Evaluation of Posterior Capsule Integrity by Ultrasound Biomicroscopy After NonPenetrating Blunt Tra

1
Evaluation of Posterior Capsule Integrity by
Ultrasound Biomicroscopy After NonPenetrating
Blunt Trauma

• Jose de la Cruz Napoli MD 1, 2
• Alfonso Ponce MD 2
• Julian Garcia MD 2
• Douglas Buxton MD 2
• 1 Cornea/Refractive Surgery Service University of
  Illinois Eye and Ear Infirmary
• 2 Trauma Service, New York Eye Ear Infirmary

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Case Presentation

• 65 y/o male with history of self inflected blunt
  trauma OD while opening a can with a screwdriver
  with refractory increased IOP. No previous
  ocular or medical history. Vsc OD HM, OS 20/150
  ph 20/70. IOP mmHg OD 45, OS 13. No iris
  irregularities noted. EOMs intact.

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• Conjunctiva
• OD 1 mm conj laceration superiorly, 3 mm conj
  laceration nasally with underlying sub conj heme.
  Intact sclera
• Cornea
• OD 3 microcystic edema, no evidence of corneal
  penetration.
• Anterior Chamber
• OD Deep chamber, 3 cell flare, increased
  space between iris and anterior capsule. No
  hyphema, hypopion or KP noted.

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• Angle
• OD Poor visualization of angle structures but
  no obvious recession or dialysis.
• Lens/Capsule
• OD Anterior capsule intact with an irregular,
  wrinkled surface. No view past anterior capsule.
• Fundus exam
• No view.

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UBM OD

• Intact anterior capsule with cortical debri,
  posterior capsular rupture, aphakia, zonules
  intact.

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B-Scan OD

• Vitreous opacities. Dynamic exam showed a
  hyper-echogenic material suggestive of nuclear
  material (from supine to upright position).

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Clinical Course Surgical Course

• IOP continued elevated despite maximum
  medical therapy including systemic agent such as
  acetazolamide and glycerol.
• A diagnosis of phacolytic glaucoma secondary to
  traumatic posterior capsular rupture with
  expulsion of cataractous lens was made
• Mannitol given to prepare the patient for
  surgery.

• Parsplana vitrectomy
• Parsplana lensectomy
• Anterior central capsulotomy
• Removal of nucleus from posterior pole postpone
  IOL placement to maximize visual rehabilitation
  in second surgery
• 6 weeks later, secondary IOL placement of lens in
  sulcus, (clear cornea approach, 3 piece lens,
  VAsc 20/40)

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Posterior Capsular Rupture

• Although blunt ocular trauma frequently damages
  the crystalline lens, isolated rupture of the
  posterior capsule is an infrequently reported
  occurrence
• Isolated rupture caused by acute stretching
  forces caused by blunt injury
• If the posterior capsular break is large, lens
  hydration progresses rapidly and an intumescent
  cataract will develop shortly after trauma
• Increased intracapsular volume tears the capsular
  break further or causes the prolapse of the lens
  cortex into the vitreous

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• Ultrasonography is indicated in ocular trauma to
  search for retinal detachment, choroidal
  hemorrhage, retained IOFB, posterior scleral
  rupture and vitreous incarceration into the
  wound, all of which have been considered
  important indicators for planning vitreo-retinal
  surgery. B-Scan allows high quality topographic
  analysis of the globe combined with real time
  kinetic evaluation.

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• Ultrasound Biomicroscopy (UBM) is an elegant
  method of imaging the anterior segment and
  ciliary body 50 to 100 MHz B-scan probe that
  provides markedly enhanced resolution of the
  anterior ocular structures and scanning fields up
  to 15mm in width and depth.
• The combination of UBM together with B-scan is a
  valuable tool in diagnosing an otherwise
  intraoperative diagnosis of posterior capsular
  rupture and expulsion of nuclear material to the
  posterior pole

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Conclusion

• The ability of the UBM to provide high resolution
  images of the anterior segment allowed for
  adequate visualization of angle/lens/capsular
  structures despite a limited view by slit lamp
  examination. It also provided important
  pre-operative information therefore allowing to
  choose an adequate surgical plan.
• Ultrasound Biomicroscopy is a useful tool in the
  diagnosis and assessment of capsular support as
  well as zonular integrity after non penetrating
  blunt trauma to the eye.