Dr Christopher Go1, Dr Samantha Bobba1, Dr Jay Chandra1
1Westmead Hospital, Sydney, Australia
Subretinal lenticular material is a rare clinical condition. To date, there have been eight reported cases; two from blunt trauma and the other 6 from different surgical techniques including couching, lensectomy, phacoemulsification and vitrectomy. This case series reports two unusual cases of subretinal lenticular material. To our knowledge, there is no report of subretinal intraocular lens in the literature.
Case One describes a 27 year old male referred for query left subluxed intraocular lens after cataract surgery. The operation was “difficult but uncomplicated”. The patient underwent a lens repositioning day one post-operatively with reason not documented. On examination, a dislocated capsular complex noted with no evidence of the IOL. Examination was made difficult due to obscuration from the displaced capsule. B scan demonstrated a retinal detachment and a planned vitrectomy was performed. Intraoperatively, a submacula IOL was found after introduction of heavy liquid and removed with intraocular forceps. The patient subsequently underwent subsequent operation including a sutured IOL with good outcome (6/12).
Case Two is a 74 year old male referred following right cataract surgery complicated by posterior capsule tear (PCT) and dropped nucleus. On examination, he had a 180 degree circumferential giant tear with radial extension to the optic disc, and RPE burn beneath the radial extension. There were several dislocated lens fragments, mostly in the vitreous cavity but one had migrated sub-retinally which was initially mistaken as a choroidal detachment. This was later removed when the heavy liquid was replaced with silicone oil. Whilst the retina remained flat, his best corrected VA post-operatively was poor (6/120).
Vigorous vitreous manipulation following PCT is considered the likely pathogenesis for subretinal nucleus, which is consistent with Case Two. However, a PCT was not observed in Case One, and the mechanism is still unknown. It may be related to lens repositioning or an undetected pre-operative giant retinal tear. The authors also question whether the IOL could be left subretinally if removal was difficult as two of the reported subretinal cases were left behind with good visual outcome. This case series demonstrates how imperative it is to undergo an extensive dilated examination prior to cataract surgery and be mindful of the risks of surgical revision.
Chris is a second year registrar training in the Sydney Eye Hospital Network currently rotating at Royal Hobart Hospital.