CASE REPORT

Bilateral Symmetrical Cataract After Total Thyroidectomy Due to Hypocalcemia in a

Young Woman.

Department of Ophthalmology, Faculty of Medicine, University of Hasanuddin, Makassar,

Indonesia

BACKGROUND: Cataract is defined as a loss of transparency/translucence due to lens

opacification. Based on the etiology, cataracts can be classified into age-related cataracts,
pediatric, and other causes. Several other common causes include metabolic disorders, one
of which is hypocalcemia. Hypocalcemia is defined as a decreased serum calcium level.
Hypocalcemia typically occurs due to the lack of parathyroid hormone (PTH) resulting
from parathyroid gland injury during thyroid or parathyroid surgeries. A cataract is one of
the ocular symptoms found in hypocalcemia cases.
OBJECTIVE: To report a bilateral symmetrical hypocalcemic cataract after total
thyroidectomy in a young woman.
CASE REPORT: An Ethiopian woman, aged twenty-six years old, presented with painless
vision reduction on both eyes. Five years before her reduction of vision, she was diagnosed
with hypocalcemia. Her serum calcium level was very low (3 mg/dL) due to parathyroid
gland injury during total thyroidectomy because of toxic goiter. She had been consuming
calcium gluconate supplements twice per day. She was diagnosed with bilateral
symmetrical posterior subcapsular cataract with iridescent punctate opacity in the anterior
cortex and posterior lens. Systemic examination showed a horizontal surgical scar on the
anterior neck and a positive Chvostek sign.
CONCLUSIONS: Bilateral symmetrical cataract may occur in permanent hypocalcemic
conditions due to complications of thyroid gland surgery. These patients should be
routinely followed up and checked for serum calcium levels.
KEYWORDS: Hypocalcemia, bilateral cataract, total thyroidectomy, hypoparathyroidism,
tetany, serum calcium and Ethiopia.
 INTRODUCTION overactive internodular tissue require
total thyroidectomy surgery; therefore,
Cataract is defined as a loss of
decreasing the amount or mass of the
transparency/translucence due to lens
overactive tissue. There are some
opacification. Based on the etiology,
complications of total thyroidectomy,
cataracts can be classified into age-related
including bleeding, airway obstruction,
cataracts, pediatric, and other causes.
and recurrent laryngeal nerve injury with
Several other common causes include
an altered voice. Other complications
metabolic disorders, one of which is
include thyroid insufficiency, recurrent
hypocalcemia. (1)
thyrotoxicosis, and temporary secondary
Hypocalcemia is defined as a hyperparathyroidism.
decreased serum calcium level. Hyperparathyroidism occurs due to the
Hypocalcemia typically occurs due to removal of the parathyroid gland or
impaired parathyroid hormone (PTH) infarct due to damage on the end of the
and vitamin D production. Hypocalcemia parathyroid arteries. Permanent
often occurs in adults due to the lack of hypoparathyroidism rarely occurs with
serum PTH resulting from parathyroid only 1% of cases. It is related to several
gland injury during thyroid or parathyroid hypocalcemic systemic manifestations
surgeries. Cataract is one of the ocular such as tetany, confusion, muscle
symptoms of hypocalcemia. (2) weakness, and paresthesia. (3)
Hypocalcemic cataract is one of the long-
Thyrotoxicosis is a
term consequences of hypocalcemia
hyperthyroidism condition, resulting in
along with papilledema, basal ganglia
increased thyroid hormone levels causing
calcification, nephrocalcinosis, and
various symptoms. Thyrotoxicosis is
prolonged QT interval. The author
classified into four clinical types: diffuse
reported an Ethiopian woman aged
toxic goiter (Graves’ disease), toxic
twenty-six years with bilateral cataract
nodular goiter, toxic nodule,
after thyroid surgery with signs and
hyperthyroidism with rare causes. Diffuse
symptoms of systemic hypocalcemia.
toxic goiter and toxic nodular goiter with
 CASE REPORT hypertension (HTN), or tuberculosis
(TB).
A young woman aged 26 years
old presented to the Jimma University Visual examination showed a 6/36
Department of Ophthalmology (JUDO) result in both eyes. Her intraocular
with a chief complaint of painless pressure (IOP) was 14 mmHg on the right
progressive reduction of vision on both eye and 12 mmHg on the left eye. Her
eyes for 2 years. She had a total conjunctiva was normal with the clear
thyroidectomy 7 years ago due to toxic and transparent cornea, anterior chamber
diffuse goiter. A week following the depth (AC) +3 with Van Herrick
surgery, she started to experience classification, and no cell or flare. Her
paresthesia or numbness on her hands and pupil was round regular, and reactive,
legs, muscle cramps, joint stiffness, without posterior synechiae on both eyes.
confusion, and irritability. She was There was a bilateral symmetrical
diagnosed as hypocalcemic due to the posterior subcapsular opacity and
injured parathyroid gland during the iridescent punctate opacity on the anterior
surgery and was started on a calcium and posterior lens cortex (Fig. 1).
gluconate supplement. At diagnosis, her
serum calcium level was very low (3
mg/dL), and she was started with calcium
gluconate supplement 500 mg three times
per day. On examination, her serum
calcium level was increased to 8.4 mg/dL Figure 1.

