Sir,

We report a case of posterior lens nucleus displacement following an intravitreal injection of bevacizumab (IVB). To the best of our knowledge this complication has not been previously reported.

Case report

A 67-year-old Caucasian male reported to the Eye casualty with complaints of persistent blurred vision in the left eye (OS) following IVB injection for retinal vein occlusion, 6 days earlier. The intravitreal injection had been performed from the infero-temporal quadrant. Best corrected visual acuity (BCVA) was hand movements, OS. Anterior segment examination was suggestive of cortical cataract and the state of the posterior capsule (PC) could not be identified (Figure 1). The ultrasonography B-scan was suggestive of a lens nucleus in the inferior vitreous cavity (Figure 2). BCVA prior to the injection was 6/36.

Figure 1
figure 1

Slit-lamp photograph of the left eye obtained 6 days after the intravitreal injection, shows the presence of a traumatic cataract.

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Figure 2
figure 2

The ultrasonography B-scan image of the left eye shows the high-reflective, bi-convex, globular structure in the inferior vitreous cavity, suggestive of a posterior lens displacement (the arrow points to the lens). The retina was attached.

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A diagnosis of traumatic cataract with posterior nucleus displacement was made and therefore considered for vitreoretinal surgery. A dye-assisted anterior capsulorhexis was performed, only cortical matter in the capsular bag along with a large PC tear extending from 2 to 7 o’clock was noted. Following aspiration of cortical matter, the nucleus was removed via a pars-plana vitrectomy and lensectomy procedure. An intra-ocular lens (IOL) was placed in the sulcus. At 3 months follow-up, the BCVA was 6/24 with a stable IOL and no vitreoretinal complications.

Comment

Although intravitreal injections are relatively safe procedures, there are reports of complications including vitreous prolapse, intraocular lens dislocation, and inadvertent capsule penetration.2, 3, 4 The injecting doctor mentioned that this patient had moved his eye during the procedure and this possibly may have led to the posterior capsular damage by the 30 gauge needle. Our case reiterates the need for adherence to a few steps while performing the intravitreal injections. These include adequate warning to the patient immediately prior to the injection, maintaining correct direction of the needle at all times, that is, towards the mid vitreous cavity, right distance from limbus, and adequate anaesthesia.1, 4, 5 Indirect ophthalmoscopy should be performed at the end of the procedure.

To conclude, serious complications arising from a routine intravitreal injection can occasionally occur. It is important to adhere to meticulous injection techniques.