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 Table of Contents    
CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 389-392  

A new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism


1 Department of Ophthalmology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
2 Pediatric Infectious Diseases Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
3 Department of Internal Medicine, Mazandaran University of Medical Sciences; Diabetes Research Center, Mazandaran University of Medical Sciences, Sari, Iran

Date of Submission10-Aug-2021
Date of Decision21-Dec-2021
Date of Acceptance30-Apr-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Reza Jafari
Department of Ophthalmology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_238_21

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   Abstract 


Hypoparathyroidism is a disorder characterized by hypocalcemia. Premature cataract is one of the signs of hypoparathyroidism, but it is very rare. The present text is a case report of a rare case of a new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. The patient is a 30-year-old male with a chief complaint of progressive, painless vision loss and tearing in both eyes and photophobia in the left eye for the past 10 months and paresthesia, muscle spasms, and tingling for 2 years before referral. He had a history of hypoparathyroidism disorder that was undertreated with medication. Central posterior subcapsular cataract in both the eyes had been diagnosed. He underwent cataract surgery of the left eye under topical anesthesia. The visual acuity improved from 20/40 to 20/20 postoperatively, and the patient did not have any visual symptoms. This case is the first report of cataract with feathery opacity pattern reported with high-quality imaging from a patient. This feathery opacity pattern may explain the difference in the morphology of this patient's cataracts from others.

Keywords: Cataract, hypocalcemia, hypoparathyroidism


How to cite this article:
Jafari R, Kamali M, Rad MM. A new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. Oman J Ophthalmol 2022;15:389-92

How to cite this URL:
Jafari R, Kamali M, Rad MM. A new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. Oman J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];15:389-92. Available from: https://www.ojoonline.org/text.asp?2022/15/3/389/360403




   Introduction Top


Hypoparathyroidism is a disorder characterized by hypocalcemia. Symptoms associated with hypocalcemia depend on its severity, duration, and rate of development.[1] Symptoms of the disease include paresthesia, tingling, muscle cramps, severe spasms in the hands and feet (tetany), seizures, and an unpleasant tingling sensation around the mouth and in the hands and feet that results from increased neuromuscular irritability due to hypocalcemia.[1],[2] Premature cataract is one of the signs of hypocalcemia, but it is very rare.[3] Chronic hypocalcemia, Vitamin D deficiency, calcitonin reduction, and metabolic disturbance can lead to cataract formation.[4],[5] Prolonged hypocalcemia due to diseases may induce cataract development over time, so we report a rare case of a new pattern of bilateral cataracts associated with hypocalcemia secondary to uncontrolled hypoparathyroidism.


   Case Report Top


The patient was a 30-year-old male. He was admitted to the general educational hospital in one of the cities Mazandaran Province, Iran, with a chief complaint of progressive, painless vision loss and tearing in both eyes and photophobia in the left eye for the past 10 months and paresthesia, muscle spasms, and tingling for 2 years before referral. The patients' medical history was obtained, and physical and paraclinical examinations were done. He had a history of hypoparathyroidism disorder that was undertreated with medication due to the poor compliance treatment. Other factors in the patient's medical history and family history were not remarkable. Furthermore, there was no history of seizure and cardiac arrhythmia. He had some medical documents that showed the history of hypoparathyroidism and his medical management.

Among these documents, a brain magnetic resonance imaging (MRI) and computed tomography (CT) scan (more visible in CT scan in comparison with MRI) showed intracranial calcifications, and electrocardiogram showed prolonged QT interval [Figure 1] and [Figure 2]. Biochemical analyses demonstrated low parathyroid hormone (8 pg/ml, normal range: 10–55 pg/ml), low serum calcium (Ca = 4 mg/dl, normal range: 8.5–10.6 mg/dl), and high phosphorus (IP = 7.8 mg/dl, normal range: 2.5–5.1 mg/dl) levels. Other biochemical analysis markers were normal. Furthermore, liver and renal functional tests revealed normal results. Thus, according to the consultation with an endocrinologist, the characteristic of clinical symptoms, imaging, and the biochemical profile, the specialist confirmed the diagnosis of typical hypoparathyroidism. The idiopathic form of hypoparathyroidism was diagnosed and the patient had undergone combination therapy of oral calcium (calcitriol), phosphate binding (sevelamer), and Vitamin D3 supplement for the previous 9 months. It is supposed that in patients with hypoparathyroidism, calcium phosphate crystals are deposited in the lens causing cataract.
Figure 1: In retroillumination, common pattern of central posterior subcapsular cataract with multiple granular pearly crystalline lens opacity in the posterior pole of the cortex adjacent to the posterior capsule can be seen in some metabolic diseases

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Figure 2: In retroillumination, unique feather-shaped opacity in crystalline lens is clearly visible. Feathery opacity has main shaft and serial parallel branches attached to it

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The patient referred to the hospital with ocular symptoms and ophthalmic examination revealed cataract in both the eyes. The patient had symptoms of progressive, painless vision loss and epiphora or tearing in both the eyes and photophobia in the right eye for the 10 months, which has exacerbated over the past 3 months. The visual acuity was 20/40 and intraocular pressure was 12. Central posterior subcapsular cataract in both the eyes was diagnosed. Photophobia in the left eye that exacerbates in the light was due to central posterior subcapsular cataracts. The retinal examination was normal and showed transparent aqueous humor. Stroma and epithelium of the cornea were transparent and no significant opacities were observed [Figure 3] and [Figure 4]. He underwent cataract surgery of the left eye under topical anesthesia. The visual acuity improved from 20/40 to 20/20 postoperatively, and the patient did not have any visual symptoms.
Figure 3: In retroillumination common pattern of central posterior sub capsular cataract with multiple granular pearly crystaline lense opacity in the posterior pole of cortex adjacent to the posterior capsule can be seen in some metabolic diseases (Left eye)

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Figure 4: In retroillumination unique feathery shape opacity in crystaline lense clearly visible. Feathery opacity has main shaft and serial parallel branches attached it (Left eye)

Click here to view


In the 6-month follow-up, there was no evidence of new sediment on the posterior capsule after surgery in the left eye. Moreover, posterior capsular opacity had not occurred due to the management of hypocalcemia. However, the cataract severity in the right eye had not changed since the diagnosis due to calcium management; 6 months after the operation, he underwent cataract surgery for the right eye.


