Capsular bag distention syndrome noted 5 years after intraocular lens implantation

Late capsular blockage syndrome: Clinical and anterior segment optical coherence tomography characteristics

BACKGROUND

Late capsular blockage syndrome (CBS) is a rare phenomenon which is found after cataract surgery. The mechanism, anterior segment optical coherence tomography (OCT) presentation, and clinical characteristics are not well studied.

METHODS

We studied patients who developed late CBS in Taipei Veterans General Hospital from 2012 to 2019. Age, sex, systemic disease, ocular disease, interval between cataract surgery and CBS, axial length, type of intraocular lens implanted, grading of posterior capsular opacity, refraction, visual acuity, and anterior segment OCT findings were documented. Patients are categorized into two groups according to anterior segment OCT findings. All patients underwent Nd:YAG laser capsulotomy and were prescribed a low-dose topical steroid for 7 days. Postcapsulotomy refraction and visual acuity were recorded. All the clinical data were compared in the two groups.

RESULTS

This study included 18 eyes with late CBS. Patients' median age was 80 (range, 54-92) years. The mean duration between cataract surgery and CBS diagnosis was 80.28 (range 15-136) months. According to anterior segment OCT findings, we subcategorized the patients into two groups: gravel appearance (n = 7) and milky (n = 11) appearance. After laser capsulotomy, mean visual acuity improved 0.18 ± 0.10 on the LogMAR. A significant myopic shift in refraction after laser capsulotomy was noted in the gravel appearance group compared to the milky appearance group ( p = 0.027). No patient developed complications or needed further treatment for CBS during the median follow-up of 14.5 months (range 1-84 months).

CONCLUSION

High-resolution anterior segment OCT is useful for analyzing patients with late CBS. Our study implies that the two types of CBS presentation indicate different causes of late CBS formation, as well as distinct clinical presentation and postlaser capsulotomy refractive outcome. In addition, YAG laser capsulotomy is a safe late CBS treatment modality.

Case Series: Late Postoperative Capsular Block Syndrome Causing Reduced Vision Years After Uncomplicated Cataract Surgery

SIGNIFICANCE

Late postoperative capsular block syndrome is a treatable complication presenting months to years after cataract surgery using continuous curvilinear anterior capsulorhexis and a posterior chamber intraocular lens implantation. Patients may present to optometric practices because of symptom onset significantly after the immediate post-operative period.

PURPOSE

The purpose of this study was to describe the defining clinical features, proposed pathophysiology, and treatment of late postoperative capsular block syndrome. Case 1 was a 68-year-old man who presented with a sudden onset of blurry vision in the right eye 2 years after uncomplicated cataract surgery. Clinical examination revealed turbid fluid distending the posterior lens capsule, a 2-D myopic shift, and an absence of intraocular inflammation. Laser posterior capsulotomy successfully released the trapped fluid and reversed the myopic shift without complication. Case 2 was a 67-year-old man who presented with a gradual onset of hazy vision in the right eye 7 years after uncomplicated cataract surgery. Cloudy fluid was observed to be filling the space between the intraocular lens and the posterior lens capsule, and the refractive error was stable. The fluid was liberated and visual function was restored with uncomplicated laser posterior capsulotomy.

CONCLUSIONS

Patients with late postoperative capsular block syndrome may present with blurry vision months to years after cataract surgery performed with continuous curvilinear capsulorhexis and posterior capsule intraocular lens implantation. The defining clinical sign is entrapment of turbid fluid between the intraocular lens and the posterior capsule that may result in reduced vision or refractive error shift. Late postoperative capsular block syndrome is distinguishable from other late complications of cataract surgery, including delayed endophthalmitis or phacoantigenic uveitis, by lack of concurrent robust ocular inflammation.

Outcome of Surgical Treatment in Late-Onset Capsular Block Syndrome

Purpose

To further investigate the pathogenesis of late-onset capsular block syndrome (CBS) and to evaluate the safety of surgical treatment.

