Clinical image: Rare photographic documentation of uveal melanoma progression.

To present clinical images of a patient with neovascular glaucoma and hypermature cataract masking orbital extension of a uveal melanoma. Observations: A 67-year-old female was referred for neovascular glaucoma and found to have an intraocular tumor with massive orbital extension. She refused surgery and returned one year later with progression of the tumor with metastases and expired seven months later. Conclusions and importance: Unexplained glaucoma and cataract should be investigated for harboring underlying intraocular tumors to prevent delays in diagnosis. Providers also should obtain greater understanding of psychosocial and socioeconomic barriers to healthcare.

Lens-induced uveitis in a patient with hypermature cataract.

Objective: Our paper aims to report an unusual case of phacogenic uveitis with secondary glaucoma occurring after spontaneous rupture of the lens capsule in a patient with hypermature age-related cataract, to describe its particularities and to review the classification of the lens-induced uveitis. Methods: We described the case of an 83-year-old male with a history of hypermature cataract, who presented to our clinic for right eye pain. Examination revealed circumciliary congestion, diffuse corneal edema, lens debris floating in the anterior chamber, pseudohypopyon and the opacification of the whole lens. An elevated intraocular pressure was also associated. We did not observe any history of previous intraocular surgery or trauma. Results: We diagnosed the case as a phacogenic uveitis with secondary glaucoma and we planned to remove the inflammation trigger, namely the lens and its fragments by the most adequate technique, in order to control the inflammation and the IOP spikes, to alleviate the pain and to improve the patient's visual function and the quality of life. Conclusions: Phacogenic uveitis may present a cloudy cornea and a turbid anterior chamber that mimics endophthalmitis. Careful examination, medical history and ancillary investigations are helpful in establishing an accurate diagnosis and the appropriate treatment can reduce or eliminate the inflammation completely, decrease the intraocular pressure, being able to allow, depending on the particularities of the case, the visual gain.

Phacolytic glaucoma: A nearly forgotten entity.

PURPOSE: To report a case of phacolytic glaucoma with rupture of anterior lens capsule in a case of hypermature cataract. METHODS: Case report and literature review. RESULTS: An 80-year-old woman presented with cloudiness and pain in the left eye for 1 day. The patient had visual acuity limited to perception of light with raised intraocular pressure of 70 mm Hg. Careful slit-lamp evaluation revealed corneal epithelial edema in superior quadrant and a deep and turbid anterior chamber. Ultrasound biomicroscopy confirmed the presence of a deep anterior chamber, a hypermature cataractous nucleus with lax capsular bag, and ruptured anterior lens capsule. The patient underwent extracapsular cataract extraction. Cytological examination of the lenticular fluid revealed the presence of lens protein-laden macrophages. Post-operatively, the patient had best-corrected visual acuity of 6/60 with advanced glaucomatous optic neuropathy. CONCLUSION: Phacolytic glaucoma can present with a cloudy cornea and a turbid anterior chamber mimicking endophthalmitis. Careful examination and ancillary investigations including ultrasound biomicroscopy was helpful in making an accurate diagnosis.

Visual Prognosis and Satisfaction of Advanced Cataract Patients Unable to be Evaluated by Fundus Imaging

