Outcome of posterior capsulotomy in late capsular block syndrome with posterior capsular opacification

A potential role for inflammatory cytokines in a rare late-onset capsular block syndrome: a case report

BACKGROUND

Late-onset capsule block syndrome (CBS) is a rare complication of cataract phacoemulsification and the implantation of a posterior chamber intraocular lens (PCIOL), which manifests six months to years after surgery. The hallmark of CBS is the formation of an opaque liquid substance between the implanted intraocular lens (IOL) and the posterior capsule. However, its pathogenesis remains unclear.

CASE PRESENTATION

A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor.

CONCLUSIONS

Anterior segment vitrectomy surgery proved to be a successful treatment for late-onset CBS, presenting a challenging case. In the human lens, inflammatory cytokines originating from the opaque substances may contribute to abnormal metabolism in the sealed area, a consequence of late-onset CBS.

Acute Effects of Neodymium-Doped Yttrium Aluminum Garnet Laser Capsulotomy on Anterior Segment Parameters in Capsular Bag Distension Syndrome

Background: Capsular bag distension syndrome (CBDS) can be effectively treated using either Neodymium-doped Yttrium Aluminum Garnet (Nd:YAG) laser capsulotomy or surgery. Assessing anterior segment, particularly immediately after Nd:YAG laser capsulotomy, could provide clinically relevant information on ocular dynamics, refractive changes, and complication mechanisms, especially in late postoperative CBDS. Objective: To explore the acute effects of Nd:YAG laser posterior capsulotomy on anterior segment parameters in late postoperative CBDS. Methods and results: In this study, 20 patients underwent Nd:YAG laser posterior capsulotomy after cycloplegia, during which milky-white fluid material migrated into the anterior vitreous. Anterior segment parameters were assessed before and immediately after laser using Scheimpflug-Placido topographer. The main outcome measures were differences in best-corrected visual acuity (BCVA), aqueous depth (AqD), anterior chamber volume (ACV), iridocorneal angle (ICA), corneal volume (CV), and central corneal thickness (CCT) at the baseline versus at immediately after laser. The mean age and duration since surgery for CBDS presentation were 70.25 ± 6.21 and 6.15 ± 1.31 years, respectively. The AqD, ACV, ICA, and spherical equivalent increased significantly compared with baseline (4.18 vs. 4.02 mm, p = 0.001; 177 vs. 173.55 mm3, p = 0.004; 51.15° vs. 50.15°, p = 0.023; -1.00 vs. -2.00 D, p = 0.003, respectively). These changes were also associated with significantly improved BCVA an hour after capsulotomy [0.2 (0.05-0.2)] relative to baseline [0.3 (0.2-0.5)], (p = 0.001). CCT and CV decreased nonsignificantly; horizontal AC diameter and K1 and K2 increased nonsignificantly (p > 0.05). Conclusions: Nd:YAG laser posterior capsulotomy appears to be an effective CBDS treatment for acutely improving vision, potentially due to immediate refractive changes caused by altered anterior segment parameters.

Unusual Late Presentation of Capsular Bag Distension Syndrome Associated With Propionibacterium acnes Endophthalmitis

This report describes an unusually delayed presentation of capsular bag distension syndrome (CBDS), which was found to be associated with Propionibacterium acnes (P. acnes) endophthalmitis. Our patient presented with a gradual decrease in vision after uneventful cataract surgery done 13 years back. On examination, there was a thick turbid fluid entrapped behind the intraocular lens (IOL). Ultrasound biomicroscopy (UBM) confirmed the presumed diagnosis. The case was managed by pars plana vitrectomy (PPV) with posterior capsulotomy, and the entrapped turbid fluid was aspirated and sent for histopathology, which revealed a positive growth of P. acnes. The patient had excellent outcomes with complete resolution post-operatively.

