Traumatic phacocele: review of eight cases.

Blunt trauma can result in indirect scleral rupture with subsequent dislocation of the crystalline lens in the subconjunctival or subtenon space. This retrospective review of eight patients with traumatic phacocele highlights the clinical presentation, management and visual outcome. This study provides evidence that timely and effective intervention can ensure good visual recovery.

Blunt trauma has protean ocular manifestations with phacocele being a rare event, resulting from indirect scleral rupture of the globe. The eye has been described to behave like an incompressible sphere because of its liquid contents.1 Hence, blunt trauma of sufficient magnitude can result in rupture of the eyeball either at the site of impact (direct) or in a remote area (indirect). This indirect rupture of sclera leads to dislocation of the crystalline lens into the subconjunctival or subtenon space. We report eight patients with traumatic phacocele with an aim to evaluate the clinical presentation, management and visual outcome.

Case Report

The present case series is a retrospective review of eight patients out of a total of 10 patients of traumatic phacocele, between July 2000 and June 2004. Two cases of phacocele were excluded, out of which one was associated with high myopia and another case had undergone previous glaucoma surgery.

The data were compiled from evaluation of clinical records to document the clinical course, details of management and visual outcome. Diagnosis of phacocele was based on history of blunt trauma, presence of a well-delineated subconjunctival mass and aphakia with intact bulbar conjunctiva and cornea. Detailed slit-lamp biomicroscopic examination and B-scan ultrasonography was done in every case.

Exploration and surgical repair of ruptured sclera along with lens removal and anterior vitrectomy was performed in every case. The decision of intraocular lens implantation with scleral fixation was taken at the time of repair, based on the extent of ocular injury noted.

The age of the subjects ranged from 11 to 76 years with a mean of 49±21.2 years [Table]. Males predominated in a ratio of 3:1. The mean follow-up period was 14 months. The cause of impact was wood piece (n=2), fist (n=3), coconut leaf broom (n=1) and metallic rod (n=2). Preoperative best corrected visual acuity (BCVA) ranged from hand movement (n=2) to perception of light (n=6). Slit-lamp examination revealed diffuse subconjunctival hemorrhage with a well-delineated subconjunctival mass in all cases [Fig. 1]. Lid ecchymosis along with conjunctival chemosis and corneal edema was observed in five eyes. Anterior chamber was deep with varying amounts of hyphema and inflammatory reactions in all cases along with some degree of vitreous hemorrhage detected by ultrasonography.

Table 1

Demographic profile and clinical features of the patients

Figure 1

Superonasal phacocele (Case 2)

All eyes were aphakic, with the luxated lens being subconjunctival. In four eyes there was uveal tissue prolapse at the site of scleral rupture. Intraocular pressure was non-recordable by non-contact tonometer (Reichert, AT 550, model no-13901) due to hypotony. The sites of scleral rupture were superonasal quadrant (n=4), superior quadrant (n=2) and superotemporal quadrant (n=2). The mean interval between trauma and seeking consultation was 11 days (1 to 31 days). All patients were managed surgically within a day of reporting. The shapes of the scleral rupture were S-shaped (n=2) and curvilinear of varying length (n=6). The chord length of the rupture was calculated by taking into account the distance between the two extreme ends of the ruptured sclera directed circumferentially, measured with a caliper under operating microscope. The maximum chord length of rupture was 13 mm with minimum being 6mm. The closest distance of the ruptured scleral site from the limbus was 2.5 mm (n=1); 2 mm (n=5) and 0.5 mm (n=2).

Surgical intervention included exploration of wound under general anesthesia and management by lens removal, anterior vitrectomy and repair of wound in all cases [Fig. 2]. Minimal abscission of prolapsed uveal tissue had been done in four eyes. Scleral fixation of intraocular lens was performed either during the initial repair (n=4) [Fig. 3] or after three months of the primary repair (n=3). However, aphakic correction was done by contact lens in one patient due to extensive scleral rupture amounting to 13 mm chord length. Final BCVA at 12 months postoperative period ranged from 20/20 to 20/100 (n=6). Visual acuity did not improve in two eyes because of thick macular epiretinal membrane, identified in the postoperative follow-up period.

Figure 2

Surgical exploration of the phacocele (Case 1)

Figure 3

Scleral fi xation of intraocular lens (Case 1)

Discussion

This retrospective review summarizes our four years′ experience of clinical presentations and management of phacocele in an academic practice. Phacocele has been reported to comprise 13% of all lens luxations.2 It was first reported by Fejér in 1928.3 The predominant site of indirect scleral rupture is the superonasal quadrant4 followed by the superotemporal quadrant.1 The scleral rupture frequently occurs between the limbus and spiral of Tillaux.1

In the present series, phacocele was most common in the superonasal quadrant. A similar finding was also reported by Yurdakul et al.5 However, Charan and Mathur6 reported inferior displacement and Krámar et al.7 reported superotemporal displacement of lens following blunt trauma. Subconjunctival luxation of crystalline lens is very rare in children due to elasticity of outer coats of the globe and softer crystalline lens. The authors encountered superior luxation of partially absorbed lens following blunt trauma with a coconut leaf broom in a child of 11 years. This result is therefore not in agreement with the conclusion of Fejér,3 that phacocele occurs exclusively in the elderly beyond 40 years of age. In that child, the scleral rupture occurred in the internal scleral sulcus region. The authors feel that the inherent weakness of this zone due to the presence of Schlemm′s canal and the perforating blood vessels might have predisposed the child to phacocele.

In the present series, the final BCVA was 20/20 in two patients. In both these patients, the scleral rupture was repaired on day one of injury with primary scleral fixation of intraocular lens. In two of the cases, treatment failed to improve vision beyond perception of hand movements as both had extensive scleral disruption and developed thick macular epiretinal membrane. Four patients had BCVA of 20/100 at six weeks postoperative period. Vitreous opacities were the cause of interference of visual outcome in these four cases.

In conclusion we would like to emphasize that though the most common victims of blunt trauma are young individuals, phacocele is seen much more frequently at a later age because of the increased scleral rigidity and hard crystalline lens. This study provides evidence that timely and effective intervention can ensure good visual recovery.