PURPOSE: We evaluated the surgical prognoses of patients with advanced cataract who were unable to be evaluated by fundus imaging and their satisfaction with daily life.METHODS: We retrospectively reviewed 748 eyes of 480 patients who underwent cataract surgery from January 2015 to December 2017. Preoperative factors, surgical technique, degree of cataract, and the best-corrected visual acuity for 1 and 6 months after surgery were analyzed. Among 91 eyes of 78 patients with advanced cataract who were unable to be evaluated by fundus imaging, the degree of discomfort before surgery and postoperative satisfaction were evaluated.RESULTS: Hypertension was positively correlated with visual acuity after cataract surgery (p = 0.004). Low corneal endothelial cell count, primary open-angle glaucoma, a history of trabeculectomy due to glaucoma, corneal dystrophy or corneal opacity, advanced cataract unable to be evaluated by fundus imaging, hypermature cataract, extracapsular cataract extraction, and intracapsular cataract extraction and visual acuity <0.5 after 1 month showed negative correlations with the visual outcomes after 6 months (p = 0.019, p = 0.002, p = 0.037, p = 0.001, p = 0.004, p = 0.012, p = 0.00, and p = 0.00, respectively). The risk of a final visual acuity <0.5 after cataract surgery was 3.18-fold higher in cases of advanced cataract, unable to be evaluated by fundus imaging (p = 0.003). Ten patients with 10 eyes postponed surgery due to poor prognoses, which was expected, and six patients (60%) had a best-corrected visual acuity <0.5 after 6 months. Six patients (60%), expected to have a poor prognosis were satisfied after surgery and the postoperative satisfaction was high when compared with a poor visual outcome.CONCLUSIONS: Poor surgical prognoses were expected in advanced cataract patients unable to be evaluated by fundus imaging. However, advanced cataract patients, who postponed surgery due to an unfavorable visual prognosis, showed a higher subjective satisfaction when compared with the postoperative visual acuity.

Intraocular lens implantation performed first to protect the posterior capsule in Morgagnian cataracts during phacoemulsification.

This study evaluated the safety of a modified method to implant an intraocular lens (IOL) into the capsular bag immediately after capsulorhexis with a whole or partial nucleus to protect the posterior capsule (PC) during phacoemulsification in a series of 12 Morgagnian cataracts. For 3 cases of hypermature cataracts with smaller and rigid nuclei, after a complete capsulorhexis, an IOL was directly inserted into the capsular bag, which protected the PC during the subsequent phacoemulsification process in the iris plate. For the other 9 cases with larger and softer nuclei, after the nucleus was partially emulsified, the IOL was inserted into the bag. Even with an obvious surge for some cases, the surgeries were uneventful in all 12 cases, with no PC rent or vitreous loss. IOL implantation into the capsular bag with a whole or partial nucleus can provide effective protection for the PC for hypermature cataract during phacoemulsification.

Spontaneous Lens Absorption Initially Misdiagnosed as Crystalline Lens Luxation

Spontaneous lens absorption (SLA) is a rare complication of hypermature cataract. However, this condition has been reported in several cases of hypermature cataracts that were caused by trauma, senility, uveitic disorders such as Fuchs' uveitis syndrome (FUS), and infectious disorders including leptospirosis and rubella. We report a case of spontaneous absorption of a hypermature cataract secondary to FUS. To our knowledge, this is the first report of SLA that was followed by dislocation of the capsular remnants into the vitreous and resulted in a misdiagnosis as crystalline lens luxation.

Clinical evaluation of two-step capsulorhexis during phacoemulsification with intraocular lens implantation for hypermature cataract / 中华实验眼科杂志