Characterization and Management of Late Postoperative Capsular Block Syndrome Following Phacoemulsification or Phacovitrectomy

PURPOSE

To compare the clinical characteristics of eyes affected by late postoperative capsular block syndrome (CBS) after routine phacoemulsification or phacovitrectomy, and to demonstrate the outcomes of neodymium-doped yttrium-aluminum-garnet (Nd:YAG) capsulotomy and posterior continuous curvilinear capsulorrhexis (PCCC) in the treatment of CBS.

DESIGN

Retrospective interventional case series study.

METHODS

Twenty-eight patients with late postoperative CBS, comprising 13 eyes after phacoemulsification (Group A) and 15 eyes after phacovitrectomy (Group B), were analyzed. Seventeen patients with minimal (degree I), mild (II), and moderate (III) posterior capsular opacification (PCO) underwent Nd:YAG capsulotomy (Group A, 10 eyes and Group B, 7 eyes), while 11 patients with severe (degree IV) PCO underwent PCCC (Group A, 3 eyes and Group B, 8 eyes).

RESULTS

A statistically significant postoperative improvement in best-corrected visual acuity (Group A, P = .0002 and Group B, P = .0070) and a significant postoperative decrease in aqueous flare value (Group A, P = .0077 and Group B, P = .0127) were observed. No significant differences were observed in intraocular pressure, aqueous depth, and diopters (P > .05). No surgical complications were experienced by either group.

CONCLUSIONS

Late postoperative CBS had similar characteristics whether it developed after phacoemulsification or after phacovitrectomy. Nd:YAG capsulotomy and the PCCC technique are efficient approaches to mild and moderate PCO and severe PCO with CBS, respectively. PCCC may be a viable alternative for treating dense PCO with CBS in pseudophakic eyes.

Virtual Eye Simulation: An Aid in Evaluation of Capsular Block Syndrome

Objective:

To demonstrate the findings of three consecutive cases of postoperative Capsular Block Syndrome (CBS) diagnosed with the aid of Pentacam virtual eye simulation images.

Methods:

Observational case series report. Three patients underwent uneventful cataract removal and presented with blurry vision ranging from 4 days to 5 years after the surgeries were performed.

Results:

In a case of early-onset postoperative CBS, virtual eye simulation images clearly revealed a reduced posterior chamber depth caused by the accumulation of transparent fluid in the area between the intraocular lens and the posterior capsule. In two cases of late-onset postoperative CBS, virtual eye simulation images better visualized the alignment between intraocular lens (IOL) and iris than slit lamp examination and Schiemflug images. All three of the cases underwent neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy, and their capsular bag distensions were resolved immediately. The patients with misalignments between IOL and iris experienced more improvement in best-corrected visual acuity as opposed to the one who did not.

Conclusion:

Virtual eye simulation is found to be a useful way in visualizing misalignment between IOL and iris and assisting diagnoses of both early- and late-onset postoperative capsular block syndrome.

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.

Anterior chamber depth and refractive change in late postoperative capsular bag distension syndrome: a retrospective analysis

Purpose

To assess the characteristic findings and effects of laser capsulotomy in patients with late postoperative capsular bag distension syndrome (CBDS).

Methods

Twenty patients diagnosed with late postoperative CBDS between July 2010 and August 2013 were retrospectively reviewed. Before and 1 week after capsulotomy, changes in the anterior chamber depth (ACD) were assessed using ultrasound biomicroscopy. Changes in the refractive status and uncorrected visual acuity (UCVA) were also measured 1 week and 1 month after capsulotomy. For patients who received bilateral cataract surgery, preoperative ACD and axial length measured by IOLMaster were compared between the two eyes.

Results

Twenty-two eyes from 20 patients who had undergone laser capsulotomy showed a mean UCVA improvement of 0.27 ± 0.24 logMAR (range, 0.00–0.90). ACD was increased by an average of +0.04 mm (95% confidence interval, +0.01 to +0.06 mm, p = 0.034), equivalent to predicted refractive change of +0.10 D. The discrepancy between actual (+1.33 D) and predicted refractive change after capsulotomy suggests that refractive change may not be generated from IOL displacement in late postoperative CBDS. Preoperative ACD was deeper in the eye with late postoperative CBDS in all bilaterally pseudophakic patients (mean, 3.68 mm vs. 3.44 mm in the fellow eye, p = 0.068).

