Abstract
Purpose
To report fibrotic cataract as a sign of posterior capsule violation post vitrectomy.
Observations
A 16 year old female presented to our retina clinic after multiple prior vitrectomies at an outside hospital for traumatic retinal detachment. On presentation, it was noted that she still had a silicone oil inside the eye, and a dense, fibrotic cataract limiting the posterior pole view. The decision was made to pursue cataract phacoemulsification plus silicone oil removal. We utilized the Zepto capsulotomy system given the white cataract. After gentle bimanual irrigation and aspiration of the cataract, it was discovered there were two small, round, posterior capsule defects with fibrosis around these holes that extended anteriorly, involving the capsular fornix and anterior capsule. This was confirmed intraoperatively on heads-up OCT. A three-piece intraocular lens was placed into the capsular bag, but given the contracted capsular fornix, the IOL was decentered inferonasally, so it was repositioned in the sulcus with good centration.
Conclusions
It is known that pars plana vitrectomy leads to accelerated cataract formation postoperatively. This case report is the first to our knowledge that describes a fibrotic cataract as a sign of posterior capsular violation.
Importance
We demonstrate that presence of fibrotic cataract post vitrectomy should raise suspicion for capsular violation and should prompt further discussion with the patient regarding appropriate surgical planning and expectations.
1
Introduction
Multiple studies have demonstrated that 60–98% of older patients develop a cataract within two years following pars plana vitrectomy. The most common cataract to form is nuclear sclerosis, with posterior subcapsular cataracts also commonly found. , Herein, we detail a report of a patient presenting with a fibrotic cataract following a pars plana vitrectomy for retinal detachment. Intraoperatively, there was evidence of posterior capsule violation from the initial retinal surgery. No such other reports of a fibrotic cataract as a sign of iatrogenic capsular violation exist in the known literature.
2
Case report
A 16-year-old female presented to our emergency room for decreased vision in the left eye. She had a past ocular history of traumatic retinal detachment of the left eye treated with multiple vitrectomies in Colombia over a 1–2 year time frame prior to presentation and surgery with our service. The emergency room determined her decreased vision was secondary to a new cataract in the left eye, and she was referred to our clinic.
On initial evaluation, visual acuity in the left eye was hand motion with and without correction and intraocular pressure was 12 by non-contact tonometry. Her exam demonstrated a white cataract in the left eye with a poor view posteriorly. Initial ocular ultrasound showed a slightly enlarged globe due to intraocular silicone oil, with the retina grossly attached. The decision was made to remove the silicone oil in combination with cataract surgery.
During surgery, trocars were first placed in the inferotemporal, superotemporal, and superonasal quadrants. The Zepto capsulotomy system (Centricity Vision, Carlsbad, CA) was employed given the fibrotic appearing cataract ( Fig. 1 ). Immediately after energy was applied, it was noted that the capsulotomy was larger than the reported average 5.0 mm capsulotomy produced using the Zepto capsulotomy system. This was presumed to be due to release of significant contracture of the anterior capsule centrally. Additionally, the anterior capsule was visibly adherent to the underlying lens in the superotemporal quadrant over the area of densest fibrosis. The fibrosis was lysed using intraocular scissors and forceps (MicroSurgical Instruments, Redmond, WA). Hydrodissection was avoided since they cataract was fibrotic and the status of the posterior capsule was unknown. Bimanual irrigation/aspiration was performed to remove the chalky cataract fragments. As the case progressed, it was noted that the fibrotic cortical material was emanating from the superotemporal quadrant. After careful examination, two small, round posterior capsule defects with fibrotic material surrounding them were discovered through which silicone oil was emanating forward into the capsular bag ( Fig. 2 ). Intraoperative heads-up OCT (Carl Zeiss Calisto, Oberkochen, Germany) was utilized to verify that the fibrotic material originated at these two posterior capsule defects and wrapped anteriorly around the capsular fornix and onto the anterior capsule ( Fig. 3 ).
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