Laboratory Studies

Consider ruling out endophthalmitis via anterior chamber tap and vitreous tap with smears for Gram and Giemsa stains and cultures with antimicrobial sensitivities.

Culture media should include blood agar, Sabouraud media, chocolate agar, and thioglycolate broth.

Imaging Studies

In cases of ocular trauma, a 20-MHz ultrasound probe^[23]and a 35-MHz ultrasound probe^[24]have been reported to help facilitate the visualization of the posterior capsule's integrity. The effective use of 50-MHz ultrasound biomicroscopy has been described in the assessment of occult zonular defects in traumatic cataracts.^[25]

B-scan ultrasonography may be useful in localizing and measuring posteriorly displaced lens debris, particularly large nucleus fragments.

Procedures

Perform anterior chamber tap and vitreous tap if endophthalmitis is suspected.

Histologic Findings

If anterior chamber paracentesis is performed, histology may demonstrate foamy macrophages^[10]and lens particles.

A coexisting phacoantigenic uveitis often exists, and the lens histology may include the classic finding of zones of granulomatous and nongranulomatous inflammation that surround degenerating lens material. Inflammatory intraocular spindle cell mass simulating a neoplasm has been reported in lens-induced uveitis,^[21]with a histologic finding of a large tumefaction of histiocytes and myofibroblasts.

Anterior chamber angle histologic examination of enucleated eyes may confirm the presence of macrophages in the trabecular meshwork, perhaps contributing to decreased outflow facility.