Conclusions

Late postoperative CBDS showed refractive changes that were resolved successfully after laser capsulotomy. The convex lens effects of opalescent material in the distended capsular bag may play a major role in myopic shift. A larger preoperative ACD is possibly associated with the development of late postoperative CBDS.

Late Postoperative Capsular Block Syndrome: A Case Series Studied before and after Nd:YAG Laser Posterior Capsulotomy

Purpose

To evaluate the clinical characteristics of the unusual late postoperative capsular block syndrome (CBS) and the effect of Nd:YAG laser posterior capsulotomy on visual acuity and refractive error as well as its possible complications.

Methods

In this retrospective cohort study, 12 eyes of 11 patients with late CBS who had undergone Nd:YAG laser posterior capsulotomy were reviewed. A complete ophthalmic examination including Scheimpflug camera and anterior segment optical coherence tomography (AS-OCT) imaging had been performed before and after posterior capsulotomy.

Results

The mean time between cataract surgery and posterior capsulotomy was 4.7 ± 1.5 years (range 3-9 years). Best-corrected visual acuity increased in 11 cases (91.7%). Only one eye showed a 0.5-D hyperopic shift following posterior capsulotomy. There were no postlaser complications such as increased intraocular pressure (IOP), severe inflammation, cystoid macular edema, or retinal detachment. In all patients, the posterior capsule was vaulted posteriorly and could not be seen clearly. The AS-OCT confirmed CBS in the studied cases, demonstrating a distended capsular bag. Rotating Scheimpflug imaging examination showed the white substance located behind the intraocular lens (IOL).

Conclusions

Late CBS is usually not accompanied by shallow anterior chamber, forward IOL displacement, or raised IOP. Nd:YAG laser posterior capsulotomy is a useful treatment and the prognosis of patients with this complication appears favorable. Furthermore, although AS-OCT measurements are easier to obtain than rotating Scheimpflug imaging examination, both are useful to visualize the distended capsular bag containing the white material and the IOL position.

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.

["Lacteocrumenasia"--Capsular block syndrome III]

Capsular block syndrome (CBS) is a complication of uncomplicated cataract surgery. Depending on etiology and the time of onset CBS can be subdivide into three types. The cases of 4 patients with CBS type III who presented with a milky fluid in the space between the posterior surface of the implanted intraocular lens (IOL) and the anterior surface of the distended posterior capsular bag are described. All patients complained of reduced vision. The therapy of choice is Nd:YAG laser posterior capsulotomy but with suspected low-grade endophthalmitis surgical intervention can also be carried out and submitting the plug for bacterial culture.

Atypical angle closures

PURPOSE OF REVIEW

Primary angle closure typically causes acute intraocular pressure rise in the phakic elderly. Alternative diagnoses, however, for which iridotomy is usually ineffective, occur commonly in younger, nonhyperopic, and pseudophakic patients.

RECENT FINDINGS

High-resolution ultrasonography has advanced our understanding of these entities. Management of platueau iris, present in over half of angle closures with patent iridotomy, may depend on disease stage. Early postoperative pseudophakic patients with myopic shift and narrow angle should be treated with laser capsulotomy for capsular block. Bilateral angle closure is usually due to an offending systemic pharmacologic agent, which must be stopped to resolve the closure. Ciliary body swelling often produces angle closure by blocking the access of aqueous to the anterior chamber, sometimes paradoxically after hypotony. Annular choroidal effusions, difficult to detect without ultrasound, may mimic angle closure. Although cycloplegic and corticosteroid therapy may resolve some entities, pars plana vitrectomy and lensectomy may be necessary to resolve severe ciliary block. We also discuss unique variants of angle closure in patients with retinal disease.

SUMMARY

Atypical angle closures should always be considered. Careful examination techniques and new technology can detect the mechanisms involved and direct treatment.