Interesting Case

[Jokestr]

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Hey everyone, I'm going to try and post a couple of pictures to see if I can get some feedback from some of the more experienced ophthalmologists. I just got back from rural Nicaragua, where I was doing mostly epidemiological work on eye problems(I just matched in optho and plan to continue international work in Nica after residency). I saw some very interesting pathology while there, as most of the patients had little or no medical care throughout their lives. History on this kid was a 9-year-old boy who had a worsening opacity and decreased vision over the past 1-2 years. Dad claimed he had seen well out of the eye before that, but this might be in question, as you will see his strabismus. There was no history of any trauma or other problems with the eye before this increasing opacity. Anyways, the pics are not great after processing, but hopefully you can appreciate this incredible white opacity and give me some ideas on what it might be. The only two opacities I was aware of in this situation would be a cataract or the dreaded retinoblastoma. Physical exam was limited, as there was no slit lamp available, but on examination with a direct it looked to me like it was an opacified lens, and not something behind the lens. I sent him to be seen by an optho doc in one of the larger cities for further evaluation. Mostly, I am just curious to learn more about what this might be. Anyone know of any case reports on spontaneous unilateral cataracts in a 9 year old? Any other suggestions? Thanks a lot! PS, dad and son approved of the picture taking and I’m pretty sure HIPAA isn’t quite as strict in a place where there is no running water or consistent electricity 😉. Let me know if there are any problems with the pics.

 

[drrahulbhola]

Thanks for posting this interesting case on the discussion forum. As mentioned by you this opacity does appear to be lenticular although a slit lamp exam is the gold standard test to comment on the level of anterior media opacities. This opacity seems like a total cataract in the right eye, it would be essential to do a good SLE on the other eye to rule out an assymmetric bilateral cataract. Traditionally it has been taught that in any unilateral cataract think of PHPV, Posterior Lenticonus, Post-traumatic cataract or cataract secondary to uveitis but in my limited experience I have seen unilateral developmental cataracts but mostly they are assymmetric and involves the other eye in matter of days. I still remember seeing two interesting cases in my fellowship that developed a total bilateral idiopathic cataract at the age of 7 and 8 in matter of days and these kids had only Finger counting vision when we saw them in the clinic for the first time. In the first picture it seems as if there are some inferior posterior synechiae (6-8 o'clock), did you observe any clinically? the best test would be to dilate the pupil and see if it dilates symmetrically. In case the synechiae are true then it warrants for a complete uveitis work up. The other tests like reducing sugars, glucosamine, tests for metabolic disorders could be performed if there are any systemic diagnostic clues. Developmental cataracts can develop strabismus ( again traditionally it is taught any media opacity before 2 years of age results in esotropia and after 2 exotropia but in practice this rule does not hold true always). In my opinion this cataract should be removed as early as possible although it might be a lost battle, the most essential thing would be to do an extensive exam on the other eye.

Hey everyone, I'm going to try and post a couple of pictures to see if I can get some feedback from some of the more experienced ophthalmologists. I just got back from rural Nicaragua, where I was doing mostly epidemiological work on eye problems(I just matched in optho and plan to continue international work in Nica after residency). I saw some very interesting pathology while there, as most of the patients had little or no medical care throughout their lives. History on this kid was a 9-year-old boy who had a worsening opacity and decreased vision over the past 1-2 years. Dad claimed he had seen well out of the eye before that, but this might be in question, as you will see his strabismus. There was no history of any trauma or other problems with the eye before this increasing opacity. Anyways, the pics are not great after processing, but hopefully you can appreciate this incredible white opacity and give me some ideas on what it might be. The only two opacities I was aware of in this situation would be a cataract or the dreaded retinoblastoma. Physical exam was limited, as there was no slit lamp available, but on examination with a direct it looked to me like it was an opacified lens, and not something behind the lens. I sent him to be seen by an optho doc in one of the larger cities for further evaluation. Mostly, I am just curious to learn more about what this might be. Anyone know of any case reports on spontaneous unilateral cataracts in a 9 year old? Any other suggestions? Thanks a lot! PS, dad and son approved of the picture taking and I’m pretty sure HIPAA isn’t quite as strict in a place where there is no running water or consistent electricity 😉. Let me know if there are any problems with the pics.

 

[Jokestr]

Thanks a lot for your wisdom! Hopefully some of the other students/residents can learn something too.I know it gives me some things to go read about.
To answer your questions, I did not observe any synechiae, this may be a photographic difference. Also I hope this child gets a thorough work-up, although the chance of the physicians doing a full metabolic work-up is probably slim due to the limited resources in Nicaragua. I am hoping they would at least be able to provide a better diagnosis than I was, and also hopefully remove the cataract and give this child a chance at restored vision(VA was CF @ 3 ft OD) while at the same time preventing this from possibly happening in his good eye.