cataract with fibrovascular downgrowth over the posterior capsule. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 18];1:704-6. Available from: https://www.ijoreports.in/text.asp?2021/1/4/704/327644



Pediatric traumatic cataract following a penetrating injury is complex due to its varied presentation and its management may be difficult due to associated corneal tear, iris injury, vitreous hemorrhage, endophthalmitis, traumatic optic neuropathy, and retinal tears and detachment.[1],[2] Management of each case has to be individualized to get a good visual outcome. Here we discuss a case of pediatric traumatic cataract with fibrovascular downgrowth over the posterior capsule following a penetrating injury that was successfully managed.


  Case Report Top


A 6-year-old boy presented to us with complaints of gradual diminution of vision in right eye since 3 months. Parents gave history of corneal tear repair performed 3 months ago following penetrating injury with knife in the right eye. He was a known case of nephrotic syndrome on remission. Ocular examination revealed best-corrected visual acuity (BCVA) of 20/80p and 20/20 in the right and left eye, respectively. The slit-lamp examination [Figure 1]a showed an obliquely linear corneal tear 11 to 2 0'clock above the visual axis about 6 mm in length. The iris was adhered to the undersurface of the tear centrally with shallow anterior chamber superiorly. The lens was cataractous with a fibrous stalk extending from the undersurface of healed corneal tear up to the anterior capsule corresponding to the corneal tear. Preoperative ultrasound biomicroscopy (UBM) showed a sealed corneal tear with iris adherence, with fibrous growth from the iris onto an intact posterior capsule (PC) superiorly corresponding to the corneal tear. B-scan showed an echo-free vitreous cavity with attached retina. He was scheduled for lens aspiration with intraocular lens implantation (IOL). Intraoperatively, iris, which was adhered to corneal wound, was separated with scissors. Anterior capsular rupture was noted corresponding to the corneal tear superiorly along with an inferior tear from 5 to 7 o'clock hours toward the equator. Anterior capsulotomy was centered over the intact capsule without communicating with the two existing anterior capsular tear openings. After aspiration of the cortical matter, a plaque on the PC was noted. The plaque could be peeled off with pediatric forceps over the central area but was adherent superiorly hence severed at the base of the stalk. Immediately, it bled and resulted in to a clot superiorly [Figure 1]b. Attempts were made to dislodge, aspirate, or remove the clot but in vain as it seemed to be an intracapsular bleed. This supported the possibility of fibrovascular downgrowth over the PC superiorly probably from the undersurface of the iris through the anterior capsular opening. Assuming that the bleed would get absorbed eventually and the visual axis being clear, we implanted a hydrophobic single-piece intraocular lens in the bag [Figure 1]c. We also deferred primary posterior capsulotomy (PCC) in view of the active bleeding. Subconjunctival injection of 0.5 ml gentamycin (20 mg) combined with 0.5 ml dexamethasone (1 mg) was given. Postoperatively he was advised tapering course of prednisolone1% eye drops with atropine eye-ointment (1%). Topical antibiotic was given for 2 weeks. Postoperative 4 weeks, BCVA improved to 20/50 in the right eye.
Figure 1: Intraoperative photograph of the right eye showing: (a) Sutured corneal tear, white cataract, and ruptured anterior capsule with fibrotic edge in line with the corneal tear at 12 o clock. (b) Fresh bleed from the fibrovascular downgrowth. (c) Posterior chamber intraocular lens in the bag over the blood clot

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Over the next few weeks, the blood clot appeared to retract and eventually disappeared leaving behind frond of blood vessels with dense posterior capsular opacification (PCO), thus confirming our suspicion of fibrovascular downgrowth. On postoperative 6-week follow-up, we noted a new blood clot inferior to the PCO in the right eye [Figure 2]. This was a fresh bleed from the vascular frond over the PC. Vision in that eye dropped to 20/150. Hence, intravitreal injection of Avastin was given in an attempt to shrink the new vessels before planning membranectomy for the PCO. As no change was noted in the new vessels over the posterior capsule 3 weeks following injection, we planned a membranectomy and anterior vitrectomy with endocoagulation of the vessels via the pars plana route with fluid air exchange. Postoperatively his vision improved to 20/20 in the eye with − 2.5 DC at 160° and LE 20/20 and slit-lamp examination showed an adequate opening in the posterior capsule with no vessels over the PC remnant [Figure 3]. The child continued to have a clear visual axis until the last follow-up of more than a year.
Figure 2: One and a half month postoperative slit-lamp photograph showing an intraocular lens, a fibrovascular downgrowth over an opacified posterior capsule with a new blood clot at 6'clock inferior to its edge

