We described 3 patients with IOL or lens dislocation that could be clearly determined to be due to family violence. Differential diagnosis of lens or IOL dislocation includes various ocular and systemic diseases. Trauma is known as one of the main causes of lens or IOL dislocation. However, pseudo-exfoliation (PE) was reported to be more associated with IOL dislocation [3]. In our case series, although the number of cases is small, there were more traumatic cases (28%) and less PE cases (14%) compared to previous reports [4, 6, 7, 9].
The proportion of males in all IOL dislocation cases was 56% in this study, but all IOL dislocation cases related to family violence were female. There are many reports that males are more common in IOL dislocation cases [10, 4, 5, 1, 7, 9]. When combined with this study and the previous reports, family violence-related IOL or lens dislocation cases were 1 male and 4 females [11, 12]. It is noteworthy that family violence-related IOL dislocation is clearly higher in females at 80%. Generally, females are more prone to become victims of family violence [14, 15]. Thus, as shown in the current case series, female IOL dislocation cases without obvious risk factors for IOL dislocation should be considered to be possibly due to family violence.
All IOL dislocation cases in this study were in-the-bag IOL cases. The number of in-the-bag IOL dislocations has been increasing recently, with an incidence of 0.05-3.0% in previous reports [2, 1, 16–18, 3, 19–21]. Due to the limitation of our study, we could not determine the incidence of in-the-bag IOL dislocations. Possible predisposing factors for in-the-bag IOL dislocation were reported to be pseudoexfoliation, retinitis pigmentosa, a history of vitrectomy, ocular trauma, and a long axis [7]. Some of these traumas reported in late IOL dislocations may contain family violence cases.
The patients in this study did not complain of family violence voluntarily at first visit. In addition, all of our cases were not recognized as family violence victims at the initial examination in former clinics. Patients tend to hide the fact that they are victims of family violence [22]. There are some reports that most abused women did not volunteer a history of violence even to their regular clinicians [23, 24]. Doctors lack knowledge about family violence and lack of education for how to deal with family violence [25]. Our cases may only be the tip of the iceberg. In some cases, it is necessary to avoid family attendance and take a detailed interview.
Case 2 raised an important issue. We could not avoid IOL dislocation occurring in the fellow eye 1 year after IOL dislocation in her left eye. In fact, it is difficult for ophthalmologists alone to deal with family violence. To prevent the recurrence, when an ophthalmologist diagnoses family violence, it may be better to work in partnership with a specialized team of family violence.
On the other hand, the most common sites of injury due to family violence were reported to be the eyes, the side of the face, and the throat or neck [26]. Of ocular injuries in battered women, 86% were result of a punch with a closed fist, and orbital fracture, ruptured globe and traumatic hyphema were reported as serious injuries [27]. Family violence and sexual assault were reported as frequent cause of orbital fractures among women [28]. This study revealed that family violence against women may cause IOL dislocation. Further studies in a larger number of cases are necessary to clarify actual conditions of eye injury due to family violence.