Glittering Christmas tree cataract – The role of Scheimpflug, anterior segment optical coherence tomography, and biochemical analysis

Rama Rajagopal; Anupriya Kohli; Angayarkanni Narayanasamy; Karthick Jayavel; Hemalatha Chidambaram

doi:10.4103/IJO.IJO_2692_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 322-323

Glittering Christmas tree cataract – The role of Scheimpflug, anterior segment optical coherence tomography, and biochemical analysis

Rama Rajagopal, Anupriya Kohli, Angayarkanni Narayanasamy, Karthick Jayavel, Hemalatha Chidambaram
Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Submission	14-Oct-2022
Date of Acceptance	14-Dec-2022
Date of Web Publication	28-Apr-2023

Correspondence Address:
Rama Rajagopal
Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai - 600 006, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2692_22

Abstract

Christmas tree cataract has rarely been described. It is characterized by a polychromatic luster, the exact etiology of which is unclear. Postulated causes for this include the possible role of cholesterol or calcium deposition. We describe a case of a unilateral Christmas tree cataract in a patient who underwent cataract surgery and highlight the role of Scheimpflug and anterior segment optical coherence tomography (ASOCT) in complementing the clinical diagnosis. Further, biochemical analysis of the lens matter revealed an increase in calcium and cholesterol.

Keywords: ASOCT, biochemical analysis, Christmas tree cataract, Scheimpflug

How to cite this article:
Rajagopal R, Kohli A, Narayanasamy A, Jayavel K, Chidambaram H. Glittering Christmas tree cataract – The role of Scheimpflug, anterior segment optical coherence tomography, and biochemical analysis. Indian J Ophthalmol Case Rep 2023;3:322-3

How to cite this URL:
Rajagopal R, Kohli A, Narayanasamy A, Jayavel K, Chidambaram H. Glittering Christmas tree cataract – The role of Scheimpflug, anterior segment optical coherence tomography, and biochemical analysis. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 5];3:322-3. Available from: https://www.ijoreports.in/text.asp?2023/3/2/322/374973

Christmas tree cataract has unique clinical features consisting of refractile lens opacities. Few studies have reviewed both the role of imaging^[1] and biochemical alterations^[2] in the lens to get a better insight of the etiopathogenesis.^[3],[4],[5] Despite this, the etiology is uncertain. Ours is probably the first case report that has comprehensively reviewed all these parameters.

Case Report

A 63-year-old female presented with slit-lamp examination findings depicting unilateral refractile needle-like lens opacities located in the central cortex and anterior nucleus, suggestive of Christmas tree cataract [Figure 1]. ASOCT (CIRRUS 5000 HD) and Scheimpflug imaging (Pentacam HR) revealed scattered hyperreflective areas corresponding to the refractile lens opacities with backshadowing [Figure 2] and [Figure 3]. Quantitative biochemical analysis for cholesterol and calcium estimated spectrophotometrically in the lens matter showed higher levels relative to the lens matter from a cataract control of a 56-year-old male patient as normalized to the total protein of the lens. Serum lipid profile and calcium level were within normal limits. Physician review ruled out neurological/systemic deficit.

Figure 1: Diffuse slit-lamp image showing polychromatic needle-shaped lens opacities

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Figure 2: Scattered hyperreflective areas (white arrow) corresponding to the needle-shaped crystals on ASOCT

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Figure 3: Scheimpflug image showing crystals with varying degrees of hyperreflectivity (white arrow) and corresponding areas of backshadowing (dotted arrow)

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Discussion

The exact etiology and cause for the morphologic appearance of Christmas tree cataract is largely unknown. Polychromatic luster has been ascribed to the differences in refractive index, thickness, and parallel sides of the membrane plates.^[2]

Postulated mechanisms for the glistening pattern noted include alteration in the lens metabolism resulting in the deposition of cholesterol^[3] and elevated calcium levels resulting in lens degradation causing cystine accumulation.^[4] In support of this hypothesis, we found the same in our lens study based on relative quantitative analysis, which has not been reported so far. Further analysis with techniques such as scanning electron microscopy can help in demonstrating the cholesterol and/or cysteine crystals in situ. However, in a similar cataract case reported by Hayes et al.,^[2] both cholesterol and calcium could not be demonstrated in the lens matter. We understand the limitation of our study and the need to validate our findings.

Systemic association with myotonic dystrophy has been seldom described,^[1] but is negative in most studies.

Both in ASOCT and Scheimpflug imaging, crystals appeared hyperreflective to varying degrees with backshadowing corresponding to the density of crystals. The details were appreciated more explicitly on the Pentacam.

Conclusion

Christmas tree cataract has characteristic features both clinically as well as on Scheimpflug and ASOCT. While our study strongly supports the accumulation of cholesterol and calcium in the lens, we reiterate the need for further studies including biochemical analysis in a larger cohort to substantiate our findings and for a better insight into its etiopathogenesis.

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

1.	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. [Full text]
2.	Hayes BP, Fisher RF. Ultrastructural appearances of a lens with marked polychromatic lusture: Evidence for diffraction as a cause. Br J Ophthalmol 1984;68:850-8.
3.	Anders N, Wollensak J. Christmas tree ornament cataract- an indication for disordered lipid metabolism. Klin Monbl Augenheilkd 1992;201:30-3.
4.	Shun-Shin GA, Vrensen GF, Brown NP, Willekens B, Smeets MH, Bron AJ. Morphologic characteristics and chemical composition of Christmas tree cataract. Invest Ophthalmol Visc Sci 1993;34:3489-96.
5.	Pau H, Forster 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;219:295-97.