Indian Journal of Ophthalmology

LETTER TO THE EDITOR
Year
: 2019  |  Volume : 67  |  Issue : 10  |  Page : 1780--1781

Comment on: Progressive posterior lenticonus with total lenticular opacity


Nirupama Kasturi, Vignesh Elamurugan 
 Department of Ophthalmology, Jawaharlal Postgraduate Medical Education and Research, Puducherry, India

Correspondence Address:
Dr. Nirupama Kasturi
Department of Ophthalmology, Jawaharlal Postgraduate Medical Education and Research, Puducherry - 605 006
India




How to cite this article:
Kasturi N, Elamurugan V. Comment on: Progressive posterior lenticonus with total lenticular opacity.Indian J Ophthalmol 2019;67:1780-1781


How to cite this URL:
Kasturi N, Elamurugan V. Comment on: Progressive posterior lenticonus with total lenticular opacity. Indian J Ophthalmol [serial online] 2019 [cited 2019 Nov 20 ];67:1780-1781
Available from: http://www.ijo.in/text.asp?2019/67/10/1780/267451


Full Text



Sir,

We read the unique case report of bilateral lenticonus titled “Posterior lenticonus with persistent fetal vasculature” (published in Indian J Ophthalmol 2018; 66:1335-6)[1] with interest and would like to make some contributions.

A 5-year-old girl presented to us with a whitish opacity in the left eye noticed by the parents for 2 months' duration. Ocular examination showed normal corneal diameters with unilateral total cataract and exotropia in the left eye [Figure 1]a. Ultrasound B-scan showed a large bulge in the posterior lens capsule extending up to 10 mm axially which confirmed the diagnosis of posterior lenticonus [Figure 1]b. There was no persistent fetal vasculature. Bimanual lens aspiration was performed after a curvilinear capsulorhexis with gentle hydrodissection and low vacuum settings. Intraoperatively, the posterior capsule appeared thinned out centrally and stretched posteriorly as the intraocular pressure increased and bulged forward as the pressure decreased. Ganesh et al. described this as a “jellyfish sign.”[2] In the bag fixation of hydrophobic acrylic foldable intraocular lens (IOL) resulted in posterior tilting, even in the presence of an intact posterior capsule and relative thickening of the capsule around the axial cone. Hence, a three-piece IOL was placed in the sulcus after primary posterior capsulotomy (PPC) and limited anterior vitrectomy [Figure 1]c. Postoperatively, her fundus was normal and vision improved to 20/400. She is on follow-up with amblyopia therapy.{Figure 1}

Posterior lenticonus is a progressive circumscribed bulge in the posterior capsule and cortex. In most cases, it occurs unilaterally and sporadic; bilateral presentation suggests an autosomal dominant inheritance. The pathogenesis is intriguing and has attracted multiple theories apart from hyaloid artery traction like overgrowth of posterior lens fibers due to aberrant hyperplasia of subcapsular epithelium or an inherited weakness of the posterior lens capsule.[3],[4] The posterior bulge increases with age, and as the cataract advances it tends to obscure the lenticonus. Preoperative ultrasound B-scan or ultrasound biomicroscopy can aid the surgeon in diagnosing such cases and avoiding intraoperative surprises. Cataract surgery is challenging due to the fragile and bulging posterior capsule. Hydrodissection is contraindicated. Fluctuations in the intraocular pressure and anterior chamber turbulence can threaten the capsular bag stability. A low flow rate and low bottle height are dedicated to avoiding a posterior capsule rupture. It is required to perform a PPC if the bulge is more than 5 mm, in young children as posterior capsule opacification is rapid and virtually inevitable with a floppy, outstretched capsule or to convert a preexisting posterior capsule rupture to a desired size.[5]

Lee et al. found that the final visual outcome was better in patients with total lenticular opacity when compared with a posterior polar opacity, probably due to an earlier age at presentation and cataract extraction.[6] The dense amblyopia accompanying this condition is due to high index myopia and astigmatism, stimulus deprivation, and anisometropia. Earlier surgery may be indicated to prevent visual impairment in children with posterior lenticonus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Khokhar S, Dhull C, Mahalingam K, Agarwal P. Posterior lenticonus with persistent fetal vasculature. Indian J Ophthalmol 2018;66:1335-6.
2Ganesh S, Brar S, Chopra K. Jellyfish sign for intraoperative identification of posterior lenticonus. Int Ophthalmol 2016;2017;37:1239-41.
3Crouch ER Jr, Parks MM. Management of posterior lenticonus complicated by unilateral cataract. Am J Ophthalmol 1978;85:503-8.
4Khalil M, Saheb N. Posterior lenticonus. Ophthalmology 1984;91:1429-30.
5Yang GY, Liu LQ, Liu CL. Surgical treatment and pathologic analysis of posterior lentiglobus with cataract. Int J Ophthalmol 2011;4:572-4.
6Lee BJ, Kim JH, Yu YS. Surgical outcomes after intraocular lens implantation for posterior lenticonus-related cataract according to preoperative lens status. J Cataract Refract Surg 2014;40:217-23.