Delhi Journal of Ophthalmology

Spontaneous absorption of the lens: A case report

Prajakta Dandekar
Department of Ophthalmology, Graded Specialist, Military Hospital, Gwalior, Madhya Pradesh, India

Corresponding Author:

Prajakta Dandekar
DNB (Ophthalmology)
Graded Specialist, Military Hospital, Gwalior, Madhya Pradesh, India
E-mail: prajakta0409@gmail.com

Received: 30-JUN-2020

Accepted: 22-JUL-2020

Published Online: 12-MAR-2021

DOI:http://dx.doi.org/10.7869/djo.632

Abstract
Spontaneous absorption of the natural lens is rare. A fifty-six-year-old lady came to the Eye Dept with a chief complaint of gradual, painless and progressive diminution of vision in the left eye since last ten years. Undilated anterior segment examination revealed a mature cataract, and on dilatation an opaque calcified anterior lens capsule in the centre and translucent capsule with calcified spots in the peripheral part was visible. Neodymium-doped Yttrium Aluminum Garnet (Nd YAG) laser capsulotomy of the anterior capsule allowed us to examine the posterior segment. No nucleus or lens particle found in the posterior segment. Ultrasound B scan also revealed absent nucleus. After anterior vitrectomy, we implanted IOL through a 6mm scleral tunnel. Postoperatively, the patient's vision improved to 6/6. Unrecognised capsular tears with unnoticed ocular inflammation can lead to spontaneous lens absorption as in our case evident from the capsular calcification.

Keywords :Spontaneous, Absorption, Lens, Intraocular lens

Introduction 
Absorption of a natural crystalline lens is very rare. It can be spontaneous; or it may be associated with conditions like maternal Rubella, Leptospirosis, uveitis, Persistent Hyperplastic Primary Vitreous (PHPV), Hallerman- Streif- Francois syndrome, Down syndrome, and morgagnian cataract.1 J.C. Saunders (1811) mentioned his possibility of spontaneous absorption, and since then, various authors have presented their case reports. However, calcified and opaque anterior lens capsule in the centre with a wholly absorbed lens matter and well preserved capsular support makes this case unique.2

Report
Fifty-six years old female patient came to the Eye Department with chief complaints of gradual, painless and progressive decreased vision in her left eye since last 10 yrs. There was no h/o redness or discharge from the eye, no h/o ocular injury or ocular surgery, no h/o any systemic diseases or any long term steroid intake. General and systemic examination was normal. On ocular examination: The distant vision in the right eye was 6/36 (measured by Snellen's chart) improving to 6/9 with -0.5 diopter cylinder at the axis of 125 degrees, and the left eye was counting fingers close to face with the projection of rays accurate in all quadrants and vision not improving further with pinhole. Autorefraction of both eyes showed OD: -0.75 DC X 125; OS: ERROR. On examination of the anterior segment, the right eye was within normal limits, and left showed mature cataract. 
The patient was now dilated with eyedrop Tropicamide 0.8% + Phenylephrine 5% combination to check whether the pupil dilates fully and for the examination of the posterior segment. The dilated anterior and posterior examination in the right eye was within normal limits. In the left eye, the pupil was 6 mm dilated, with posterior synechiae present from 4 to 8 0'clock position. Surprisingly, instead of a mature cataract, we found an opaque calcified anterior capsule in the centre and translucent capsule with calcified white spots in the periphery. Posterior details were not visible. So we were dealing with what? Was it a mature cataract? Or a case of unnoticed trauma? Or anterior capsular opacification/calcification? Is there a lens behind this capsule?
So, to find the answers, we did a Neodymium-doped Yttrium Aluminum Garnet (Nd YAG) laser capsulotomy keeping anterior offset. It was initially started with a window no. Three and then shifted to 4 with 2.3 to 8.5 millijoules of energy variation. 10 - 15 shots were required to make an opening of approximately 5 mm in the dense anterior capsule (Figure 1). There revealed no natural or intraocular lens in the left eye, and the posterior segment appeared to be within normal limits. The vision in the left eye improved to 6/12 with pinhole and also with + 7.00 diopter spherical and +2.5 diopter cylinder at the axis of 100 degrees. We planned an Ultrasound (USG) B Scan of the left eye to check for the peripheral retina since the pupil was mid dilated. USG B scan also revealed absence of lens. Hence, the diagnosis, spontaneous absorption of the lens in the left eye. 


