Evaluation of Posterior Capsule Integrity by Ultrasound

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					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
   1Cornea/Refractive Surgery Service University of
            Illinois Eye and Ear Infirmary
   2 Trauma Service, New York Eye & Ear Infirmary
            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. EOM’s
• 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
• 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
• Fundus exam
  – No view.
                    UBM OD
Intact anterior capsule with cortical debri, posterior
      capsular rupture, aphakia, zonules intact.
            B-Scan OD
Vitreous opacities. Dynamic exam showed a
hyper-echogenic material suggestive of nuclear
   material (from supine to upright position).
  Clinical Course                             Surgical Course
  IOP continued elevated despite              •   Parsplana vitrectomy
   maximum medical therapy including          •   Parsplana lensectomy
   systemic agent such as acetazolamide       •   Anterior central capsulotomy
   and glycerol.                              •   Removal of nucleus from posterior
                                                  pole postpone IOL placement to
• A diagnosis of phacolytic glaucoma              maximize visual rehabilitation in
   secondary to traumatic posterior               second surgery
   capsular rupture with expulsion of         •   6 weeks later, secondary IOL
   cataractous lens was made                      placement of lens in sulcus, (clear
                                                  cornea approach, 3 piece lens,
• Mannitol given to prepare the patient for       VAsc 20/40)
    Posterior Capsular Rupture
• Although blunt ocular trauma frequently
  damages the crystalline lens, isolated rupture of
  the posterior capsule is an infrequently reported
• 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
• 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
• 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
• 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.

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