|Year : 2023 | Volume
| Issue : 2 | Page : 324-326
Traumatic anterior phacocele
Richa Agarwal, Alka Tripathi, Kritika Agnihotri
Department of Ophthalmology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
|Date of Submission||03-Nov-2022|
|Date of Acceptance||23-Dec-2022|
|Date of Web Publication||28-Apr-2023|
Department of Ophthalmology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh - 273 008
Source of Support: None, Conflict of Interest: None
A 72-year-old lady complained sudden-onset loss of vison in the left eye after falling from bed. She was only able to perceive light from the left eye. Anterior segment examination showed a solid subconjunctival mass in the superonasal quadrant adjacent to limbus, suggestive of anterior phacocele. Ultrasound B-scan confirmed the diagnosis, and patient was taken for surgery which led to good visual recovery. Appropriate and timely diagnosis and management of such cases can improve prognosis of such cases.
Keywords: Lens dislocation, phacocele, ocular trauma
|How to cite this article:|
Agarwal R, Tripathi A, Agnihotri K. Traumatic anterior phacocele. Indian J Ophthalmol Case Rep 2023;3:324-6
Traumatic dislocation of crystalline lens through a scleral defect into the subconjunctival space is termed as phacocele. The incidence of phacocele is low. It was seen in 1%–13% cases of all types of lens dislocation in various studies, which is far less when compared to the other types of lens dislocation. We report a case of dislocation of crystalline lens in the anterior subconjunctival space after blunt trauma.
| Case Report|| |
A 72-year-old woman presented to the ophthalmology department with a sudden-onset diminution of vision in her left eye (LE) for the past 2 weeks. She had a history of fall from bed and got her LE hit by the corner of a table, following which she had pain and decreased vision in the LE. She had no systemic illness or any history of ocular surgery. Her general physical examination was normal. She was well oriented to time, place, and person with stable vitals. On eye examination, her best corrected visual acuity was 20/20 in the right eye (RE) and perception of light was positive with projection of rays accurate in the LE. The intraocular pressure was digitally low in LE. On slit-lamp examination, there was a solid globular mass in the subconjunctival space, which was located in the superonasal (SN) quadrant and measured 8 × 9 mm with a smooth surface and rounded margins, suggestive of herniated crystalline lens [Figure 1]a. There was diffuse corneal haze with Descemet membrane folds [Figure 1]b. Anterior chamber was irregular in depth, pupil was drawn upward, and there was absence of crystalline lens in patellar fossa. Indirect ophthalmoscopy revealed vitreous hemorrhage. Her RE was normal with immature senile cataract.
|Figure 1: Slit-lamp photograph of the right eye. (a) A well-defined, elevated subconjunctival mass in the superonasal quadrant. (b) Corneal edema with an undrawn pupil|
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Ultrasound B-scan of LE revealed the presence of vitreous hemorrhage with posterior vitreous detachment in the axial scan [Figure 2]a; in the transverse scan of nasal quadrant, a hypoechoic lesion was seen in the subconjunctival space with mild–moderate internal reflectivity and high surface reflectivi ty, suggestive of dislocated lens [Figure 2]b. The lens echoes were not detected in the posterior segment.
|Figure 2: B-scan ultrasonography: (a) vertical axial scan: vitreous hemorrhage with posterior vitreous detachment; (b) transverse scan of the nasal quadrant: a hypoechoic lesion in the subconjunctival space with moderate internal reflectivity along with high surface reflectivity suggestive of herniated lens|
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A diagnosis of traumatic anterior phacocele in the LE was made. The patient was taken up for surgical removal of the dislocated crystalline lens with globe exploration, and the repair of the occult scleral wound was done. The patient was left aphakic. Postoperatively, her vision was hand movement close to the face, which improved to 20/120 on putting a + 10 D lens. The patient is now being planned for a contact lens trial and a scleral-fixated intraocular lens (IOL) implantation after 3 months.
| Discussion|| |
Blunt ocular trauma can cause significant visual morbidity. Coup–contrecoup injury due to blunt trauma can cause scleral rupture resulting in extrusion of the crystalline lens into the subconjunctival or sub-Tenon's space. McDonald and Purnell reported in 1951 that the incidence of phacocele was only 13% among all cases of lens dislocations they studied.
The most common site of dislocation is SN quadrant, which is followed by supertemporal quadrant. Most frequently, the crystalline lens is extruded in the subconjunctival space between the limbus and the spiral of Tillaux. Rarely, posterior sub-Tenon's dislocation with scleral rupture occurs and is often associated with retinal tears and retinal detachment.
A hard lens and a rigid sclera are essential for a crystalline lens to get dislocated to the subconjunctival space; therefore, this occurs rarely in children. A review of previously reported cases of traumatic anterior phacocele [Table 1] also suggests an elderly preponderance with involvement of SN quadrant of the LE in majority of the reports. Involvement of SN quadrant more than any other quadrant was explained in the study by Cherry, as was in our case. All the previously reported cases had undergone surgical removal of dislocated lens along with scleral wound suturing and showed variable outcomes.
|Table 1: Salient features of previously reported cases of anterior phacocele|
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Ultrasound B-scan reveals absence of lens echoes, along with vitreous hemorrhages, retinal detachments, or endophthalmitis. B-scan can also reveal the location of dislocated lens when both the axial transverse scans of all quadrants are done properly, as the axial scan alone cannot reveal an anterior phacocele and can be missed, similar to our case. Anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy also aid in diagnosing the location of crystalline lens. Meticulous exploration of wound must be done, and occult scleral rupture should be repaired with or without an IOL implantation. Scleral fixation of IOL is preferred due to insufficient capsular bag support and decompensated cornea.
Any retained nuclear fragment should be surgically removed as it may lead to inflammation later. Timely intervention of traumatic rupture of eye can provide good visual outcome.
| Conclusion|| |
Detailed examination with all the diagnostic modalities available can help in providing good visual recovery in a case of traumatic phacocele.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]