Case Reports

Phacoantigenic uveitis after cataract couching: a persistent myth

Case Report Details

First Author: I.Jeddou MOROCCO

Co Author(s):    Y. Chaoui Roqai   M. Khmamouch   M. Belmalih   R. Zerrouk   K. Reda   A. Oubaaz     

Abstract Details

Purpose:

Couching is the oldest form of cataract surgery whereby a sharp instrument is used to dislodge the cataractous lens from the visual axis into the vitreous cavity. It dates back to the Assyrian Code Hammurabi around 1700 B.C. and remained the most popular method of cataract surgery until the 19th Century. Unfortunately, despite scientific progress, we face situations where we have to manage the abysmal outcomes of this largely unsuccessful practice including glaucoma, phacoantigenic uveitis, retinal detachment or endophtalmitis. The purpose of our observation is to highlight the danger of this remaining practice and describe its therapeutic management.

Setting:

Ophthalmology department of the Military Training Hospital of Rabat. Morocco

Report of Case:

A healthy 80 years-old patient, living in a rural area, came to the ophthalmology department for a progressive bilateral blurry vision back three years ago. The patient is illiterate and after a piece of advice from his entourage, went to a traditional healer who performed couching of the cataractous crystalline lens of his left eye for about 120 euros four months ago. The patient didn’t feel any improvement in his visual acuity and decided to visit the ophthalmology department. Best-corrected visual acuity (BCVA) was counting fingers in both eyes. The examination of the right eye showed a mature white cataract. Slit-lamp biomicroscopy of the left eye showed conjunctival hyperemia, protein Tyndall effect on the anterior chamber, aphakia associated with vitritis. The intraocular pressure (IOP) was 30 mmHg. Dilated-fundus examination showed a hypermature cataractous lens completely dislocated into the vitreous cavity without any retinal detachment. B-mode ultrasonography showed the completely dislocated lens surrounded by vitreous inflammation in the left eye without any retinal detachment in both eyes. We started an oral antibiotic and corticosteroid therapy leading to a regression of the inflammatory reaction of the anterior chamber and the vitreous. Then, under sub-Tenon’s anaesthesia, we performed through standard closed three-port incisions a total pars plana vitrectomy with an emphasis on the vitreous fibres around the dislocated lens. We realized, under continuous irrigation, an intravitreal phacofragmentation of the dislocated cataractous lens. At that time, we made a complete checking of the retina locking for any retinal tear. Finally, we made anterior chamber iris fixation of an intraocular lens (IFIOL). The evolution was positively marked by normalization of the IOP and improvement of the BCVA to 20/25 one month after surgery. Afterward, we performed phacoemulsification of the right eye. There wasn’t any complication after one year of follow-up.

Conclusion/Take Home Message:

Cataract surgery by couching is unfortunately still practiced in developing countries especially in rural areas among illiterate elderly subjects. It’s a dangerous and non-efficient practice that could lead to various complications: corneal dystrophy, glaucoma, phacoantigenic uveitis as it’s the case in our observation, retinal detachment or even endophtalmitis which may require evisceration in some cases. Pars plana vitrectomy associated with intravitreal phacofragmentation is a safe and effective surgical method for treating phacoantigenic uveitis and the completely dislocated crystalline lens after couching. A careful examination of the retina should be done intraoperatively and in the follow-up to look after any retinal tear. This ancestral method is no longer justified given the development of cataract surgery techniques currently available. Its eradication must go through the education of populations and the accessibility to health care in developing countries.

Financial Disclosure:

None