Treatment & Management

Ellant JP, Obstbaum SA. Lens-induced glaucoma. Doc Ophthalmol. 1992. 81(3):317-38. [QxMD MEDLINE Link].
Epstein DL. Diagnosis and management of lens-induced glaucoma. Ophthalmology. 1982 Mar. 89(3):227-30. [QxMD MEDLINE Link].
Richter CU. Lens-induced open-angle glaucoma. Ritch R, Shields MB, and Krupin T. The Glaucomas. 2nd. St. Louis, Mo: 1996. 2: 1026-31.
Serle JB. Nontraumatic lens-induced glaucoma. Higginbotham ET, Lee DA. Management of Difficult Glaucoma. Boston, MA: 1994. 263-73.
Gadia R, Sihota R, Dada T, Gupta V. Current profile of secondary glaucomas. Indian J Ophthalmol. 2008 Jul-Aug. 56(4):285-9. [QxMD MEDLINE Link].
Epstein DL, Jedziniak JA, Grant WM. Obstruction of aqueous outflow by lens particles and by heavy-molecular-weight soluble lens proteins. Invest Ophthalmol Vis Sci. 1978 Mar. 17(3):272-7. [QxMD MEDLINE Link].
Rosenbaum JT, Samples JR, Seymour B, Langlois L, David L. Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma. Arch Ophthalmol. 1987 Nov. 105(11):1582-4. [QxMD MEDLINE Link].
Smith D, Wrenn K, Stack LB. The epidemiology and diagnosis of penetrating eye injuries. Acad Emerg Med. 2002 Mar. 9(3):209-13. [QxMD MEDLINE Link].
Kalamkar C, Mukherjee A. Incidence, clinical profile, and short-term outcomes of post-traumatic glaucoma in pediatric eyes. Indian J Ophthalmol. 2019 Apr. 67 (4):509-514. [QxMD MEDLINE Link].
Kim TH, Kim SJ, Kim E, Chung IY, Park JM, Yoo JM, et al. Spontaneous anterior lens capsular dehiscence causing lens particle glaucoma. Yonsei Med J. 2009 Jun 30. 50(3):452-4. [QxMD MEDLINE Link]. [Full Text].
Hemalatha C, Norhafizah H, Shatriah I. Bilateral spontaneous rupture of anterior lens capsules in a middle-aged woman. Clin Ophthalmol. 2012. 6:1955-7. [QxMD MEDLINE Link]. [Full Text].
While B, Mudhar HS, Chan J. Lens particle glaucoma secondary to untreated ?congenital cataract and persistent fetal vasculature. Eur J Ophthalmol. 2012 Oct 25. [QxMD MEDLINE Link].
Arranz-Marquez E, Fatela-Cantillo B, Figueroa M, Teus MÁ. [Late onset lens particle glaucoma in Marfan syndrome]. Arch Soc Esp Oftalmol. 2015 Jan. 90 (1):40-3. [QxMD MEDLINE Link].
Pahk PJ, Adelman RA. Ocular trauma resulting from paintball injury. Graefes Arch Clin Exp Ophthalmol. 2008 Nov 26. [QxMD MEDLINE Link].
Su Y, Mao Z, Liu Y, Yang Y, Liu X. Late-onset lens particle glaucoma as a consequence of posterior capsule rupture after pars plana vitrectomy. Eye Sci. 2012 Mar. 27(1):47-9. [QxMD MEDLINE Link].
Barnhorst D, Meyers SM, Myers T. Lens-induced glaucoma 65 years after congenital cataract surgery. Am J Ophthalmol. 1994 Dec 15. 118(6):807-8. [QxMD MEDLINE Link].
Kee C, Lee S. Lens particle glaucoma occurring 15 years after cataract surgery. Korean J Ophthalmol. 2001 Dec. 15(2):137-9. [QxMD MEDLINE Link].
Hassan NA, Reddy MA, Reddy SS. Late occurrence of lens particle glaucoma due to an occult glass intralenticular foreign body. Middle East Afr J Ophthalmol. 2009 Apr. 16(2):97-9. [QxMD MEDLINE Link]. [Full Text].
Richter CU, Arzeno G, Pappas HR, Steinert RF, Puliafito C, Epstein DL. Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy. Ophthalmology. 1985 May. 92(5):636-40. [QxMD MEDLINE Link].
Lim MC, Doe EA, Vroman DT, Rosa RH Jr, Parrish RK 2nd. Late onset lens particle glaucoma as a consequence of spontaneous dislocation of an intraocular lens in pseudoexfoliation syndrome. Am J Ophthalmol. 2001 Aug. 132(2):261-3. [QxMD MEDLINE Link].
Guffey Johnson J, Margo CE. Intraocular inflammatory mass associated with lens-induced uveitis. Surv Ophthalmol. 2017 Jul - Aug. 62 (4):541-545. [QxMD MEDLINE Link].
Jain SS, Rao P, Nayak P, Kothari K. Posterior capsular dehiscence following blunt injury causing delayed onset lens particle glaucoma. Indian J Ophthalmol. 2004 Dec. 52(4):325-7. [QxMD MEDLINE Link].
Nguyen TN, Mansour M, Deschenes J, Lindley S. Visualization of posterior lens capsule integrity by 20-MHz ultrasound probe in ocular trauma. Am J Ophthalmol. 2003 Oct. 136(4):754-5. [QxMD MEDLINE Link].
Kucukevcilioglu M, Hurmeric V, Ceylan OM. Preoperative detection of posterior capsule tear with ultrasound biomicroscopy in traumatic cataract. J Cataract Refract Surg. 2013 Feb. 39(2):289-91. [QxMD MEDLINE Link].
McWhae JA, Crichton AC, Rinke M. Ultrasound biomicroscopy for the assessment of zonules after ocular trauma. Ophthalmology. 2003 Jul. 110(7):1340-3. [QxMD MEDLINE Link].
Osman EA, Mousa A, Al-Mansouri SM, Al-Mezaine HS. Glaucoma After Open-globe Injury at a Tertiary Care University Hospital: Cumulative Causes and Management. J Glaucoma. 2016 Mar. 25 (3):e170-4. [QxMD MEDLINE Link].
Roizenblatt M, Edwards TL, Gehlbach PL. Robot-assisted vitreoretinal surgery: current perspectives. Robot Surg. 2018. 5:1-11. [QxMD MEDLINE Link]. [Full Text].
Moisseiev E, Kinori M, Glovinsky Y, Loewenstein A, Moisseiev J, Barak A. Retained lens fragments: nucleus fragments are associated with worse prognosis than cortex or epinucleus fragments. Eur J Ophthalmol. 2011 Nov-Dec. 21(6):741-7. [QxMD MEDLINE Link].
Aaberg TM Jr, Rubsamen PE, Flynn HW Jr, Chang S, Mieler WF, Smiddy WE. Giant retinal tear as a complication of attempted removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol. 1997 Aug. 124(2):222-6. [QxMD MEDLINE Link].
Arbisser LB. Managing intraoperative complications in cataract surgery. Curr Opin Ophthalmol. 2004 Feb. 15(1):33-9. [QxMD MEDLINE Link].
Arbisser LB, Charles S, Howcroft M, Werner L. Management of vitreous loss and dropped nucleus during cataract surgery. Ophthalmol Clin North Am. 2006 Dec. 19(4):495-506. [QxMD MEDLINE Link].
Monshizadeh R, Samiy N, Haimovici R. Management of retained intravitreal lens fragments after cataract surgery. Surv Ophthalmol. 1999 Mar-Apr. 43(5):397-404. [QxMD MEDLINE Link].
Terasaki H, Miyake Y, Miyake K. Visual outcome after management of a posteriorly dislocated lens nucleus during phacoemulsification. J Cataract Refract Surg. 1997 Nov. 23(9):1399-403. [QxMD MEDLINE Link].
Margherio RR, Margherio AR, Pendergast SD, et al. Vitrectomy for retained lens fragments after phacoemulsification. Ophthalmology. 1997 Sep. 104(9):1426-32. [QxMD MEDLINE Link].
Yang CS, Lee FL, Hsu WM, Liu JH. Management of retained intravitreal lens fragments after phacoemulsification surgery. Ophthalmologica. 2002 May-Jun. 216(3):192-7. [QxMD MEDLINE Link].
Kapusta MA, Chen JC, Lam WC. Outcomes of dropped nucleus during phacoemulsification. Ophthalmology. 1996 Aug. 103(8):1184-7. [QxMD MEDLINE Link].
von Lany H, Mahmood S, James CR, et al. Displacement of nuclear fragments into the vitreous complicating phacoemulsification surgery in the UK: clinical features, outcomes and management. Br J Ophthalmol. 2008 Apr. 92(4):493-5. [QxMD MEDLINE Link].
Lai TY, Kwok AK, Yeung YS, et al. Immediate pars plana vitrectomy for dislocated intravitreal lens fragments during cataract surgery. Eye. 2005 Nov. 19(11):1157-62. [QxMD MEDLINE Link].
Chen CL, Wang TY, Cheng JH, et al. Immediate pars plana vitrectomy improves outcome in retained intravitreal lens fragments after phacoemulsification. Ophthalmologica. 2008. 222(4):277-83. [QxMD MEDLINE Link].
Schaal S, Barr CC. Management of retained lens fragments after cataract surgery with and without pars plana vitrectomy. J Cataract Refract Surg. 2009 May. 35(5):863-7. [QxMD MEDLINE Link].
Salehi A, Razmju H, Beni AN, Beni ZN. Visual outcome of early and late pars plana vitrectomy in patients with dropped nucleus during phacoemulsification. J Res Med Sci. 2011 Nov. 16(11):1422-9. [QxMD MEDLINE Link]. [Full Text].
Stefaniotou M, Aspiotis M, Pappa C, Eftaxias V, Psilas K. Timing of dislocated nuclear fragment management after cataract surgery. J Cataract Refract Surg. 2003 Oct. 29(10):1985-8. [QxMD MEDLINE Link].
Scott IU, Flynn HW Jr, Smiddy WE, et al. Clinical features and outcomes of pars plana vitrectomy in patients with retained lens fragments. Ophthalmology. 2003 Aug. 110(8):1567-72. [QxMD MEDLINE Link].