(8.2-10.2 mg/dL). The patient then

discontinued her supplement and was
advised to increase the consumption of
calcium derived from food. She denied
any history of ocular trauma. In addition,
she did not have other systemic diseases
such as diabetes mellitus (DM),

Figure 2.
The fundus examination showed
no abnormality. Systemic physical
examination showed a horizontal surgical
scar on her anterior neck and a Positive
Chvostek sign. Her laboratory results
showed significantly low parathyroid
hormone levels (4.03 pg/mL, normal 10-
65 pg/mL). Her serum phosphate level
was 6.5 mg/dL (normal 2.5-4.5 mg/dL).
Her serum magnesium level was 1.8
mg/dL (normal 1.7-2.4 mg/dL). Troponin
I level was 0.01 ng/mL.
Figure 3.
Other investigations showed no
significant findings. Her complete blood
count (CBC) was within the normal limit.
Erythrocyte sedimentation rate (ESR) was
30 mm/hour; fasting blood glucose was
103 mg/dL. Venereal Diseases Research
Laboratory (VDRL) and Provider
Initiative HIV Counseling and Testing
(PIHCT) showed negative results.
With the above findings, she was
diagnosed with a hypocalcemic cataract.
She was informed and planned for the
subsequent management, which is
phacoemulsification with Posterior
Chamber Intra Ocular Lens (PC-IOL).
However, she wanted to try alternative
management first (religious prayer with
holy water). To date, there was no change
in cataract maturity.
DISCUSSION
Cataract is defined as a loss of
transparency/translucence due to lens
opacification. Based on the etiology,
cataracts can be classified into age-related
cataracts, pediatric, and other causes.
Several other common causes include
metabolic disorders, one of which is
hypocalcemia. In particular, cataract at a
young age should warrant further
investigations regarding the main cause of
the condition. (4) Cataract is a main serum calcium levels is required to
manifestation of hypoparathyroidism. observe early hypocalcemia. (7) In cases
(1,5) of vitamin D deficiency, hypocalcemia is
usually not severe. Hypocalcemia can
Hypocalcemia is defined as a
also occur in conditions related to severe
decreased serum calcium level. Calcium
tissue injuries such as burn injury,
regulation is critical in maintaining cell
rhabdomyolysis, tumor lysis, or
function, membrane stability, neural
pancreatitis. The cause of hypocalcemia
transmission, bone structure, and blood
in these conditions include
clotting. The normal total of plasma
hypoalbuminemia, hyperkalemia, calcium
calcium concentration is 8.9-10.1 mg/dL
deposition on the tissue, and impaired
(4.5-5.1 mEq/L). Hypocalcemia typically
PTH secretion.
occurs due to impaired PTH (parathyroid
hormone) and vitamin D production. The A hypocalcemic cataract is
etiology of hypocalcemia can be described as a lenticular opacity on the
classified based on the low lens due to hypoparathyroidism. The
(hypoparathyroidism) or high serum PTH etiology and pathogenesis still require
level (secondary hyperparathyroidism). further investigations. However, in
Adult hypoparathyroidism often occurs general, experts stated that metabolic
due to the lack of serum PTH levels disorders, chronic hypocalcemia,
resulting from the injured parathyroid hyperkalemia, decreased calcitonin,
gland during thyroid or parathyroid vitamin D insufficiency might be the
surgeries and idiopathic cause of cataract formation. (8) Cataract
hyperparathyroidism. (5) After formation is thought to result from the
thyroidectomy, transient damaged membrane with \ low calcium
hypoparathyroidism occurs in 5-10% of levels in the aqueous humor and
patients; the incidence of transient increased sodium levels on the lens (9).
hypocalcemia ranges from 19-38%, and
The opacity is generally located
permanent hypocalcemia occurs in 1% of
on the cortical subcapsular regio, level
patients. (6) Therefore, an observation of