Methods

Seven patients diagnosed with late-onset CBS were retrospectively analyzed. Anterior chamber depth (ACD), intraocular pressure (IOP), refractive diopter, and best-corrected visual acuity (BCVA) before and after surgery were recorded. The opaque substance was tested with Western blot, and a flow cytometer multiple array assay system was utilized to evaluate the levels of inflammatory cytokines from opaque substance and aqueous humor, respectively.

Results

Patients who had undergone surgical treatment showed a significant BCVA and spherical equivalent refractive error improvement (P = 0.002, P = 0.021, resp.). Nevertheless, ACD and IOP before and after surgery were in normal range with no difference (P = 0.165, P = 0.749, resp.). αB-crystallin and βB-crystallin were detected in all opaque substances. Tumor necrosis factor-alpha (TNF-α) and interlukin-1β (IL-1β) levels in opaque substance were significantly higher than those in aqueous humor (P = 0.038, P = 0.007, resp.), while IL-2 and IL-6 were not detected in any samples.

Conclusions

Opaque substance is derived from human lens epithelial cells. Inflammatory cytokines may be involved in the pathogenesis of late-onset CBS. In addition, surgical treatment is an effective approach. This trial is registered with ChiCTR-IOR-17011287.

Adhesion of the posterior capsule to different intraocular lenses following cataract surgery

PURPOSE

To investigate the prevalence and morphologic and clinical features of posterior capsule-optic inadhesion following cataract surgery.

METHODS

In this prospective cohort study, we examined 518 consecutive patients who had undergone uneventful phacoemulsification and posterior chamber intraocular lens (IOL) implantation. They were assigned into five groups based on the type of IOL used: MC X11 ASP, Rayner 920H A, ZCB00, SN60WF and KS-3Ai. Routine ophthalmic examinations were performed. Patients were followed up at 1 day, 1 week, and 1 and 2 months postsurgery. Anterior segment photography, Scheimpflug imaging and KR-1W aberrometry were conducted after the patients' pupils were dilated.

RESULTS

The overall rate of posterior capsule-optic inadhesion on the first day after surgery was 215/518 (41.5%), and it decreased to 37/518 (7.1%) at 2 months postsurgery. Posterior capsule-optic inadhesion can be morphologically classified into five types with three outcomes, of which gradual absorption of the accumulated fluid predominated for all IOLs. The clinical characteristics of patients with inadhesion varied with IOL type. Notably, visual quality data (Strehl ratios and modulation transfer function) were poorer in patients with posterior capsule-optic inadhesion, especially in those with irregular forms of suspension. Four cases of capsular contraction syndrome were identified among the patients with inadhesion.

CONCLUSIONS

Posterior capsule-optic inadhesion is a prevalent capsule-IOL interaction following cataract surgery. Although the accumulated fluid is absorbed in the majority of patients, its adverse effects on visual outcomes, especially visual quality in the operated eye(s), must not be underestimated in patients with persistent inadhesion.

Scheimpflug imaging of ultra-late postoperative capsular block syndrome

PURPOSE

To report the clinical findings of three cases with ultra-late postoperative capsular block syndrome (CBS) by Pentacam Scheimpflug imaging.

METHODS

Case series.

RESULTS

Three cases of ultra-late postoperative CBS are presented.

DISCUSSION

This report highlights the importance of conducting Pentacam Scheimpflug imaging in late CBS. Each case either enhanced our understanding or improved our differential diagnosis of late CBS.

Detection and influencing factors of capsular bag distention syndrome after cataract surgery using the Pentacam Scheimpflug system

PURPOSE

To investigate the prevalence and morphologic changes of capsular bag distention syndrome after cataract surgery using the Pentacam and to analyze its clinical characteristics and influencing factors.

DESIGN

Retrospective, cross-sectional study.

METHODS

Clinical records of 239 consecutive patients who underwent cataract surgery were reviewed. Demographic data, use of intraoperative ophthalmic viscosurgical devices, type of intraocular lens implanted, axial length, and white-to-white corneal diameter were recorded. One month after surgery, dilated Scheimpflug imaging was performed. Prevalence, morphologic changes, and characteristic clinical findings of this syndrome were evaluated.

