White Intumescent Cataract With Spontaneous Posterior Capsule Rupture

To describe the management of a case about a patient with a white intumescent cataract with spontaneous
posterior capsule rupture, dislocation of the nucleus into the vitreous cavity, anterior chamber inflammation and elevated
intraocular pressure (IOP).   

White intumescent cataract can lead to intraoperative complications such as posterior capsule rupture. However,
it is uncommon to find a spontaneous posterior capsule with nucleus dislocation to the vitreous cavity, as well as leakage
of lens particles to the anterior cavity that cause lens induced uveitis with elevated IOP. 

A 52-year-old female patient with Down syndrome presented with vision loss for several weeks of evolution
in both eyes, and pain in her right eye (OD) for 2 days.   
Patient had visual acuity of counting fingers OD and 20/200 in the left eye (OI).  Slit-lamp examination revealed in the OD
mild corneal edema, cells in the anterior chamber, flare and a white intumescent cataract with an inferior mobile fragment
dislocated into the vitreous cavity. In the OI, the patient presented a sutural and posterior cataract. There was elevated
intraocular pressure (38mmHg) in the OD. Treatment with brimonidine, timolol and dexamethasone was initiated.
Simultaneous bilateral cataract surgery combined with pars plana vitrectomy in the OD under general anaesthesia was
programmed, due to the medical history of the patient. In the OD anterior capsulorhexis was performed successfully, and
spontaneous posterior capsule rupture and nucleus dislocation into the vitreous was confirmed. Vitrectomy was
performed, and intraocular lens (IOL) was positioned in the ciliary sulcus with optic capture through the anterior rhexis. In
the left eye, cataract surgery according to the usual procedure was performed with no incidents. Patient recovered
successfully, with normal IOP, stable IOLs and visual acuity recovery in both eyes. 

This case reported a patient with a white intumescent cataract and a spontaneous
posterior capsule rupture, with nucleus dislocation, intraocular inflammation and elevated IOP. The approach was to
undergo simultaneous bilateral cataract surgery, as the cataracts were the cause of the poor vision and the inflammation
trigger in the OD. It is key to program a combined surgery with anterior and posterior approach. The anterior approach is
necessary to perform a proper anterior capsulorhexis that can allow the implantation of the IOL in the sulcus with the
optic captured. Simultaneous bilateral cataract surgery under general anaesthesia is also uncommon, but it is an
interesting option in patients with a medical history as this patient.