A Case of Pediatric Cataract

This week I am taking up a case of pediatric cataract. There are no diagnostic dilemmas in this case!
A 4-year old boy with developmental cataract managed with the current gold standard treatment- lens aspiration, posterior capsulorhexis, anterior vitrectomy and PC IOL implantation. The accompanying video shows all the steps of the surgery in detail.
The key to a successful surgery in such cases is that the surgeon should adhere to the standard protocol during all surgical steps. Each step, as highlighted in the video, is important on it's own. Unlike adult cataract surgery, there is very little margin of error in these cases.

However, one should remember, a successful surgery is only the beginning of the treatment of developmental cataract. Final visual outcome is dependent on meticulous follow up including timely refractive corrections, amblyopia therapy and intraocular pressure monitoring.
I am looking forward to your comments!

A Strange Growth 'in' the Cornea

A 4-year-old boy presented with complaint of progressive diminution of vision (Visual Acuity: 3/60) in left eye for the last 2 months. He gave history of trauma to right eye sustained with a broom stick 3 months back. Slit lamp examination showed a cystic structure in cornea with normal epithelium and corneal stroma (Fig. 1).

AS-OCT (Visante) showed a cyst of homogenous moderate reflectivity originating from inferior angle with a clear separation from iris, pupil, and lens, and attached to endothelium (Fig. 2).

Corneal epithelium and stroma appeared uninvolved by cyst. The patient underwent cyst aspiration and excision of mouth of the cyst.
On follow-up, although some corneal haze still persisted (Fig. 3), a significant improvement in vision (6/12) was noted. AS-OCT showed no residual cyst at 1 year of follow-up (Fig. 4).

Take Home Message

• Corneal cysts are a rare entity.
• Documenting complete extent of lesion is very important, especially in phakic patients for a sound surgical plan.
• AS-OCT can be a useful investigative modality that can help to clearly delineate extent of the cyst and can also be used as a monitoring tool postoperatively to ensure complete removal.

A Phony Case of Corneal Ulcer Following RK

A 38-year-old man presented with complaint of sudden onset of whiteness in right eye. The patient was being treated elsewhere as a case of corneal ulcer with no improvement in symptoms since 15 days.
PAst history was significant for the fact that he had undergone Radial Keratotomy (RK) in both
eyes 15 years back.
Slit lamp examination showed a white edematous appearance of cornea with minimal congestion
(Fig. 1) . There were multiple RK scars in both eyes.

Anterior-segment optical coherence tomography (AS-OCT) (Visante) demonstrated an edematous cornea in the center with a localized descemet’s membrane detachment allowing aqueous  into the corneal stroma
(Fig. 2).

Based on clinical examination and AS-OCT findings, a diagnosis of acute corneal hydrops in the right eye was made.
The patient was started on a course of Prednisolone 1%, Homatropine 2%, and oral Acetazolamide for a period of 3 weeks. On follow-up, corneal edema disappeared with improvement of visual acuity to 6/36 on Snellen’s chart at 3 weeks.

Takeaway Message

• The absence of cilliary congestion, pain, anterior chamber reaction and epithelial defect made the diagnosis of corneal ulcer unlikely in this case.
• Although Radial Keratotomy is no longer practiced, older patients who have undergone RK can still present with complications.
• Hydrops, though a rare complication, can be seen in such cases. AS-OCT can be a helpful modality to clearly delineate Descemet’s membrane rupture in such cases

A Curious Case of Late Onset Vision Loss after Cataract Surgery

A 70-year old man presented with gradual diminution of vision in left eye since 2 years and was referred for YAG laser for Posterior capsular opacification in left eye from elsewhere. He had previously undergone cataract surgery in both eye 10 years back with good visual recovery. On examination, vision in right eye was 6/12 and in the left eye, 3/60.
Slit lamp examination of left eye showed a dense white opacity behind the IOL along with suspected distension of the capsular bag (Figure 1).

AS-OCT confirmed the clinical findings in the left eye showing a hyperintense signal between the posterior capsule and the IOL (Figure 2).

Diagnosis of Left eye Capsular Distension Syndrome was made.
The patient subsequently underwent surgical decompression of the capsular bag along with enlargement of the capsulorhexis to prevent future recurrence of the condition (Video).

Postoperatively, BCVA improved to 6/18 (+1DS -2DC X90) in left eye. The visual axis was clear, with disappearance of the opacity and the eye was quiet (Figure 3).

Postoperative ASOCT also showed absence of hyper intense shadows between the capsule and the IOL (Figure 4).

Take Home Message

• Not all cases of visual axis opacification following cataract surgery are due to posterior capsular opacification.
• In cases where the capsulorhexis is much smaller than the IOL optic, conditions like anterior capsular phimosis and capsular distension syndrome can cause late onset loss of vision.