Media Gallery

Lens nucleus dislocated into the inferior vitreous during cataract surgery. Reprinted from Survey of Ophthalmology, Vol 43. Monshizadeh R, Nasrollah S, Haimovici R: Management of retained intravitreal lens fragments after cataract surgery. 397-403. Copyright 1999, with permission from Elsevier Science.
Ruptured lens capsule with elevated intraocular pressure following trauma. Courtesy of KS Kooner, MD.

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Author

Donny W Suh, MD, MBA, FAAP, FACS Professor, Department of Ophthalmology, Chief of Pediatric Ophthalmology and Adult Strabismus, Medical Director of Eye-Mobile, Gavin Herbert Eye Institute, UC Irvine Health, University of California, Irvine, School of Medicine; Associate Clinical Professor, Department of Pediatrics, Creighton University School of Medicine; Chief Medical Officer, Suh Precision Syringe, LLC; Medical Staff, Children’s Hospital of Orange County

Donny W Suh, MD, MBA, FAAP, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Section on Ophthalmology, American Ophthalmological Society, International Strabismological Association, Iowa Medical Society, Metro Omaha Medical Society, National Eye Care Project, Nebraska Chapter of American Academy of Pediatrics, ORBIS, Surgical Eye Expeditions (SEE) International

Disclosure: Nothing to disclose.

Coauthor(s)

Jody Z He, BA MD Candidate, Eastern Virginia Medical School

Jody Z He, BA is a member of the following medical societies: American Medical Association, Lions Clubs International

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Brian R Sullivan, MD Professor, Department of Ophthalmology, Chicago Stritch School of Medicine, Loyola University Medical Center

Brian R Sullivan, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Richard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic

Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Supported in part by an unrestricted research grant from Research to Prevent Blindness, Inc, New York, New York.

At the time of writing and subsequently updating this article, the author had no financial interests in any of the products discussed herein, nor in any of the companies that manufacture or distribute them.