A 72-year-old woman states that her left eye became red and painful two days ago.
What is the differential diagnosis of a red, painful eye?
The ddx is extensive, but the most common diagnoses are: foreign body (conjunctiva or cornea), conjunctivitis, corneal abrasion, corneal ulcer, keratitis, episcleritis, scleritis, uveitis, and angle closure glaucoma. A detailed history helps narrow the ddx and examination allows accurate diagnosis.
Additional information: The patient notices slightly blurry vision and describes the pain as an ache in the eye and is particularly bothered by bright light. She denies any discharge, recent infection, trauma, or contact lens wear. Her past ocular history is notable for cataract surgery OU two and a half years ago. Her last eye exam was one year ago at which time her vision was 20/20 OU, posterior chamber lens implants were in good position and the posterior segment exam was normal. On examination today, her vision is 20/20 OD and 20/25 OS, anterior segment appearance of the left eye is shown in the slit lamp photo below:
What unusual finding is present?
There is a small lens fragment in the anterior chamber overlying the iris just below the pupil.
What additional findings would you expect to see?
Retained lens material causes inflammation. Findings include conjunctival injection and anterior chamber cells and flare; there may also be focal corneal edema, elevated intraocular pressure, and cystoid macular edema.
Additional information: Examination shows mild AC cells/flare, normal IOP, and minimal corneal edema. The retained lens fragment, a thin triangular wedge measuring approximately 3.0mm (height) x 1.0 mm (base) x 0.5 mm (thickness), is trapped between the iris and cornea in the inferior anterior chamber.
How would you manage this patient?
Management depends on the type and size of lens fragment. The inflammation is treated with a topical steroid and often an NSAID is prescribed as well. The IOP must be monitored and treated promptly if it becomes elevated. Small pieces of cortex and epinucleus tend to resolve over time and usually do not require surgical removal if the inflammation and IOP are controlled; however, nuclear fragments tend to cause more severe inflammation (i.e., AC reaction, corneal edema, and macular edema), do not resorb quickly, and require extraction.
Follow up: The patient was started on Pred Forte every 2 hours and 1 week later her IOP and AC reaction was unchanged, and the lens fragment was smaller (2 x 1 mm) and had settled into the inferior angle. There was no overlying corneal edema. Here is the slit lamp photo:
However, on the next follow up visit a week later, she reported a decrease in vision as well as more redness and discomfort of her eye for 1 day. Exam revealed no change in the appearance of the lens fragment, but there was 2+ stromal edema of the inferior cornea with Descemet’s folds extending through the visual axis. Visual acuity was 20/100, the IOP was normal, and the AC reaction was still mild. The patient underwent uncomplicated removal of the lens fragment the next day. An intraoperative image of the eye is shown below:
Discussion: This case is a reminder that retained lens material after uncomplicated phacoemulsification can present spontaneously even years later. In fact, this has been reported as late as 8 years after cataract surgery. Retained lens fragments probably occur more commonly than we are aware, but fortunately this material stays sequestered under the iris in the ciliary sulcus where it does not cause any problems. When lens material becomes dislodged into the anterior chamber, accurate diagnosis and prompt treatment are necessary, and the surgeon’s threshold for removal of the lens fragment should be low, certainly as soon as sequelae (elevated IOP, corneal edema, and macular edema) occur.