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Figure 3: Slit-lamp photograph after membranectomy with endocoagulation of vessels showing an adequate posterior capsulectomy with no new vessels confirming a clear visual axis with a properly positioned intraocular lens

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  Discussion Top


Ocular trauma is an important cause of reversible unilateral blindness in children accounting for 29–35%.[3],[4],[5] The incidence of penetrating trauma in children is as high as 43%.[6] As pediatric eye is in developmental phase, ocular trauma leads to significant visual morbidity. Prompt treatment is required to prevent complications like amblyopia, strabismus, and loss of binocular vision with development of low vision and blindness for lifetime.[7]

Fibrovascular downgrowth is a rare but devastating complication of penetrating ocular injury.[8] Complications associated with fibrovascular downgrowth are repeated intraocular hemorrhage (interface hemorrhage, hyphema, and anterior vitreous hemorrhage).[9] However, its presence over the posterior capsule is not reported. The modalities of managing such downgrowths include its removal with endophotocoagulation of the vessels and anti-VEGF injections.[9],[10]

In our case, fibrovascular downgrowth developed through the corneal wound, probably due to delayed closure of corneal tear. Vascularization is more commonly seen due to the presence of vascular endothelial growth factor and connective tissue growth factor, which leads to repeated intraocular hemorrhage like in our case. In view of the fibrovascular frond over posterior capsule, we decided to give an intravitreal injection of Avastin in right eye (RE) to shrink the new vessels before doing membranectomy. No effect was noted with Avastin. There is a need for multiple injections which may not be practical in pediatric age group, due to limited time in view of the amblyogenic age and the need for general anesthesia.


  Conclusion Top


In conclusion, this case report highlights the possibility of development of fibrovascular downgrowth over posterior capsule in a case of traumatic cataract following penetrating injury and its course to achieve a successful surgical and visual outcome.

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.
Chen SH, Pineda R 2nd. Epithelial and fibrous downgrowth: Mechanisms of disease. Ophthalmol Clin North Am 2002;15:41-8.  Back to cited text no. 1
    
2.
Gogate P, Sahasrabudhe M, Shah M, Patil S, Kulkarni A. Causes, epidemiology, and long-term outcome of traumatic cataracts in children in rural India. Indian J Ophthalmol 2012;60:481-6.  Back to cited text no. 2
  [Full text]  
3.
Strahlman E, Elman M, Daub E, Baker S. Causes of paediatric eye injuries. A population-based study. Arch Ophthalmol 1990;108:603-6.  Back to cited text no. 3
    
4.
Maltzman BA, Pruzon H, Mund ML. A survey of ocular trauma. Surv Ophthalmol 1976;21:285-90.  Back to cited text no. 4
    
5.
Niiranen M, Raivio I. Eye injuries in children. Br JOphthalmol 1981;65:436-8.  Back to cited text no. 5
    
6.
De Juan E Jr, Sternberg P Jr, Michels RG. Penetrating ocular injuries: Types of injuries and visual results. Ophthalmology 1983;90:1318-22.  Back to cited text no. 6
    
7.
Acuna OM, Yen KG. Outcome and prognosis of pediatric patients with delayed diagnosis of open-globe injuries. J Pediatr Ophthalmol Strabismus 2009;46:202-7.  Back to cited text no. 7
    
8.
Naumann GO, Rummelt V. Block excision of cystic and diffuse epithelial downgrowth of the anterior chamber. Report on 32 consecutive patients. Arch Ophthalmol 1992;110:223-7.  Back to cited text no. 8
    
9.
Mansour AM. Combined intracorneal and subconjunctival bevacizumab injections for recurrent visual loss and intraocular hemorrhage from vascularized fibrous downgrowth. Ophthalmol 2014;5:28-33.  Back to cited text no. 9
    
10.
Jadav DS, Rylander NR, Vold SD, Fulcher SF, Rosa RH Jr. Endoscopic photocoagulation in the management of epithelial downgrowth. Cornea 2008;27:601-4.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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