Retained Lens Fragments After Phacoemulsification
The incidence of posteriorly displaced, or retained, lens fragments ranges from 0.3%–1.1% in reported series. Retained lens fragments may cause severe intraocular inflammation and secondary glaucoma. Nuclear fragments usually continue to cause chronic intraocular inflammation, whereas cortical remnants usually spontaneously reabsorb (Table 20-1).
Figure 20-9 Bleb-associated endophthalmitis. A, Patient with endophthalmitis who had a sudden onset of decreased vision, redness, and pain 2 years after glaucoma filtering surgery. B, Same patient after treatment with pars plana vitrectomy and injection of intravitreal antibiotics.
(Courtesy of Harry W. Flynn, Jr, MD.)
Table 20-1 General Recommendations for Management of Retained Lens Fragments
Indications for vitrectomy include secondary glaucoma, lens-induced uveitis, and the presence of large nuclear fragments. In the 4 largest reported series, 52% of patients with retained lens fragments had an IOP of at least 30 mm Hg before vitrectomy. Removal of the lens fragments reduced this incidence by 50% or more in these series. Pars plana vitrectomy, with or without use of a fragmatome, is the preferred approach to remove harder pieces of the lens nucleus (Video 20-5). Following lens fragment removal, the retinal periphery should be examined for the presence of retinal tears or retinal detachment.
Vitrectomy for removal of retained lens fragment.
Courtesy of Colin A. McCannel, MD.
Reported studies with long-term follow-up have found that retinal detachment occurs in about 15% of eyes with retained lens fragments. Aggressive attempts to retrieve posterior lens fragments using a limbal approach are sometimes complicated by retinal detachments caused by giant retinal tears. Giant retinal tears are more commonly found 180° away from the incision used for cataract surgery.
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;124(2):222–226.
Modi YS, Epstein A, Smiddy WE, Murray TG, Feuer W, Flynn HW Jr. Retained lens fragments after cataract surgery: outcomes of same-day versus later pars plana vitrectomy. Am J Ophthalmol. 2013;156(3):454–459.
Vanner EA, Stewart MW. Vitrectomy timing for retained lens fragments after surgery for age-related cataracts: a systematic review and meta-analysis. Am J Ophthalmol. 2011;152(3): 345–357.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.