HIDDEN BEHIND THE FOG

Ophthalmology department of Prof. Doutor Fernando Fonseca Hospital, Lisbon, Portugal

This is the case of an 80-year-old caucasian woman with a personal history of high blood pressure, diabetes and asthma. Regarding ophthalmological history, she underwent phacoemulsification 15 years ago with implantation of a three-piece intraocular lens (IOL) in the sulcus of her left eye due to a presumed complicated surgery.

The patient came to our emergency department complaining of painless progressive decrease in vision from her left eye with months of evolution. Upon observation, best BCVA was OD 0.10 LogMAR, OS 1 LogMAR and IOP 11/12 mmHg. Slit lamp examination of the left eye revealed a totally opacified cornea with bullous keratopathy showing corneal stromal swelling, descemet folds, and diffuse small bullae with some larger ones in the inferior temporal cornea. There weren´t any epithelial defects or keratic precipitates, and the conjunctiva was not hyperemic. The remaining eye segments were impossible to visualize due to severe corneal haze. Observation of the right eye showed a transparent cornea without any signs of Fuchs endothelial dystrophy, or any other pathological findings. Specular microscopy revealed endothelial cell count of 2667 cells/mm² for right eye and 1 cell/mm² for left eye, consistent with severe decompensation and cell loss.

The patient started treatment with lubricant 5id and topical dexamethasone 3id and was reevaluated every week for signs of clinical improvement and to establish a definite etiology. Corneal transparency started to slowly increase and about 2 months after the first encounter, observation showed a less swelled stroma and small bullae, although maintaining the larger ones. As we could visualize the anterior segment for the first time, we were surprised by the presence of one of the haptics of the IOL that had perforated the iris and had lodged in the anterior chamber near the iridocorneal angle on temporal inferior region possibly touching corneal endothelium and ultimately causing its decompensation. Facing this unexpected finding and when asked about contributing factors for a IOL subluxation, the patient admitted having had a major head and trunk trauma about 3 years before, that might had dislocated the lens and consequently caused endothelial damage. The patient is now waiting for surgery with a BCVA OS 0.4 LogMar and a slightly less opacified cornea.

In this case we were surprised by a patient that initially appeared to have no reason for her corneal decompensation such as corneal dystrophy, infectious endothelitis or recent surgery, but turned out to have dislocated IOL due to trauma causing a bullous keratopathy. In this situation, adequate treatment with lubricant and topical steroids were essential, allowing visualization of anterior segment and establishment of correct diagnosis.