and separated from the anterior and
posterior capsule by a thin transparent
cortex layer. Lenticular changes began as
multiple punctum or fine vacuoles and
were replaced with linear opacity or
irregular white lamination. Cortical
opacity has a radial or spoke-like
appearance along the lens fibers toward
the middle of the lens. In cataract
patients, due to secondary
hypoparathyroidism resulting
surgery or kidney failure, the lens
changes occur rapidly, and progressivity
can be halted by calcium correction.
Papilledema can be found
hypocalcemic condition. Papilledema can
occur with or without increased
intracranial pressure
“pseudopapilledema”. This condition may
occur because hypocalcemia reduces
axonal transport, causing axonal and
optical disc edema. (8,10,11,12) The
morphology and bilateral manner of
cataracts without other primary ocular
conditions in our case indicated that the
cause was the long-term reduction of
serum calcium level. The patient had
long-term hypocalcemia after
thyroidectomy, which requires a longer
period to return to the normal level. The
serum calcium level at diagnosis was very
low. It took seven years of treatment to
increase her serum calcium level.
The clinical manifestation of mild
and chronic hypocalcemia is generally
asymptomatic. Increased neuromuscular
irritability occurs in moderate and severe
hypocalcemia, causing paresthesia on the
hand and foot fingertips and oral
circumference region. Hypocalcemia can
from
also cause calcium deposition on the soft
tissue, resulting in the reduction of vision
such as cataract, papilledema or basal
ganglia calcification. Chvostek and
in the
Trousseau signs can be observed on
physical examination. Seizure, carpopedal
spasm, bronchospasm, laryngospasm, and
or
prolonged QT interval may occur in
severe hypocalcemia. The patient in our
report had most of the systemic
manifestations, which improved with
calcium gluconate supplementation. (2)
Chronic hypocalcemia due to
hypoparathyroidism is treated with a
calcium supplement (1000-1500 mg/day
in divided doses) and vitamin D2 or D3
total (25.000-100.000 U per day) or calcitriol
(1.25 (OH) 2D, 0.25-2 g/day). (11) PTH
(1-84) (Natpara) has been approved as a
treatment of refractory
hypoparathyroidism. (2,14) Vitamin D the main cause. The treatment of the main
deficiency can be treated with vitamin D cause of hypocalcemia should be properly
supplementation with appropriate dosage conducted to reduce the complication
based on the severity and main cause of rate, such as bilateral symmetrical
the deficiency. (2,15) The patient cataract. Long-term follow-up in patients
consumed calcium gluconate 500 mg after thyroid and parathyroid surgery
three times per day, in line with the should be conducted, especially the serum
recommended dosage. The patient did not calcium level. The treatment of bilateral
consume vitamin D and calcitriol. symmetrical cataract in young patients
should include serum electrolyte levels,
Metabolic disorders such as
especially calcium.
hyperphosphatemia, reduced calcitonin,
vitamin D insufficiency, and kidney
failure are other causes of bilateral
REFERENCES
symmetrical cataract. Idiopathic
hypoparathyroidism is one of the main 1. Alshamrani AZ. Cataracts
Pathophysiology and Managements.
causes of hypocalcemia leading to Egypt J Hosp Med. 2018
bilateral symmetrical cataract. (8,11,15) Jan;70(1):151–4.
In our report, the patient had a history of 2. Jameson J, Fauci AS, Kasper DL,
total thyroidectomy and was diagnosed Hauser SL, Longo DL, Loscalzo J, et
al, editors. Harrison's principles of
with hypocalcemia 7 years before internal medicine, 20th ed. New
presenting to the Ophthalmology York: McGraw Hill; 2018
department. Various other investigations 3. Bailey and Love’s. Short practice of
did not show any other disorders that surgery. 25th edition, 2008: 783–7.

