A CURIOUS CASE OF CHRONIC CORNEAL OEDEMA

To describe a case of chronic corneal oedema due to retained nuclear fragment after uneventful phacoemulsification misdiagnosed as viral keratitis 

Tertiary care eye hospital

Case report and literature review

An 89-year-old gentleman with multiple episodes of inferior corneal oedema and low-grade anterior segment inflammation over 18 months was diagnosed and managed as viral keratitis; however, the episodes kept recurring every time treatment, vis-à-vis topical steroids, were tapered or stopped. Past ophthalmic history revealed bilateral phacoemulsification surgeries; right eye was operated in 2015 with documentation of intra-operative 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 two months after the surgery. 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 inferior iris chafing.

History of cataract surgery few months prior to onset of the symptoms, lack of other features of viral keratitis, such as keratic precipitates and inferior corneal oedema in the presence of slight pupillary peaking led to the suspicion of either a retained lens fragment (RLF) or other possible iatrogenic insult. As the view of inferior anterior chamber was limited, we performed anterior-segment optical coherence tomogram (ASOCT) focused on the inferior angle, which revealed a hyper-reflective mass, which was in fact a retained lensfragment in the anterior chamber; this was removed surgically as an emergency procedure. This resulted in significant improvement in the corneal oedema, as well as marked symptomatic relief confirmed by the patient.

Inferior corneal oedema in an eye after cataract surgery should raise the suspicion of a retained lens fragment. Anterior segment OCT helped to clinch the diagnosis and may serve extremely useful in eyes with poor view of the anterior chamber and angle using gonioscopy. Retained lens fragment in anterior chamber after uneventful cataract surgery is uncommon yet an important cause of iatrogenic inflammation and corneal oedema.