“Egg in the eye appearance” of traumatic pre-existing posterior capsular defect presenting as near-total cataract

Abstract

A 10-year-old girl was brought by her parents with complaints of a sudden drop in vision in the left eye (LE) with the appearance of a white reflex for a 1-month duration. There was a history of needle stick injury to the LE 5 years ago which was conservatively managed elsewhere. Previously, she had a vision of 6/9, N6 LE, with glasses as per her old records. The best corrected visual acuity (BCVA) was 6/6, N6 right eye (RE), hand motion (HM), and <N36 LE at the time of presentation. There was a small corneal scar at the 3 o'clock position in the peripheral cornea of the LE. Dilated examination of LE revealed near-total cataract, an intact anterior lens capsule, and a large elliptical area of pre-existing posterior capsular defect (PPCD) resembling an “egg in the eye appearance” [Figure 1]. Ultrasonography (USG) B scan of the LE showed the characteristic “fishtail sign” and confirmed the herniation of the lens matter through posterior capsular dehiscence into the anterior vitreous cavity [Figures 2 and 3] with an intact retina.Figure 1: Intra-operative picture of the LE taken after nicking the anterior capsule showing the fibrosed edges of the large elliptical posterior capsular dehiscenceFigure 2: Ultrasound B scan of the LE showing conical protrusion of the breached posterior lens capsuleFigure 3: Ultrasound B scan of the LE showing “fishtail sign” with herniation of the lens matter into the anterior vitreous cavity through the posterior capsular dehiscenceThe patient underwent a careful continuous curvilinear capsulorhexis (CCC), bimanual irrigation–aspiration of the lens matter, and anterior vitrectomy with reduced parameters of low bottle height, low irrigation, and aspiration, taking care to avoid hydro-dissection and shallowing of the anterior chamber. Intra-operatively, the large posterior capsular dehiscence [Figure 4] was carefully evaluated and cleared off any vitreous incarceration. A foldable three-piece intraocular lens (IOL) was implanted in the ciliary sulcus [Figure 5]. Post-operatively, the patient did well and regained 6/6, N6 vision in the LE, and remained the same until the last follow-up after 1 year [Figure 6].Figure 4: Intra-operative picture of the LE showing the large elliptical posterior capsular defect after lens aspirationFigure 5: Intra-operative picture after intraocular lens implantation into the LEFigure 6: Clear visual axis on follow-up after 1 yearDISCUSSION The history of past needle stick injury in our patient with sudden transformation into near mature cataract later points toward the presence of a PPCD which gradually caused microleakage and rapid maturation of the cataract. A dilated examination using a slit lamp and under an operating microscope helped to identify the thick, well-demarcated, elliptical borders of the PPCD, through the near-total cataract simulating an “egg in the eye” appearance. The thickened and fibrosed margins of the PPCD have been attributed to the migration of the hyperplastic epithelial cells to this region.[1] USG B scan confirmed the PPCD with lenticular matter hanging in the vitreous cavity (fishtail sign).[2] Other clinical signs which have been described in the literature include white demarcation lines and white crystalline particles floating in the vitreous, but they may not be evident in all white cataracts with PPCDs.[2] A relatively smaller CCC, closed-chamber bimanual irrigation–aspiration with reduced parameters (low bottle height, irrigation, and aspiration), avoiding hydro-dissection and shallowing of AC, controlled anterior vitrectomy, and switching between the cut and aspiration modes to remove the prolapsed lens matter and vitreous are essential to ensure a clear visual axis and safe IOL implantation.[2] CLINICAL SIGNIFICANCE All total cataracts are not the same, and surgery without a thorough history, careful examination, and proper planning could be catastrophic to the patient. Surgical management in pediatric cataracts with PPCD remains a challenge due to the increased risk of lens matter drop in the vitreous cavity. Identifying the PPCD, explaining the potential risks to the patient, and taking adequate precautions to avoid lens matter drop are vital steps to a successful outcome. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and her parents have given their consent for images and other clinical information to be reported in the journal. The patient and her parents 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 Nil. Conflicts of interest There are no conflicts of interest. Acknowledgements The patient and her parents are acknowledged.