might cause hypocalcemia or bilateral 4. Midha NK, Garg MK, Kumar D,

Meena DS, Bohra GK. RapidLy
symmetrical cataract.
Developing Cataract in Young Adult
Patients: Always a Matter for Further
CONCLUSIONS Evaluation. Cureus [Internet]. 2021
Aug 19 [cited 2021 Oct 14];
Hypocalcemia should be Available from:
considered in any patient and searched for https://www.cureus.com/articles/5375
7-rapidLy-developing-cataract-in-
 young-adult-patients-always-a-
matter-for-further-evaluation
5. Saha S, Gantyala SP, Aggarwal S,
Sreenivas V, Tandon R, Goswami R.
Long-term outcome of cataract
surgery in patients with idiopathic
hypoparathyroidism and its
relationship with their calcemic
status. J Bone Miner Metab. 2017
Jul;35(4):405–11.
6. Underbjerg L, Sikjaer T, Mosekilde L,
Rejnmark L. Postsurgical
Hypoparathyroidism-Risk of
Fractures, Psychiatric Diseases,
Cancer, Cataract, and Infections:
POSTSURGICAL
HYPOPARATHYROIDISM. J Bone
Miner Res. 2014 Nov;29(11):2504–
10.
7. Freedman DB, Smith N, Housley D.
Profound hypocalcaemia associated
with bilateral cataracts post-total
thyroidectomy. Ann Clin Biochem Int
J Lab Med. 2007 Jul 1;44(4):400–2.
8. Liao X, Huang X. Characteristic
Cataract Associated with Idiopathic
Hypoparathyroidism. J Clin Exp
Ophthalmol [Internet]. 2016 [cited
2021 Oct 14];07(04). Available from:
https://www.omicsonline.org/open-
access/characteristic-cataract-
associated-with-idiopathic-
hypoparathyroidism-2155-9570-
1000588.php?aid=79450
9. Daba KT, Weldemichael DK,
Mulugeta GA. Bilateral hypocalcemic
cataract after total thyroidectomy in a
young woman: case report. BMC
Ophthalmol. 2019 Dec;19(1):233.
10. Cusano NE, editor.
Hypoparathyroidism: A Clinical
Casebook [Internet]. Cham: Springer
International Publishing; 2020 [cited
2021 Oct 14]. Available from:
http://link.springer.com/10.1007/978-
3-030-29433-5
11. Taşlı NG, Akbaş EM. Ocular
Findings Associated with
Hypoparathyroidism. Ocul Immunol
Inflamm. 2020 Apr 8;1–5
12. Goyal J. Bilateral Papilledema in
Hypocalcemia. Delhi J Ophthalmol.
2012 Oct 1;23(2):127–30
13. Bollerslev J, Rejnmark L, Marcocci
C, Shoback DM, Sitges-Serra A, van
Biesen W, et al. European Society of
Endocrinology Clinical Guideline:
Treatment of chronic
hypoparathyroidism in adults. Eur J
Endocrinol. 2015 Aug;173(2):G1–20.
14. Kim ES, Keating GM. Recombinant
Human Parathyroid Hormone (1–84):
A Review in Hypoparathyroidism.
Drugs. 2015 Jul;75(11):1293–303.
15. Brown C, Akaichi F. Vitamin D
deficiency and posterior subcapsular
cataract. Clin Ophthalmol. 2015
Jun;1093.