Objective To investigate the clinical effect and safety of two-step capsulorhexis in phacoemulsification with intraocular lens (IOL) implantation for hypermature cataract.Methods A non-randomized controlled clinical trial was carried out in Huaibei People's Hospital.Forty eyes of 40 patients with hypermature cataracts were enrolled from January 2016 to March 2017.The patients were divided into 2 groups according to different capsulorhexis.Two-step curvilineal capsulorhexis was used during the phacoemulsification with IOL implantation in 20 eyes of the 20 patients in the two-step capsulorhexis group (to complete a 4 mm-diameter capsulorhexis with the ripping forceps firstly and then extented the capsulorhexis diameter until 5-6 mm),and conventional curvilineal capsulorhexis was used during the phacoemulsification with IOL implantation in 20 eyes of the 20 patients in the conventional capsulorhexis group.The demography was matched between the two groups and the same foldable IOLs were used in the surgery.The uncorrected visual acuity,successful rate of capsulorhexis,intra-and post-operative complications were compared.Results The postoperative visual acuity was considerably improved both in the two groups after surgery.The UCVA in postoperative 1 day and 3 days were 4.70±0.09 and 4.70±0.08 in the two-step capsulorhexis group,which were significantly better than 4.60 ± 0.08 and 4.60 ± 0.08 in the conventional capsulorhexis group (both at P＜0.05),and no significant differences were found in the UCVA in postoperative 7 days,1 month and 3 months between the two groups (all at P＞0.05).The successful rate of capsulorhexis in the two-step capsulorhexis group was 100％ (20/20),which was significantly higher than 80％ (16/20) in the control group (x2 =4.44,P＜0.05).Posterior capsule rupture occurred in 4 eyes in the conventional capsulorhexis group,and no posterior capsule rupture was found in the two-step capsulorhexis group (x2=4.44,P＜0.05).The incidence rates of corneal edema in postoperative 1 day and 3 days were 40％ and 45％ in the conventional capsulorhexis group,which were significantly higher than 10％ and 15％ in the two-step capsulorhexis group (x2 =4.80,4.19,both at P＜0.05),and the corneas were clear in 7 days after surgery.No significant differences were found in intraocular pressure between groups and various time points (Fgroup =0.091,P =0.765;Ftime =7.048,P ＞ 0.05).Conclusions Two-step capsulorhexis during phacoemulsification with IOL implantation for hypermature cataract is safe and effective in improving the successful rate of continuous curvilineal capsulorrhexis,reducing intra-operative and postoperative complications,and it is beneficial to the recovery of postoperative visual acuity.

Deslocamento espontâneo do núcleo do cristalino para câmara anterior / Spontaneous dislocation of the lens nucleus to the anterior chamber

Resumo Ruptura espontânea da cápsula anterior do cristalino, evoluindo com deslocamento anterior do núcleo é uma complicação rara da catarata hipermadura. Relatamos o caso de uma paciente do sexo feminino, 79 anos, que se apresentou com ruptura espontânea da cápsula anterior do cristalino com deslocamento anterior do núcleo em olho direito sem histórico de trauma ocular. O diagnóstico foi confirmado pela visualização das abas da cápsula anterior, principalmente quando o núcleo foi removido. Realizamos facoemulsificação do núcleo pelo risco de descompensar a córnea. É importante destacar a raridade do caso, sendo o primeiro relatado no Brasil.

Abstract Spontaneous rupture of the anterior lens capsule, evolving with anterior dislocation of the lens nucleus is a rare complication of hypermature cataract. We report a case of a female patient, 79 years old, who presented with spontaneous rupture of the anterior lens capsule with anterior dislocation of the nucleus in the right eye with no history of ocular trauma. The diagnosis was confirmed by the visualization of the tabs of the anterior capsule, especially when the nucleus was removed. We perform phacoemulsification of the nucleus by the risk of decompensating the cornea. It is important to highlight the rarity of the case, the first being reported in Brazil.

Impact of lens thickness on complications of hypermature cataract surgery: A prospective study.

PURPOSE: To assess the correlation between lens thickness (LT) measured by ultrasonography and duration of surgery as well as complications. SETTING: The study was conducted in a hospital in the Parisian suburb of Bobigny, France. DESIGN: A prospective and monocentric study was conducted. All patients undergoing surgery for hypermature cataract between January 2013 and March 2014 were included. METHODS: Morphological features, including LT, axial length, anterior chamber depth and vitreous length were assessed using A-scan ultrasonography. The other parameters assessed were the duration of surgery, occurrence of complications during surgery, visual acuity (VA) and corneal edema score one week after surgery. RESULTS: Thirty eyes of 29 patients were included. Mean LT was 4.11±0.64mm (median: 3.89mm). Mean surgery duration was 24.2±8.7min. Three patients experienced complications during surgery: 2 capsular breaks and 1 posterior lens dislocation. At one week, the mean decimal VA was 0.49±0.34 and the mean corneal edema score was 0.76±1.09. The Pearson correlation coefficient was r=0.27 (P>0.05) between LT and surgery duration while it was r=-0.53 (P=0.01) between VA and LT. No correlation was found for the other parameters studied. DISCUSSION: In this study, the linear correlation between LT and the surgery duration was low. The visual recovery at day 7 appeared inversely correlated with the LT. CONCLUSIONS: LT did not seem to be a marker for longer surgery duration but appeared related to the visual recovery at one week.

