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

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

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

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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