RESULTS

Using Scheimpflug imaging, the prevalence of capsular bag distention syndrome was high at 26.8% (64/239), and it was possible to classify its morphologic changes into 3 types. Patients with the syndrome had poorer best-corrected visual acuity and lower satisfaction scores than those without the syndrome (P = .041 and P = .008, respectively). Although there was no significant difference observed in rate of this syndrome between the 2 ophthalmic viscosurgical devices used in our study (P > .05), implantation of 4-haptic intraocular lenses was associated with a high prevalence of the syndrome (odds ratio, 2.07; 95% confidence interval, 1.05 to 4.07; P = .0346). Patients with this syndrome had significantly longer AL (26.26 ± 2.84 mm) and white-to-white diameter (12.02 ± 0.34 mm) than those without (AL, 24.63 ± 2.89 mm; white-to-white diameter, 11.81 ± 0.32 mm; P = .0002 and P < .0001, respectively).

CONCLUSIONS

Scheimpflug imaging revealed the prevalence of capsular bag distention syndrome to be high, and these patients generally had poorer visual outcomes. Intraocular lens design and dimensions of the eyes significantly influenced the prevalence of this syndrome.

Late-onset capsular block syndrome: unusually delayed presentation

Capsular block syndrome (CBS) has been known to occur as a rare complication of cataract surgery with continuous curvilinear capsulorhexis and a posterior-chamber lens implant. Typically, it presents with reduced vision in the early postoperative period and is characterised by a forward displacement of the posterior-chamber intra-ocular lens and an accumulation of intra-capsular opaque material. Management of CBS is usually by Nd:YAG laser capsulotomy. In this report, we describe a unique case of very-delayed-onset CBS with good visual acuity, occurring 8 years after surgery. It was treated successfully with surgical removal of the opaque material.

Scheimpflug imaging in late Capsular Bag Distention syndrome after phacoemulsification

PURPOSE

To describe two cases of late Capsular Bag Distention syndrome (CBDS) and posterior capsular opacification (PCO) as documented on Pentacam.

DESIGN

Case series.

METHODS

A 55-year-old male and a 72-year-old female presented three years after phacoemulsification and intraocular lens (IOL) implantation with a complaint of decreased vision. Scheimpflug imaging was done using Pentacam. Patients underwent Nd:YAG capsulotomy for PCO, and postcapsulotomy capsular bag dynamics were imaged on Pentacam.

RESULTS

Three years after phacoemulsification, patients presented with blurred vision and posterior bowing of opacified posterior capsule. Anterior capsular opening was apparently sealed by lens optic, and space between IOL and opacified posterior capsule was filled with turbid fluid. Nd:YAG laser capsulotomy was done. All findings, including collapse of distended bag, were precisely documented on Scheimpflug images.

CONCLUSIONS

Pentacam Scheimpflug imaging is a useful technique to diagnose and document the presence and progress of CBDS and PCO.

Incomplete capsular bag distension syndrome after neodymium:YAG capsulotomy

We report a 60-year-old man with incomplete capsular bag distension syndrome 2 years after neodymium:YAG (Nd:YAG) laser capsulotomy for capsule opacification, which developed from extracapsular cataract extraction with intraocular lens (IOL) implantation performed 4 years before presentation to our clinic. The patient reported floaters of 15 days duration. Slitlamp examination showed shallowing of the inferior and medial anterior chamber. Dilated pupil examination showed a peripheral capsular bag inferiorly and medially behind the IOL. The bag was distended and filled with turbid fluid. The central and superior capsule was absent as a result of the previous Nd:YAG treatment. The IOL lie over the anterior capsule, and peripheral capsule leaves' edges were adhered. An Nd:YAG laser puncture of the incomplete capsular bag resolved the condition.

Late postoperative capsular block syndrome: entrapment of liquefied after-cataract by capsular bend

We report a case of capsular bend-related entrapment of liquefied after-cataract that resulted in late postoperative capsular block syndrome in a 56-year-old man. Slitlamp examination showed a capsular bend formation at the square edge of the optic. Superiorly, leakage in the capsular bend resulted in fluid extending into Soemmering's ring, although communication with the anterior chamber was limited by the capsular bend. Fluid was seen between the lens and posterior capsule.

