A 57-year-old otherwise healthy male presented to our department with sudden mild eye pain. Seven days earlier, he had undergone pars-plana vitrectomy for superior bullous rhegmatogenous retinal detachment caused by a superior horseshoe retinal tear. Surgical procedure consisted of three-port 23-gauge pars plana vitrectomy. The trocars were introduced 4 mm posterior to the limbus managing a scleral tunnel. Core and peripheral vitrectomy was performed uneventfully. Subretinal fluid was drained under perfluorocarbon liquid. Cryopexy was applied transsclerally on the retinal tear. Perfluorocarbon/air exchange was then performed. One superior trocar was removed and the sclerotomy was sutured with 7.0 absorbable thread followed by air-SF6 20% exchange. The gas was injected continuously from the terminal trocar and the air extrusion was controlled by the other left trocar. After suturing the remaining sclerotomies, the globe was hypotonic on finger pressure. Therefore a complement of injection of SF6 20% was added with 30 gauge syringe 4 mm from the limbus in the superior quadrant.
The following day, ophthalmic examination was unremarkable as the patient had positive light perception with a quiet anterior chamber, and an intra-ocular pressure (IOP) of 23 mm Hg. The lens examination showed a subcapsular posterior cataract. The retina was flat posterior to the bubble. The patient was discharged on day one post-operatively and topical corticosteroid and antibiotics were prescribed. Seven days later, he presented with sudden photophobia, mild eye pain and hyperemia. On ophthalmic examination, the visual acuity was limited to positive light perception with mild corneal edema, and the IOP was 30 mm Hg. A slight hypopyon was noted inferiorly with a fibrinous exudate (Fig. 1). Posterior segment evaluation was hindered by the anterior segment inflammation. Ultrasonography B-scan was ineffective due to the complete gas bubble.
Differential diagnoses included infectious endophthalmitis and Toxic Anterior Segment Syndrome (TASS). The absence of severe pain, eyelid edema, chemosis and the mild eye redness were against the diagnosis of post-operative endophthalmitis.
The patient was treated with topical mydriatics and topical and oral corticosteroids (prednisolone, 60 mg/day). On day ten post-operatively, the anterior segment inflammation had resolved and good pupillary dilation was obtained revealing centrally clouded anterior capsule with absence of nucleus (Fig. 1). Fundus examination was hindered by the lens capsule opacification. B-scan ultrasonography revealed a globular echogenic structure in the inferior posterior vitreous cavity resting on the retina corresponding to a dislocated lens nucleus (Fig. 1). The final diagnosis of posterior nucleus dislocation with lens-material antigenic uveitis was retained.
Reviewing the surgical procedure video, the posterior capsule tear had been detected when completing the gas injection with 30-gauge syringe, the globe being hypotonic and the angle of injection too anteriorly placed.
Medications were continued with a good control of ocular inflammation. Three weeks later, the patient underwent uneventful 25-gauge vitrectomy with aspiration of the soft nucleus. The anterior capsule opacification was removed by pars plana approach with the vitrector and a sulcus three piece-lens implantation was performed (Fig. 2).
On last follow-up, visual acuity was 20/50, with a quiet eye, well-centered intra-ocular lens (IOL) (Fig. 2), and reattached retina.