Bump and blur

aka Ophthalmology Befuddler 029

A 71 year-old man tripped at home and bumped his forehead on the wall as he went to ground. He did not lose consciousness and apart from a minor bruise on his forehead and a major bruise on his ego, his only complaint is markedly blurred vision in his right eye. He has had previous cataract surgery on both eyes.

This is what you see on close inspection of his eye:

IOL Anterior Chamber

Questions

Q1. What is the likely diagnosis?
Answer and interpretation

Anterior dislocation of an intraocular lens

There are two types of traumatic lens displacement (aka ectopia lentis):

  • Dislocation — anterior or posterior displacement of the lens resulting from complete disruption of the lens zonule fibers.
  • Subluxation — results from incomplete disruption of the lens zonule fibers

The following questions relate to lens displacement in general (not just implanted intra-ocular lenses).


Q2. What are the risk factors for this condition?
Answer and interpretation

Risk factors for lens displacement in the context of minimal trauma include:

  • Marfan’s syndrome (upwards)
  • Homocystinuria (downwards)
  • Tertiary syphilis
  • Previous intra-ocular lens insertion (e.g. cataract surgery)
  • Pseudo-exfoliation syndrome.

Severe Pseudoexfoliation Syndrome (RootAtlas)


Q3. What features should be sought on history and examination?
Answer and interpretation

History:

  • Symptoms: monocular diplopia or visual distortion with subluxation marked visual blurring with dislocation.
  • Presence of risk factors (see Q2)
  • Any associated injuries (ocular or otherwise)?

Examination:

  • Visual acuity: decreased
  • Slit lamp exam: edge of a subluxated lens can be seen when the pupil is dilated. Iridodonesis — trembling or shimmering of the iris after rapid eye movements in lens dislocation.
  • Look for associated ocular and other injuries. Look for evidence of risk factors (e.g. Marfanoid appearance)

Lens subluxation with vitreous (RootAtlas)


Q4. What is the management of this condition?
Answer and interpretation

Management of lens displacement involves:

  • immediate ophthalmology consultation
  • treatment options vary from observation to surgical removal  and replacement depending on the location of the dislocated lens and associated eye injury

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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