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Correspondence to Mayank A Nanavaty; [email protected]
Background
Retained lens fragment (RLF) in anterior chamber after uneventful cataract surgery is uncommon yet an important cause of iatrogenic inflammation and corneal oedema. Presentation is often in the first few weeks after surgery; however, delayed presentations are not uncommon. There are reports where the diagnosis has been missed and fragments discovered during keratoplasty undertaken for refractory corneal oedema. In this case report, we highlight a similar case, interestingly misdiagnosed as viral keratitis, which is known to be often overdiagnosed, the same being confirmed in various previous reports in literature.
Case presentation
An 89-year-old man was referred for endothelial keratoplasty for inferior corneal decompensation in his left eye secondary to a diagnosis of recurrent herpetic keratitis. He had well-controlled hypertension, trigeminal neuralgia and a history of previous total knee replacement. Past ophthalmic history revealed bilateral phacoemulsification surgeries; right eye was operated in 2015 with documentation of intraoperative floppy iris, and mobile iris-lens diaphragm, necessitating suturing of the wounds and left eye was operated more recently, in 2019, documented as uneventful; however, required laser posterior capsulotomy 2 months after the surgery. On presentation he had a history of recurrent soreness and light sensitivity in his left eye for the past 18 months. During this duration, he attended the ophthalmology casualty and outpatient clinic several times and was diagnosed and managed as herpetic keratitis. Almost always, the clinical presentation was of inferior corneal oedema with Descemet folds, and he responded to medical treatment vis-à-vis topical steroids and oral acyclovir. However, it kept on recurring at varied intervals every time the steroids were tapered and stopped.
On current ocular examination, he was noted to have inferior corneal oedema with Descemet folds, no visible anterior chamber inflammation, slightly peaked but otherwise central pupil with an area of iris chafing inferiorly (figure 1). There were no significant keratic precipitates, fresh or old, and corneal sensations were normal. Uncorrected distance visual acuity (UCDVA) was 6/9 and intraocular pressure was 10 mm Hg. On dilation, the posterior chamber intraocular lens was well centred in the bag and posterior pole examination was within normal limits. Current ophthalmic medications included prophylactic dose of oral acyclovir (400 mg two times per day) and lubricating eye drops as needed.
Investigations