Cataract Surgery To Turn Off The Christmas Tree Lights

Christmas tree cataract is a rare type of lens opacification, with typical aspect of refractile multicoloured needle-shaped opacities. This condition resembles Christmas tree decoration lights due to the glitter and varying colours with the angle of light incidence. Development of this type of opacification is generally age-related, but it can also be associated with systemic pathologies such as myotonic dystrophy.

The aim of this work is to describe a clinical case and its surgical challenges.

Hospital Pedro Hispano | Unidade Local de Saúde Matosinhos

We report the case of a 77-year-old female patient, with clinical history of hypertension and non-insulin dependent Diabetes Mellitus and any relevant ophthalmic history. The patient presented to ophthalmic consultation complaining of visual acuity impairment of the right eye (RE). The patient presented a best corrected visual acuity (BCVA) of 2/10 with a negative sphere of 9.00 diopters (D) of the RE and 6/10 with negative sphere of 1.50D of the left eye, on Snellen chart. The ophthalmic examination of the RE demonstrated a shallow anterior chamber (AC) with deposition of pseudoexfoliation (PEX) material on pupillary border and anterior capsule, and polychromatic highly reflective, needle-shaped opacities of the lens, associated with nuclear sclerosis, and a normal posterior segment. The patient was proposed to lens extraction with intraocular (IOL) lens implantation and the surgery, despite challenging, was performed without any complications. The postoperative BCVA was 10/10 without correction.

A shallow AC makes it difficult to handle surgical instruments. We opted to administer 100ml of 20% mannitol 30 minutes prior to surgery, to deepen the AC.

PEX syndrome is a known cause of insufficient mydriasis and zonular/ capsular fragility. Thus, we tried to reduce the surgical trauma and intraocular manipulation. We considered mydriasis was sufficient to perform the surgery. The anterior capsulorhexis was performed following the border of pupillary border and involving anterior capsule’s PEX material.

The lens crystals were highly refringent, changing considerably the viewing of the red reflex during the procedure. We tried to execute each movement very carefully, with constant positioning in search of the best red reflex.