Golden half ring sign for identification of pseudophacocele.

Dislocation of intraocular lens (IOL) is a serious complication of blunt ocular trauma in pseudophakic eyes. Here, a 72-year-old male patient with subconjunctival dislocation of an IOL (pseudophacocele) secondary to bull horn injury was reported. In this case report, a new sign named as "golden half ring sign" was described for easy identification and localization of subconjunctival dislocation of IOL in patient with open globe injury (surgical wound dehiscence) associated dense subconjunctival hemorrhage.

Ocular trauma in pseudophakic eye can lead to dislocation of intraocular lens (IOL). IOL may dislocate in a subconjunctival space, anterior chamber, vitreous, suprachoroidal space or sometimes outside the eyeball.[123456] The subconjunctival dislocation of IOL also referred to as “pseudophacocele”. It was first described by Biedner et al. in 1977.[1] Hereby a rare case of traumatic pseudophacocele with a new sign termed as “golden half ring sign” for identification and localization of subconjunctival dislocated IOL in open globe injury (surgical wound dehiscence) associated with dense subconjunctival hemorrhage has been described.

Case Report

A 72-year-old male patient presented with complaints of pain, redness, loss of vision in his right eye following facial bull horn injury 2 days back. Patient had a history of manual small incision cataract surgery with polymethyl methacrylate (PMMA) IOL implantation in his right eye 5 years back and had good vision before injury. His visual acuity was perception of light with inaccurate projection of rays in his right eye and 20/20 in the left eye. Ophthalmic examination of the right eye showed soft eyeball and no conjunctival lacerations. The bulbar conjunctiva had dense subconjunctival hemorrhage, iris tissue and bulging of conjunctival hematoma at 11 to 2 O’clock of limbus [Figs. 1 and 2]. The anterior chamber showed total hyphema. No IOL was seen in diffuse illumination. The bright oblique (45°) slit-lamp beam of 10 mm × 2 mm size was used to scan the whole conjunctiva. During scanning of temporal bulbar conjunctiva, an inverse “C” shaped golden illumination appeared underneath subconjunctival hemorrhage, which represented the edge of the optic of IOL [Fig. 3a and b]. A small illuminated spur was also observed in golden half ring which represented broken optic-haptic junction. Ophthalmoscopy failed to visualize the posterior segment due to total hyphema. Patient underwent right eye globe exploration under local anesthesia. Intraoperative observation revealed dehiscence of manual small incision cataract surgery wound at 11 to 2 O’clock, which was 2 mm away from the limbus with total detachment of iris. There was a complete rupture of posterior capsule. The detached iris tissue, a single piece, square edge, PMMA IOL with broken haptic was seen underneath dense subconjunctival hemorrhage of temporal bulbar conjunctiva. The detached iris tissue, IOL and broken haptic were removed [Fig. 4a and b]. Anterior vitrectomy and hyphema drainage were performed. Wound was closed with 8–0 nylon interrupted sutures.

Figure 1

Slit-lamp photograph of the patient showing total hyphema (black arrow), and bulging of subconjunctival hematoma at superior limbus representing old small incision cataract surgery wound dehiscence (white arrow)

Figure 2

Slit-lamp photograph showing dense subconjunctival hemorrhage with brounish discoloration due to iris tissue in temporal bulbar conjunctiva. White arrow indicating location from where of intraocular lens was recovered

Figure 3

(a) The bright oblique (45°) slit-lamp beam (arrow) of 10 mm × 2 mm size was used to scan temporal bulbar conjunctiva for identification of dislocated intraocular lens (IOL) in subconjunctival space. When light beam was thrown on edges of optic of IOL, a inverse “C” shaped golden illumination (curved arrow) appeared on opposite part of optic of IOL underneath subconjunctival hemorrhage. A small illuminated spur (arrowhead) was also observed in golden half ring which represented broken optic-haptic junction. (b) Line diagram representing a

Figure 4

(a) Intraoperative photographs showing recovered intraocular lens with broken haptic. (b) Recovered broken haptic

Postoperatively, patient received atropine 1% for 1-week and topical moxifloxacin 0.5% 6 times a day and prednisolone 1% in tapering doses for 6 weeks. Postoperative B-scan ultrasonography of the right eye revealed disorganized globe with total detachment of retina and choroid, and vitreous hemorrhage. His visual acuity remained unchanged during 3 months follow-up.

Discussion

Subconjunctival dislocation of IOL is rare but serious complication of blunt ocular trauma.[67] Dislocated IOL can be identified with the help of slit-lamp, ophthalmoscopy, B-scan ultrasonography and ultrasoundbiomicroscopy (UBM).[12345678] B-scan and UBM are relatively contraindicated in open globe injury due to the risk of infection and intraocular content extrusion.[910] Dense subconjunctival hemorrhage with or without iris tissue in front of dislocated IOL may make difficult to identify it in diffuse illumination of the slit-lamp as seen in the present case. Trauma is the most common cause of pseudophacocele hence it is frequently associated with hyphema or vitreous hemorrhage therefore ophthalmoscopy may not be useful.[568] In the present case, oblique (45°) slit-lamp beam of 10 mm × 2 mm size when incidentally thrown on edge of optic of IOL resulted in appearance of golden ring on opposite half-edge of optic of IOL. This happened due to total internal reflection of light occurring inside the IOL optic.[11] This phenomenon is similar to the transmission of light through fiber-optic cable used in vitreo-retinal surgery. The broken optic-haptic junction was also clearly visualized with this technique.

Management of dislocation of IOL and visual outcome depends on many factors such as posterior capsule status, vitreous loss, condition of the iris, retinal detachment, and associated intraocular damage.[7121314] The globe was disorganized, therefore, our aim was just to restore anatomical integrity of the eyeball. So far as the authors are aware, the golden half ring sign has never been described in the literature. Exact localization of dislocated IOL may minimize conjunctival handling during exploration of dislocated IOL in a subconjunctival space however, it did not change final visual outcome for the patient. Long standing broken IOL or part in a subconjunctival space has risk of scleral erosion and globe perforation. The ophthalmologist should be aware about this “golden half ring sign” for easy identification and localization of dislocated IOL in a subconjunctival space in cases of open globe injuries associated with dense subconjunctival hemorrhage.