Method of bubble under water capsulorhexis in small incision used in mature cataract operation / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To observe application of underwater bubble method capsulorhexis overmature period to improve the small incision cataract surgery, so as to explore the clinical value of the surgical method. ● METHODS: From Jul. 2012 to Mar. 2016 at the grassroots of blindness 58 people fail in the 66 eyes overmature period of cataract were randomly divided into underwent capsulorhexis by underwater bubble method to improve the small incision cataract surgery group ( 36 eyes of 30 cases ) and conventional viscoelastic agent underwent capsulorhexis small incision cataract surgery group (30 eyes of 28 cases). ● RESULTS: A total of 66 eyes in success rate of continuous circular capsulorhexis: 92% ( 33/36 eyes ) of underwater bubble method, method of viscoelastic agent only 40% ( 12/30 eyes ) . Two groups of cases of postoperative corneal endothelial cell density are compared with preoperative significantly reduced, no significant statistical difference between the two groups(P>0. 05). ● CONCLUSION: Underwater bubble method capsulorhexis difficult to overmature period of cataract surgery capsulorhexis solution is a better way.

Application of lift and squeeze technique in phacoemulsification of hypermature cataract / 国际眼科杂志(Guoji Yanke Zazhi)

AlM: To evaluate the effectiveness and security of lift and squeeze technique in phacoemulsification of hypermature cataract. METHODS: From June 2010 to June 2013, totally 156 eyes with hypermature cataract, which received phacoemulsification in our hospital, were enrolled. Lift and squeeze technique was used to chop the nucleus, and 1g/L Trypan blue was used for capsulorhexis. Average time of phaco complication, corneal edema and visual outcome were recorded. RESULTS: The best-corrected visual acuity ( BCVA ) was 0. 1-0. 4 in 15 eyes (9. 6%), 0. 5-0. 7 in 82 (52. 6%) eyes, and 0. 8-1. 0 in 59 ( 37. 8%) eyes at 3mo after surgery. The phaco time was 25-56s (average 42±10s), the maximum phaco power was 30%. Posterior capsular rupture and vitreous loss happened in 2 eyes (1. 3%), and the lOLs were implanted in the sulcus. Corneal edema classified at grade Ⅰ were seen in 12 eyes (7. 7%), and 5 eyes (3. 2%) at gradeⅡ, no eye at gradeⅢ and gradeⅣ. The mean endothelial cell loss was 8. 7%at 3mo. CONCLUSlON: Crystalline lens capsule staining with Trypan blue increase the success rate of intact continuous curvilinear capsulorhexis ( CCC ) . The lift and squeeze technique reduces the stress on the zonules and capsule, and decreases the phaco time and phaco power.

Primary posterior capsular opacification in Indian rural population undergoing cataract surgery for hypermature senile cataract.