Figures 1:  Anterior Segment Examination Of The Left Eye After Nd Yag Laser

Routine investigations, viral markers and specific testing for Rubella were all within normal limits. We calculated the IOL power of the left eye in Aphakia mode and planned the patient for anterior vitrectomy with secondary IOL implantation under peribulbar anaesthesia. The initial steps of surgery were the same. We used a Sinskey hook along with a dispersive viscoelastic to break the posterior synechiae (Figure 2). We did the anterior vitrectomy (2500 cuts / min) in Cut-I/A (Irrigation/ Aspiration) mode and implanted a Rigid IOL in the sulcus through a six mm scleral tunnel. Intra-cameral Triamcinolone acetonide 1mg/0.1ml ensured no vitreous in the anterior chamber. Postoperatively, the patient's IOL was in place with vision improving to 6/6 with -2.00 diopter cylinder at 90 degrees. The patient was given an antibiotic and steroid eyedrops with tapering doses of topical steroids for a month. 


Figures 2: Sinskey Hook / Dialer Used To Break The Post Synechea

Discussion
Spontaneous absorption of cataracts is rare, with one case reported in a year as per Marlow's literature. List of diseases like Leptospirosis, Rubella, persistent pupillary remnants, phacolytic glaucoma, trauma, iridectomy can lead to spontaneous lens absorption through various mechanisms. Mohan et al. in his study described idiopathic causes like - Osmotic forces and chemical changes on either side of the lens capsule and unrecognisable tears in anterior or posterior capsule with dislocated lens getting absorbed over a long period without noticeable inflammation.3 Zeiter et al. explain that calcium deposition takes place in the lens when it gets invaded by the uveal tissue due to a rupture in the lens capsule.4 Goel N et al. also reported cases with anterior and posterior capsular rupture in a hyper mature cataract, 50% of which is associated with calcification in the capsular remnants.5 In our case report, the evidence of calcification clearly shows that there was an unrecognised capsular rupture. The posterior synechiae also reveal that some ocular inflammation did occur which went unnoticed. 

Conclusion
Spontaneous absorption of the lens is rare and has surprising presentations. Unrecognised capsular tears with unnoticed ocular inflammation can lead to spontaneous lens absorption as in our case evident from the capsular calcification.

Ethical approval
The surgical procedure involving human participant is following the ethical standards of the institutional/ national research committee, the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent
Written, informed consent is obtained from the patient for laser as well as surgical procedure.

References
  1. Dwivedi K, Agasti M. Spontaneous absorption of lens. Int J Contemp Med Res. 2016;3(5):1441–2. 
  2. Marlow SB. Spontaneous absorption of cataract. Trans Am Ophthalmol Soc. 1952;50:283. 
  3. Mohan M, Bartholomew RS. Spontaneous absorption of a cataractous lens. Acta Ophthalmol Scand. 1999;77(4):476–7. 
  4. ZEITER HJ. Calcification and ossification in ocular tissue. Harper Hosp Bull. 1961;19(2):138–9. 
  5. Goel N, Nagar M. Spontaneous rupture of the lens capsule in hypermature cataract: Presentations and outcomes. Br J Ophthalmol. 2016;100(8):1081–6.

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Dandekar PSpontaneous absorption of the lens: A case report.DJO [serial online] 2021[cited 2021 Apr 16];31:77-78. Available from: https://www.djo.org.in/articles/31/3/Spontaneous-absorption-of-the-lens-A-case-report.html