Pearls Are Eye's Best Friends

To describe a case of prolapsed Elschnig Pearls at the pupil plane of a miotic eye successfully managed using Nd:YAG laser.

Case report of a patient referred to our Ophthalmology Department.

83 year-old man was referred to our Ophthalmology Department for sudden vision loss in his left eye (LE) for 2 weeks. The patient undergone uneventfull cataract surgery bilaterally in 2013 and denied any other systemic or ophthalmic conditions or recent trauma. 

His bes-corrected visual acuity (BCVA) was 9/10 in the right eye (RE) and 3/10 in his LE. Slit-lamp examination revealed in his LE: pseudoexfoliation, very miotic pupil, prolapsed Elschnig's pearls covering the visual axis, centered IOL with anterior capsule phimosis. Pharmacologic midryasis was unsuccessfull. AS-OCT was taken, showing hyperreflective material prolapsing through the pupil margins, anterior to the IOL.

Nd:YAG laser was performed, with prior instillation of oxibuprocaine and iopidine, using 0.8 mJ of energy, clearing most of Elschnig's pearls in the visual axis, with care taken not to damage the iris. Patient was started on topical corticosteroid (dexamethasone) and timolol for 5 days, in order to reduce anterior chamber inflammation and IOP spikes.

At 2 weeks post-laser procedure, BCVA improved to 8/10 and the IOP was 15 mmHg. There were slight remnants of Elschnig's pearls at the pupil margin that did not involve the visual axis.

Regenerative posterior capsule opacification (PCO) is characterized by the formation of swollen globular cells known as Elschnig’ pearls, which are believed to be the product of aberrant capsular epithelial cell differentiation found in the capsular equator which can migrate to the posterior or, in rare instances, anterior capsule. These structures can encroach upon the visual axis and cause significant visual disturbance even more so than fibrotic PCO. It is unclear whether Valsalva Maneuver ou trauma promoted anterior chamber prolapse of the Elschnig's pearls, which would be consistent with our patient's sudden loss of vision. However, even in cases where pharmacological pupil mydriasis is insufficient, Nd:YAG laser should be attempted.