Anterior polar pyramidal cataract. Presenting as an anterior chamber foreign body

Spontaneous Lens Rupture in Congenital Cataract, Presented as Lens Fragment Within the Anterior Chamber

We report the case of a 60-year-old woman with a congenital anterior polar cataract who presented with a lens fragment within the anterior chamber of her left eye, without a medical history of surgery or trauma. Uneventful phacoemulsification with simultaneous removal of the lens fragment followed. Postoperatively, the patient's visual acuity improved from a perception of light to 20/100. Histological examination of the lens fragment revealed persistent fetal vasculature, as well as fibrous metaplasia and extensive collagenesis. To our knowledge, this is the first report of spontaneous rupture of both the anterior capsule and the lens.

Femtosecond laser - Assisted cataract surgery in pediatric pyramidal anterior polar cataract

PURPOSE

The purpose of this report is to describe the successful utilization of femtosecond laser assisted cataract surgery (FLACS) in a rare case of pyramidal anterior polar cataract in a female child.

OBSERVATIONS

The patient is a 6 years old girl that presented to the cornea clinic with a unilateral pyramidal cataract that was deemed to be visually significant, and therefore required cataract extraction and intraocular lens implantation surgery. FLACS was proposed and mother consented to proceed with the surgery. The femtosecond laser technology enabled precise completion of a central capsulotomy around the protruding pyramidal capsular lesion.

CONCLUSIONS AND IMPORTANCECONCLUSION

Various capsulorhexis techniques have been described and are used in pediatric cataracts including manual, can opener, vitrectorhexis, and laser, but none has become a standard. We propose the use of femtosecond laser for cataract extraction in cases of pediatric pyramidal cataracts, and hereby provide the first case report of such. The laser is a safe method for capsulorhexis construction and offers an additional advantage of intraoperative anterior segment OCT image guidance with visualization of the pyramidal lesion.

[Anterior uveitis and intracameral white foreign body in a patient with anterior polar cataract]

We present a rare case of spontaneous phacolysis with consecutive anterior uveitis in a patient with anterior polar cataract. Despite an intact appearing anterior lens capsule cells were found in the anterior chamber as well as a white mass in the inferior chamber angle. After failure of absorption under topical steroid treatment surgical treatment with capsulorhexis, phacoemulsification and implantation of a intraocular posterior chamber lens in the capsular bag was performed uneventfully. Postoperatively, rapid regression of the inflammatory reaction was observed.

Progression of an Anterior Polar Cataract to a Complete White Cataract in the Setting of Overlying Focal Capsular Disruption

A 10-month-old child with unilateral visually insignificant anterior polar lens opacity was examined 6 years after initial presentation and found to have complete white cataract and apparent focal disruption of the anterior capsule in the affected eye. Although anterior lens opacities are generally static and visually insignificant, progression can occur.

The morphology and natural history of childhood cataracts

The morphology of congenital cataract reflects a combination of the timing and nature of the cause, the anatomy of the lens including its capsule, its development, and changes that take place with time. Morphology may variably affect prognosis, give a clue to the etiology and the age of onset and, in an isolated case, sometimes suggest heritability. The spectrum of morphological variations is enormous and can be complex. A comprehensive approach is to classify the variations according to the area of the lens involved, and sub-dividing them by a detailed description of the shape and appearance. Each specific morphological type is then analyzed determining the etiology, visual prognosis, and management. The use of gene markers has allowed many of these variations to be identified and categorized. Cataracts in childhood can involve the whole lens, in which case they are called total, Morgagnian, or disk-like. They can affect only the center of the lens: lamellar, nuclear, oil droplet, cortical, or coronary. They can be anterior: anterior polar, anterior subcapsular, or anterior lenticonus. The posterior aspect of the lens can also be affected in different fashions: Mittendorf's dot, posterior lenticonus, posterior cortical cataracts, or posterior subcapsular. There are five more forms that must be described separately: punctuate lens opacities, sutural cataracts, coralliform or crystalline, wedge-shaped, and persistent hyperplastic primary vitreous.

