Left Behind

Cataract surgery is one of the most frequently performed procedures worldwide with generally high success rates. Despite its routine nature and various technological advances, a range of ocular complications may still arise. One uncommon yet clinically significant complication is the retention of lens fragments.

A REFRESHER ON RETAINED LENS FRAGMENTS

The human crystalline lens consists of an anterior and posterior capsule, cortex, and central nucleus. Following phacoemulsification, an ultrasonic disruption, and removal of the natural lens, retained lens fragments are reported to occur in approximately 0.1% of cases.¹ These fragments may consist of cortical and/or nuclear material and can lead to a spectrum of complications, including decreased vision, corneal edema, anterior chamber inflammation, macular edema, and/or retinal detachment.

Retained lens fragments may be found in the anterior chamber, posterior chamber, vitreous cavity, or capsular bag. Nuclear fragments are yellow in color with sharp edges, whereas cortical fragments appear white and fluffy. Although most retained lens fragments are seen in the early postoperative days, in some cases, it may be decades before they are identified or pose a threat to the patient’s ocular health.²

WHAT TO DO ABOUT RETAINED LENS FRAGMENTS

Early recognition, material identification, and appropriate management are critical to ensure positive patient outcomes. Most retained lens fragments can be easily seen during the slit-lamp examination (Figure); however, gonioscopy and B-scan ultrasonography may allow better visualization and localization. Management typically involves surgical removal of the fragments, although cortical lens fragments may dissolve spontaneously over time. It is also necessary to control IOP and treat any ocular inflammation with topical steroids such as prednisolone acetate. Topical miotics such as pilocarpine may be considered to sequester the fragment in the anterior chamber, avoiding posterior complications.³

Several studies have indicated that the remaining lens material has a more significant effect on the visual prognosis than its size; specifically, nuclear fragments may pose a higher risk of complications than cortical fragments.^3,4 It is hypothesized that this may be due to more challenging removal and/or the density of the lens material.⁴

Although there is no consensus on optimal timing, we generally find it best to remove lens fragments within 30 days of identification. Surgical removal may target the anterior chamber via irrigation and aspiration or the posterior segment via pars plana vitrectomy.

CONSIDERATIONS BEFORE CATARACT SURGERY

Although there are effective strategies for managing a retained lens fragment, it is important to consider certain risk factors, such as older age, shallow anterior chamber depth, myopic refractive error, and thickness of the natural lens, before cataract surgery.¹