AIM: To find out the incidence of primary posterior capsular opacification (PCO) in rural patients with a hypermature senile cataract undergoing cataract surgery. SETTINGS: Tertiary eye care center in central India. DESIGN: Prospective, observational, noncomparative study. MATERIALS AND METHODS: Two-hundred eyes of 200 patients presenting with a hypermature cataract underwent manual small incision cataract surgery. A single surgeon performed all surgeries under peribulbar anesthesia. After cortical clean-up, the capsular bag was inflated with viscoelastic. The presence or absence of opacity on the posterior lens capsule and location was noted. Postoperative follow-up was done for visual acuity and need for neodymium-doped yttrium aluminum garnet (ND:YAG) laser capsulotomy. RESULTS: Primary PCO occurred in 76 eyes (incidence of 38%). It was peripheral in 58 eyes (76.3%) and central in 18 eyes (23.7%). At 6 weeks postoperatively, best corrected visual acuity for eyes with central primary PCO (n = 18) was 0.2-0.3 logMAR and 0-0.2 logMAR for eyes with peripheral primary PCO (n = 58). Best corrected visual acuity at the 6- and 12-month follow-up was 0-0.2 logMAR in both groups. Fibrotic primary PCO was seen in four patients. No predilection for the development of primary PCO to a particular quadrant of posterior capsule was observed. At 1 year postoperatively, eleven (14.5%) patients required ND:YAG laser capsulotomy, six (7.90%) of whom underwent ND:YAG laser capsulotomy at the 6-month follow-up. Seven patients with central primary PCO and four patients with peripheral primary PCO required ND:YAG laser capsulotomy. CONCLUSION: A high incidence of primary PCO was noted in rural patients with a hypermature senile cataract undergoing cataract surgery. No serious intraoperative complications were noted. Visual outcome at 1-year follow-up was satisfactory. Need for early ND:YAG laser posterior capsulotomy should be explained to these patients before cataract surgery. No post ND:YAG capsulotomy complications were noted in any patient.

Bilateral spontaneous rupture of anterior lens capsules in a middle-aged woman.

Hypermature cataracts are commonly seen in developing countries. Spontaneous rupture of the anterior capsule, resulting in dislocation of the lens nucleus into the anterior chamber, presents rarely in hypermature cataracts. We describe a middle-aged woman who presented with spontaneous anterior dislocation of the nucleus in both eyes. The presence of calcification spots in the posterior capsule at the pupillary edge strongly suggested that our patient had hypermature cataracts. It is important to highlight this uncommon cause of nucleus dislocation in a patient with no previous history of ocular trauma.

Spontaneous anterior lens capsular dehiscence causing lens particle glaucoma.

To report acute onset lens particle glaucoma associated with a spontaneous anterior capsular dehiscence. A 66-year-old man presented with spontaneous anterior lens capsule dehiscence with an acute onset of right eye pain that was associated with white particles in the anterior chamber angle and intraocular pressure (IOP) of 55 mmHg. No trauma or other inflammatory antecedents were reported. A hypermature cataract was observed at slit lamp exam. After medical treatment without IOP control, we performed extracapsular cataract extraction and anterior vitrectomy. Anterior chamber aspirate confirmed the presence of macrophages. The postoperative IOP at one month was 16 mmHg OD without medication. Spontaneous dehiscence of the anterior lens capsule in a patient with a hypermature cataract may release lens cortical material, resulting in lens particle glaucoma. Prompt surgical removal of the lens material usually controls the high IOP, and the need for additional glaucoma surgery is not common.

Spontaneous Anterior Lens Capsular Dehiscence Causing Lens Particle Glaucoma

To report acute onset lens particle glaucoma associated with a spontaneous anterior capsular dehiscence. A 66-year-old man presented with spontaneous anterior lens capsule dehiscence with an acute onset of right eye pain that was associated with white particles in the anterior chamber angle and intraocular pressure (IOP) of 55 mmHg. No trauma or other inflammatory antecedents were reported. A hypermature cataract was observed at slit lamp exam. After medical treatment without IOP control, we performed extracapsular cataract extraction and anterior vitrectomy. Anterior chamber aspirate confirmed the presence of macrophages. The postoperative IOP at one month was 16 mmHg OD without medication. Spontaneous dehiscence of the anterior lens capsule in a patient with a hypermature cataract may release lens cortical material, resulting in lens particle glaucoma. Prompt surgical removal of the lens material usually controls the high IOP, and the need for additional glaucoma surgery is not common.