   Discussion Top


In the present study, the patient presented with bilateral cataract associated with hypocalcemia secondary to uncontrolled hypoparathyroidism. As seen in the presented case, the result of hypocalcemic disorder is opacities, which leads to osmotic imbalance and swelling and rupture of lens fibers.[6]

The distribution of calcium within the lens is described differently in yellow, brown, hypermature, and cortical cataracts. In addition, in some cases, calcium-rich spheroid bodies are observed in nontransparent lenses,[7] but this was not observed in our case.

Our patient was diagnosed with central posterior subcapsular cataract in both the eyes. Cortical cataract in the feathery opacity pattern was observed in both the eyes of the patient. The present case appears to have a new pattern of cataracts, with a history of predisposing factors in this patient. According to the available literature, in the idiopathic form of hypoparathyroidism, cataracts are often cortical,[8] and this has been in our patient.

Liao et al. reported a case of cataract associated with idiopathic hypoparathyroidism, a 37-year-old male with a history of vision loss in both the eyes for a period of 3 years.[8] The patient's medical history included recurring tetany and convulsion and epilepsy with the diagnosis of hypoparathyroidism. Ophthalmic examination revealed lenticular opacities located in peripheral and central regions in both the eyes, and the patient underwent cataract surgery.[8] Freedman et al. reported a case of cataract associated with total thyroidectomy, a 43-year-old male with a history of thyroidectomy 4 years ago.[9] In primary care, the patient was diagnosed with hypocalcemia in thyroidectomy follow-up. More evaluations revealed hypocalcemia secondary to hypoparathyroidism. Ophthalmic examination revealed cortical lenticular opacities in both the eyes, and the patient underwent cataract surgery. He had eye symptoms and was diagnosed with developed bilateral cataracts and the patient underwent cataract surgery.[9] Sengupta et al. reported a case of bilateral cataracts and optic disk edema, a 16-year-old girl with a history of loss of vision in both the eyes for a period of 6 months.[10] Examination revealed hypocalcemia and hyperphosphatemia associated with pseudohypoparathyroidism. The constellation of phenotypic characteristics led to a diagnosis of Albright's hereditary osteodystrophy. The patient underwent cataract surgery with an interval of 3 months for both the eyes.[10]

In our case, due to the young age of the patient, the senile process of cataract does not matter and the underlying disease is the cause of cataract. A notable point in this patient is the opacity pattern in the lens; in addition to radial cortical opacity wedges, opacity in retroillumination had a feathery pattern that is clearly visible in [Figure 2]. To date, this opacity pattern has not been reported.

This case is the first report of cataract with feathery opacity pattern reported using high-quality imaging. This feathery opacity pattern may explain the difference in the morphology of this patient's cataracts from others.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bilezikian JP, Khan A, Potts JT Jr., Brandi ML, Clarke BL, Shoback D, et al. Hypoparathyroidism in the adult: Epidemiology, diagnosis, pathophysiology, target-organ involvement, treatment, and challenges for future research. J Bone Miner Res 2011;26:2317-37.  Back to cited text no. 1
    
2.
Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med 2008;359:391-403.  Back to cited text no. 2
    
3.
Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008;336:1298-302.  Back to cited text no. 3
    
4.
Brown CJ, Akaichi F. Vitamin D deficiency and posterior subcapsular cataract. Clin Ophthalmol 2015;9:1093-8.  Back to cited text no. 4
    
5.
Thakker RV. Parathyroid disorders and diseases altering calcium metabolism. In: Warrall D, Cox T, Firth J, Benz E, editors. Oxford textbook of medicine 4th ed. Oxford: Oxford University Press, 2003. p.230-41.  Back to cited text no. 5
    
6.
Elamere NA, Paterson CA. Hypocalcaemic cataract. In: Mechanisms of Cataract Formation in the Human Lens, edited by Duncan G. New York: Academic; 1981. p. 219-36.  Back to cited text no. 6
    
7.
Jedziniak JA, Nicoli DF, Yates EM, Benedek GB. On the calcium concentration of cataractous and normal human lenses and protein fractions of cataractous lenses. Exp Eye Res 1976;23:325-32.  Back to cited text no. 7
    
8.
Liao X, Huang X, Lan C, Li J, Tan Q. Characteristic cataract associated with idiopathic hypoparathyroidism. J Clin Exp Ophthalmol 2016;7:588.  Back to cited text no. 8
    
9.
Freedman DB, Smith N, Housley D. Profound hypocalcaemia associated with bilateral cataracts post-total thyroidectomy. Ann Clin Biochem 2007;44:400-2.  Back to cited text no. 9
    
10.
Sengupta S, Ravindran RD, Kannusamy V, Tamrakar V. Bilateral simultaneous disc edema and cataract associated with Albright hereditary osteodystrophy. Middle East Afr J Ophthalmol 2012;19:166-8.  Back to cited text no. 10
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