Capsular bag distension syndrome after combined cataract and glaucoma surgery

PURPOSE

To report four cases of capsular bag distension syndrome (CBDS) after combined cataract and glaucoma surgery.

METHODS

We describe the clinical features and evolution of each case after individual treatment.

CASE REPORTS

We report four cases of CBDS after phacoemulsification, combined with trabeculectomy in two cases and with an Ahmed aqueous drainage device implantation in the other two cases. The space between the intraocular lens (IOL) and the posterior capsule was occupied by an optically clear liquid in two cases and by a turbid liquid in the other two cases, with posterior bowing of the capsule into the anterior vitreous. A myopic shift and anterior chamber shallowing occurred in three cases. After posterior Nd:YAG laser capsulotomy, the CBDS resolved in three cases. In case 1, a surgical posterior capsulotomy and anterior vitrectomy were necessary.

DISCUSSION

Capsular bag distension syndrome should be included in the differential diagnosis of a shallow anterior chamber after combined cataract and glaucoma surgery.

Évaluation d’un syndrome de blocage capsulaire tardif avec l’OCT de segment antérieur

A year after routine phacoemulsification and insertion of a soft posterior chamber IOL, a 59-year-old woman developed progressive moderate myopia. A syndrome of late capsular block was diagnosed following biomicroscopic examination, which was treated by Nd YAG laser posterior capsulotomy. The myopia disappeared immediately. This observation was illustrated with optical coherence tomography (OCT) developed for the anterior segment. After capsulotomy, the IOL moved backwards by 448 microm, which corresponds exactly to a--1D induced myopia.

Assessment of capsular block syndrome with anterior segment optical coherence tomography

A 59-year-old woman developed progressive, moderate myopia 1 year after routine phacoemulsification and insertion of a soft posterior chamber intraocular lens (IOL). After biomicroscopy, late capsular block was diagnosed and treated with a neodymium:YAG laser posterior capsulotomy. The myopia disappeared immediately. This case was illustrated using optical coherence tomography developed for the anterior segment. After capsulotomy, the IOL moved backward by 448 microm, corresponding to -0.75 diopter of induced myopia.

Capsular block syndrome caused by a reversed-optic intraocular lens

A 52-year-old man who had phacoemulsification and in-the-bag fixation of a posterior chamber intraocular lens (IOL) developed capsular block syndrome 1 day after reverse implantation of the IOL. After a neodymium:YAG (Nd:YAG) laser peripheral anterior capsulotomy, the distended capsular bag collapsed significantly and the artificial myopia partially resolved. An Nd:YAG laser peripheral anterior capsulotomy appeared to be an effective, simple, and minimally invasive method to treat this problem.

Capsular block syndrome associated with horizontal jerk nystagmus

A 78-year-old cataract patient with horizontal jerk nystagmus had phacoemulsification and intraocular lens (IOL) implantation in the capsular bag with continuous curvilinear capsulorhexis. One week postoperatively, the posterior capsule ballooned posteriorly, the anterior capsule opening was sealed to the IOL optic, and a transparent liquefied substance accumulated between the lens optic and the posterior capsule. The best corrected visual acuity was 0.6 with a myopic shift compared with the refraction after the first day. A neodymium:YAG laser posterior capsulotomy was performed, and the capsular block syndrome (CBS) resolved. The results confirm the experimental model proposed by Zacharias suggesting that saccadic eye movements contribute to CBS under certain anatomic conditions.

Capsular block syndrome associated with secondary angle-closure glaucoma

An 83-year-old man who had phacoemulsification and ciliary sulcus fixation of a posterior chamber intraocular lens developed capsular block syndrome with secondary glaucoma 1 year after surgery. The glaucoma resolved, and vision returned immediately after a neodymium:YAG laser capsulotomy was performed. Capsular block syndrome with secondary angle-closure glaucoma should be considered in pseudophakic patients presenting with increased intraocular pressure and a narrow angle.

