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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 71-72

Traumatic lenticele – A rare case report


Department of Ophthalmology, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India

Date of Submission16-Mar-2022
Date of Acceptance29-Sep-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Navneet Saxena
Department of Ophthalmology, Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_701_22

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  Abstract 


Traumatic subconjunctival dislocation of the lens (phacocele or lenticele) is of relatively rare occurrence. We report an unusual case of subconjunctival dislocation of the cataractous lens following blunt ocular trauma by cow horn in an elderly patient without having any previous ocular surgery or trauma. Blunt trauma resulted in indirect scleral rupture with subsequent dislocation of the crystalline lens in the subconjunctival space. The pathophysiological mechanism, clinical presentation, and management are discussed in this case report.

Keywords: Lenticele, subconjunctival space, trauma


How to cite this article:
Saxena N, Khan SF, Tripathi R. Traumatic lenticele – A rare case report. Indian J Ophthalmol Case Rep 2023;3:71-2

How to cite this URL:
Saxena N, Khan SF, Tripathi R. Traumatic lenticele – A rare case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:71-2. Available from: https://www.ijoreports.in/text.asp?2023/3/1/71/368220



The term phacocele is derived from the Greek word “phaco” meaning lens and “kele” meaning hernia. Phacocele (synonym = lenticele) is defined as the anterior dislocation/herniation of crystalline lens into the subconjunctival space through sclera rupture. Phacocele is a rare event caused by severe blunt trauma. Rupture may occur where the impact took place (direct rupture) or at a certain distance (indirect rupture).[1] Impact tends to occur in the inferior temporal sector of the eye globe because it is left unprotected by the orbit's bone structure that is projected toward the superior nasal region where the globe collides with the trochlea and the orbital wall. Ocular ruptures usually take place in this sector. Several predisposing factors, which favor sclera rupture with lens dislocation, are previous large surgical scar of cataract extraction/trabeculectomy/old trauma, diseases of eyewall such as scleritis and connective tissue disorder, and long-term topical medications.[1] We reported here an interesting case of dislocation of the cataractous lens in superonasal subconjunctival space caused by indirect trauma by cow horn, without any predisposing factors.


  Case Report Top


A 60-year-old female patient and laborer sustained blunt trauma to her right eye by the cow horn 2 weeks before the presentation. She noticed a sudden loss of vision, pain, and redness in her right eye following the trauma, for which she was treated non-surgically by a local general practitioner but did not improve. There was no history of any previous ocular surgery, trauma, recurrent attack of pain and redness in the eye, and long-term topical medications. No other significant personal or family history was noted. On examination, her visual acuity in the right eye was light perception and 6/24 in the left eye. Intraocular pressure (IOP) was 12.3 mmHg in the right eye and 18 mmHg in the left eye. Extraocular movements were normal in both eyes. By lifting the upper eyelid, the right eye showed a well-delineated subconjunctival mass in the superonasal bulbar conjunctiva close to the limbus with a small subconjunctival hemorrhage near the superonasal limbus, which was the likely site of scleral rupture. There was an irregular anterior chamber with blood-stained vitreous bands. The pupil was jet black and irregular, not reacting to light [Figure 1]. Slit-lamp examination revealed aphakia. Fundus examination could not be done due to vitreous hemorrhage. B-scan ultrasonography of the right eye revealed the absence of a lens from a normal anatomical position with vitreous hemorrhage [Figure 2]. Left eye examination was within normal limits, except for early cataractous changes. The patient was admitted and underwent a surgical exploration under local anesthesia. The superonasal peritomy was performed and dislocated subconjunctival cataractous lens was removed [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. A 6 mm long anterior scleral rupture, of the superonasal perilimbal area was noted, which was surgically repaired by a 10–0 nylon suture and an anterior vitrectomy was performed. The possible need for a secondary scleral fixated intraocular lens (IOL) was kept in mind. Subsequently, the patient was treated with and topical antibiotic with steroids and cycloplegic. Postoperatively, the patient exhibited VA of counting fingers 3 feet. The slit-lamp examination revealed a transparent cornea and a quiet anterior chamber [Figure 4]. The fundus could not be examined due to media opacities. Ultrasound B mode showed the retina in place with resolving vitreous hemorrhage.
Figure 1: Superior nasal subconjunctival mass corresponding to the prolapsed lens

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Figure 2: Preoperative - ultrasound showing vitreous hemorrhage

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Figure 3: (a) Subconjunctival mass corresponding to the prolapsed lens (b) Surgical exploration (c) Extraction of the prolapsed lens 6 mm long anterior scleral rupture (d) (d inset)

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Figure 4: Immediate postoperative perilimbal scleral rupture repair

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  Discussion Top


Phacocele is a rare phenomenon mainly caused by blunt trauma of sufficient magnitude leading to indirect sclera rupture of the globe. The predominant site of indirect scleral rupture is the superonasal quadrant[2],[3] followed by the superotemporal quadrant.[4] The scleral rupture frequently occurs between the limbus and spiral of Tillaux.[5] The predisposing factor for subconjunctival dislocation of the lens following trauma (even in mild intensity) are a hard lens as in advanced age or cataractous lens, increased scleral rigidity as a result of advanced age or long-standing high IOP (glaucoma) and weakening pathologies in eyeball such as a postsurgical scar, scleritis, rheumatoid arthritis, and other connective tissue disorders.[1] Subconjunctival luxation of the crystalline lens occurs exclusively in the elderly beyond 40 years of age and is very rare in children, in spite of a high incidence of trauma due to the elasticity of the outer coats of the globe and softer crystalline lens.[6]

In our case, the predisposing factor was sclera rigidity due to advanced age and hard cataractous lens. Rupture usually occurs at 2.5 mm, concentric to the limbus where tense and deep scleral fibers are transmitted into the delicate lamella of the pectineus ligament.[5]

Our case has an interesting presentation where the subconjunctival dislocation of the cataractous lens in the superonasal quadrant was caused by cow horns without any predisposing factors.


  Conclusion Top


We conclude that early detection, timely, and appropriate intervention can result in good recovery of visual function.

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.
Santos-Bueso E, Sáenz-Francés F, Díaz-Valle D, Troyano J, López-Abad C, Benítez-del-Castillo JM, et al. Ocular rupture associated with lens dislocation to the subconjunctival space. Arch Soc Esp Oftamol 2007;82:641-64.  Back to cited text no. 1
    
2.
Bhattacharjee K, Bhattarchjee H, Deka A, Bhattacharjee P. Traumatic phacocele: Review of eight cases. Indian J Ophthalmol 2007;55:466-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Cherry PM.Indirect traumatic rupture of the globe. Arch Ophthalmol 1978;96:252-6.  Back to cited text no. 3
    
4.
Mc Donald PR, Purnell JE. The dislocated lens. JAMA 1951;145:220-6.  Back to cited text no. 4
    
5.
Charan H, Mathur GB. Subconjuctival dislocation of lens. A case report. Int Surg 1969;52:115-6.  Back to cited text no. 5
    
6.
Yurdakul NS, Uğurlu Ş, Yilmaz A, Maden A. Traumatic subconjunctival crystalline lens dislocation. J Cataract Refract Surg 2003;29:2407-10.  Back to cited text no. 6
    


    Figures

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



 

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