Corneal edema with dislocated anterior polar cataract

PURPOSE

To report an unusual manifestation of anterior polar cataract.

METHODS

Observational case report. A 35-year-old woman presented with localized inferior corneal edema associated with a white nodular lesion on the iris. The anterior lens capsule was deficient centrally with scrolled edges and an underlying subcapsular opacity. The nodule was removed surgically and subjected for histopathologic examination.

RESULTS

The histopathologic examination of the white nodular lesion showed parallel collagen fibers that were positive for collagen on the Masson trichrome stain. Correlating with clinical features, these findings were suggestive of dislocated anterior polar cataract.

CONCLUSION

Anterior pyramidal cataract may dislocate spontaneously and present as an anterior chamber foreign body and may even lead to corneal endothelial cell loss.

Unique advantage of gonioscopy for viewing an anterior pyramidal cataract

Anterior polar cataracts (APC) are a relatively rare but well-documented form of congenital cataract. Occasionally, these white disc-shaped opacities protrude towards the anterior chamber with an inverse cone-like morphology and are known as anterior pyramidal cataracts. These represent three to four per cent of all types of congenital cataracts. APCs portray a dominant mode of inheritance and generally do not progress over time. Due to their small size, APCs generally have little effect on vision and are simply monitored clinically. Photodocumentation of pyramidal cataracts has traditionally shown biomicroscopic views of the opacities. In addition to a review of APC, this report describes how a gonioscope offers a unique observational advantage in viewing an anterior pyramidal cataract.

Pyramidal anterior polar cataracts

OBJECTIVE

To document clinical features and subsequent management of pyramidal anterior polar cataracts in children.

DESIGN

Retrospective, noncomparative case series and clinicopathologic correlation.

PARTICIPANTS

Fifteen patients who presented to the pediatric ophthalmology clinic.

INTERVENTION

All patients underwent measurement of visual acuity, assessment of ocular motility, examination of the anterior and posterior segments, and cycloplegic refraction. Amblyopia treatment was instituted when appropriate. When visual impairment occurred from cataract progression or amblyopia or both, cataract removal with or without lens implantation was performed. After surgery, correction of refractive error and treatment of amblyopia were instituted. Several pyramidal opacities were retrieved during cataract extraction and examined by light and electron microscopy.

MAIN OUTCOME MEASURES

Visual acuity at initial presentation, size of lens opacity before surgery, amblyopia status, most recent visual acuity after cataract extraction, and histologic examination of lens opacity.

RESULTS

Nine children had bilateral and six had unilateral pyramidal cataracts (24 eyes). There was no discernible inheritance pattern. Patients were followed for 27 months on average. Twenty of 24 eyes developed cortical opacification that extended significantly beyond the base of the pyramidal lesion. Nineteen eyes required cataract surgery: 10 eyes underwent lensectomy with anterior vitrectomy and 9 had extracapsular cataract extraction, 8 of which had insertion of a posterior chamber intraocular lens. Amblyopia was present or developed in all six patients with unilateral cataract and in eight of nine patients with bilateral cataract. Visual acuity in many eyes remained poor despite amblyopia therapy. The pyramidal opacities consisted of hyperplastic lens epithelium, which exhibited a loss of polarity and was surrounded by a collagenous matrix.

CONCLUSIONS

Pyramidal anterior polar cataracts are present at birth and may represent a variant of anterior polar lens opacities. They may be unilateral or, if bilateral, they may be either symmetric or asymmetric. They consist of hyperplastic lens epithelium in a collagenous matrix. Patients with pyramidal cataracts are likely to develop amblyopia. This can result from either unilateral occurrence or asymmetry of bilateral opacities and is often worsened by surrounding cortical opacification. Many patients require cataract surgery. All infants and young children with anterior polar opacities showing this configuration should be followed for cataract progression and amblyopia.