Retained Nuclear Fragment in the Anterior Segment

Several studies have examined the management of retained nuclear fragments in the posterior segment of the eye.^1,2 Bohigian and Wexler³ recently treated 2 patients with nuclear fragments in the anterior chamber of their eyes after phacoemulsification. We also treated a patient with a retained nuclear fragment in the anterior segment of the eye.

An 86-year-old woman underwent a phacoemulsification cataract extraction with posterior chamber intraocular lens implantation in the right eye. Her visual acuity improved to 20/25 OD 1 month postoperatively. A persistent anterior chamber reaction was noted 6 weeks postoperatively following tapering of 1% prednisolone acetate. She had a sudden decrease in vision 10 weeks later. Visual acuity had diminished to 20/200 OD. Slitlamp examination showed a wedge-shaped area of corneal edema (Figure 1). Trace cell and flare were present in the anterior chamber. Gonioscopy revealed a small lens fragment in the inferior angle (Figure 2).

Hourly, 1% prednisolone acetate was administered. There was no improvement after 1 week, and she underwent removal of the lens fragment through a temporal incision. We used 2% pilocarpine hydrochloride preoperatively for pupillary constriction, and intraoperative gonioscopy was performed to localize the fragment. Histopathologic examination revealed eosinophilic tissue arranged in lamellae consistent with lens nucleus. The most recent follow-up examination, 2 months after removal of the fragment, showed improvement of the corneal edema, and the patient's visual acuity had improved to 20/30 OD.

We hypothesize that the lens fragment in our patient remained sequestered behind the iris for several months after cataract surgery and produced a chronic, low-grade inflammation. It later migrated into the anterior chamber, gravitating to the inferior angle and resulting in the acute onset of inferior corneal edema. A similar pattern of migration of intraocular foreign bodies into the anterior chamber angle has been reported previously.⁴ Like intraocular foreign bodies in the anterior segment, nuclear fragments can incite a prolonged inflammatory reaction or mechanically damage the endothelium, leading to localized corneal edema.⁴

There are similarities between our patient and the 2 patients previously described by Bohigian and Wexler.³ Persistent corneal edema and mild inflammation characterized all eyes with retained nuclear fragments in the anterior segment. As with the prior cases, topical corticosteroid therapy was ineffective in our patient and surgical removal of the nuclear fragment was required to improve the corneal edema. Because retained lens fragments can migrate when changes in posture occur, we recommend preoperative treatment with pilocarpine to constrict the pupil and decrease the likelihood of migration behind the iris. Intraoperative gonioscopy before removal is also crucial for accurate localization.

Reprints: Steven J. Gedde, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136 (e-mail: sgedde@bpei.med.miami.edu).