A Case of Thick Anterior Capsule of Hypermature Cataract in Down Syndrome

PURPOSE: We report a case of severe thickening of the anterior capsule in a case of hypermature cataract with Down syndrome. METHODS: A 30-year-old woman with Down syndrome underwent intracapsular phacoemulsification followed by in-the-bag implantation of an intraocular lens (IOL) under general anesthesia. Pathologic examination was performed. The anterior capsule was then incised at the 12 o'clock position by intraocular scissors because continuous curvilinear capsulorhexis (CCC) was too difficult given the thickened anterior capsule. Intracapsular phacoemulsification was followed by in-the-bag implantation of IOL and the incised anterior capsule was trimmed. RESULTS Pathologic findings of the extracted anterior capsule documented a thickening of the anterior capsule 20-fold over that of a normal anterior capsule as well as depositions of fibroblasts and collagen materials. Six months after the operation, the patient's visual acuity was 0.3 and no complication was found.

A Case of Thick Anterior Capsule of Hypermature Cataract in Down Syndrome

PURPOSE: We report a case of severe thickening of the anterior capsule in a case of hypermature cataract with Down syndrome. METHODS: A 30-year-old woman with Down syndrome underwent intracapsular phacoemulsification followed by in-the-bag implantation of an intraocular lens (IOL) under general anesthesia. Pathologic examination was performed. The anterior capsule was then incised at the 12 o'clock position by intraocular scissors because continuous curvilinear capsulorhexis (CCC) was too difficult given the thickened anterior capsule. Intracapsular phacoemulsification was followed by in-the-bag implantation of IOL and the incised anterior capsule was trimmed. RESULTS Pathologic findings of the extracted anterior capsule documented a thickening of the anterior capsule 20-fold over that of a normal anterior capsule as well as depositions of fibroblasts and collagen materials. Six months after the operation, the patient's visual acuity was 0.3 and no complication was found.

Phacoemulsification in Hypermature Cataract

Phacoemulsification in hypermature cataract has not been recommended for routine procedure because of the difficult techniques and the possibility of high complication rates.48 eyes of 48 patients with hypermature cataracts were operated with phacoemulsification by one surgeon.The complications related to the status of continuous circular capsulorrhexis (CCC) were prospectively studied for three years.25 eyes (52.1%)had complete CCC and 23 eyes (47.9%)had incomplete CCC, and in 6 (12.5%)of these 23 eyes, posterior capsular rupture was occurred.Decentration of intraocular lens more than 1mm, occurred in 4 eyes (8.3%)with 3 or more radial tears. These results shows that phacoemulsification in hypermature cataract can be considered relatively safe procedure with recent techniques.CCC is also regarded as one of the most important procedures in hypermature cataract as in normal cataracts in reducing complications during and after the operation.

Treatment of Choroidal Detachment After Trabeculectomy

Choroidal detachment has frequently been found to be a complication following trabeculectomy. However there remain many controversies about the indication and the timing as to when to perform choroidal drainage. Of 131 cases of trabeculectomy from July 1990 to to June 1991 choroidal detachment was developed in 5 eyes of 4 patients with glaucoma. Among them, 2 cases were treated medically and 3 cases surgically. We classified anterior chamber depth according to grading system and made it the guideline for treatment. As choroidal detachment developed, we used medical therapy including more frequent topical application of cycloplegics and steroids, and observed anterior chamber reformation. When grade III anterior chamber the situation where central cornea touches on lens surface persisted 12 to 24 hours, we performed anterior chamber reformation, sclerotomy and choroidal drainage During the follow-up period (mean, 7 months), all cases except one were controlled without medication, but 1 case developed hypermature cataract 1 month after choroidal drainage, with increased intraocular pressure and conjunctival bleb disappeared. Once choroidal detachment develops, rapid medical treatment is necessary. If medical therapy fails, prompt surgical reformation of the anterior chamber along with drainage of any suprachoroidal fluid is needed in grade Ill anterior chamber.