Capsular block syndrome and pseudoexpulsive hemorrhage

Capsular block syndrome (CBS) has been recognized as a cause of immediate or delayed postoperative accumulation of fluid behind an intraocular lens/capsulorhexis complex. Hydrodissection-related rupture of the posterior capsule may be considered a variant of CBS that can manifest intraoperatively. We describe another intraoperative situation related to CBS in which fluid loculation during hydrodissection mimics a threatened expulsive hemorrhage.

Analysis of liquid accumulated in the distended capsular bag in early postoperative capsular block syndrome

PURPOSE

To analyze the transparent liquid between the posterior lens capsule and the posterior chamber intraocular lens (PC IOL) in early postoperative capsular block syndrome and discuss the mechanism of posterior capsule distention.

SETTING

Department of Ophthalmology, Tokyo University School of Medicine, and Tokyo Research Institute, Seikagaku Corporation, Tokyo, Japan.

METHODS

This study evaluated 3 cases of capsular block syndrome presenting with transparent liquid in the distended capsular bag 1 day after cataract surgery. The transparent liquid material between the posterior capsule and PC IOL was aspirated and analyzed using high-performance liquid chromatography (HPLC). Also, sodium hyaluronate was diluted using a dialyzer to determine whether the aqueous humor was drawn into the capsular bag by an osmotic gradient across the capsule.

RESULTS

The elution time of the samples was almost the same as that of sodium hyaluronate 1.0% (Healon) The concentration of the samples ranged from 3.29 to 9. 01 mg/mL by HPLC analysis. The sodium hyaluronate absorbed the physiological salt solutions through the dialyzer and expanded to 1. 9 times its original volume.

CONCLUSIONS

These results indicate that the main ingredient of the transparent liquid in capsular bags is sodium hyaluronate and that the distention is caused by aqueous humor being drawn into the capsular bag by an osmotic gradient across the capsule when the capsulorhexis diameter is smaller than that of the PC IOL and by viscoelastic material retained and trapped in the bag intraoperatively.

Capsular block syndrome: A case series

Capsular block syndrome (CBS) or capsular bag distension syndrome has been described after cataract removal with in-the-bag placement of a posterior chamber intraocular lens in the presence of an anterior continuous curvilinear capsulorhexis. Features of CBS include shallowing of the anterior chamber and an unexpected myopic overrefraction; occasionally, there is a persistent uveitis. The patient may be mistakenly diagnosed with pupil block glaucoma or endophthalmitis. We report 9 cases of CBS and their initial diagnoses and management. In 1 case, the capsular bag distention and anterior chamber shallowing are illustrated by ultrasound biomicroscopy.

Vitreous opacification after neodymium:YAG posterior capsulotomy

PURPOSE

To describe the clinical picture in eyes that developed vitreous opacification behind the intraocular lens (IOL) after neodymium:YAG (Nd:YAG) laser posterior capsulotomy and determine whether this type of opacification tends to occur in patients with diabetes.

SETTING

Shinjo Eye Clinic, Miyazaki, Japan.

METHODS

The clinical course in 728 eyes that had Nd:YAG posterior capsulotomy was reviewed.

RESULTS

After Nd:YAG posterior capsulotomy, opacification developed in the vitreous in contact with the IOL in 9 eyes (1.2%). All occurred in diabetic patients, and the vitreous opacification developed within 1 month after the capsulotomy. A vitrectomy was performed in 8 eyes and in 1, the opacification spontaneously absorbed. Vitreous opacification occurred in 8.9% of 101 eyes of diabetic patients, and the prevalence in diabetic eyes was significantly higher than in nondiabetic eyes (P < .0001). Nine of the diabetic eyes were opaque and 92 nonopaque. In the opaque eyes, the prevalence of panretinal photocoagulation was higher than in the nonopaque eyes (P = .013), and hemoglobin Alc (P = .030) was higher; the interval between cataract surgery and Nd:YAG capsulotomy was shorter (P = .047) and the final visual acuity, lower (P = .045).

CONCLUSION

The prevalence of vitreous opacification after Nd:YAG laser posterior capsulotomy was significantly higher in diabetic than in nondiabetic eyes. Viterectomy was effective for this type of opacification.