New classification of capsular block syndrome

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.

Capsular Block Syndrome after an Intravitreal Injection of Ranibizumab: A Case Report

Introduction

We present a case of capsular block syndrome that occurred after intravitreal injection of ranibizumab in a patient with age-related macular degeneration, which has not been reported in the literature.

Case Presentation

A 78-year-old male presented with decreased visual acuity in the right eye. Slit-lamp examination findings were unremarkable; however, AMD was diagnosed based on fundus examination, fluorescein angiography, and optical coherence tomography (OCT). Subsequently, the patient was administered an intravitreal injection of ranibizumab. A slit-lamp examination revealed residual cortical material, numerous inflammatory cells, and posterior capsular distension 1 week after the injection. OCT showed an adhesion of the intraocular lens to the continuous curvilinear capsulorhexis site. The patient's vision improved following Nd:YAG laser posterior capsulotomy.

Conclusion

Meticulous cortical removal is crucial during phacoemulsification to prevent capsular block syndrome. In patients with a history of cataract surgery, verifying the absence of residual cortical material before administering an intravitreal injection of ranibizumab is important.

Analysis of the capsular bend in posterior capsular opacification using anterior segment optical coherence tomography

PURPOSE

To investigate the link between the capsular bend and the morphological types and characteristics of posterior capsular opacification (PCO) using anterior segment optical coherence tomography.

METHODS

Thirty eyes with PCO were examined, and three types of PCO were identified: pearl, fibrosis, and mixed. We assessed anterior capsular overlap, intraocular lens-capsule adhesion, and capsular bending. In addition to measuring the intraocular lens-posterior capsule distance and capsule bending angle (CBA), the PCO parameters (area, density, and score at 6-, 5-, and 3-mm intraocular lens optic regions) were recorded. The associations between capsular bend and PCO type and characteristics were investigated. A control group of 12 eyes without PCO was used to compare the study variables.

RESULTS

With p values greater than 0.001, there was a statistically significant difference in the mean PCO area and score at the 6-, 5-, and 3-mm optic zones in different PCO types, with the pearl type having the highest value, followed by the mixed type, and finally the fibrosis type. The PCO group had a significantly higher mean CBA than the control group (P = 0.001). CBA was positively related to intraocular lens-posterior capsule distance, PCO area, and PCO score at the 6-, 5-, and 3-mm zones (P = 0.001). The receiver operating characteristic curve's cut-off point for CBA was 96.85° when comparing PCO cases to controls. Partial overlap and incomplete adhesion were statistically more common in the PCO eyes than in the control (P = 0.001, 0.003, respectively).

CONCLUSION

PCO types and CBA have a strong relationship with PCO score and intraocular lens-posterior capsule space. In PCO's eyes, CBA has a cut-off value of 96.85°.

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.

Findings in pseudophakic eye that developed liquefied aftercataract-like substance one day after vitrectomy

Purpose

Observations

Conclusions and importance

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.

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.

Case Report: Role of Anterior Segment Optical Coherence Tomography in Late-onset Capsular Block Syndrome

SIGNIFICANCE

We report the use of anterior segment optical coherence tomography (AS-OCT) as a valuable tool for capsular block syndrome diagnosis and follow-up.

PURPOSE

The purposes of this study are to report a case of late-onset capsular block syndrome or lacteocrumenasia and to describe differential diagnosis with other more common phacoemulsification complications such as intraocular lens (IOL) or posterior capsule opacification.

CASE REPORT

We report the case of a 56-year-old man with a clinical history of cataract surgery in his left eye. Five years after cataract surgery, he complained of blurred vision and was referred for IOL removal to our hospital. After careful slit-lamp examination, we found that the lens was clear, and opacity belonged to the accumulation of a whitish material in the capsular bag behind the lens. AS-OCT gave the definite diagnosis of capsular block syndrome. Intraocular lens removal had been wrongly indicated, and we treated our patient by YAG laser posterior capsulotomy. AS-OCT confirmed the absence of a further accumulated material, so no other interventions were needed. After treatment, best-corrected visual acuity improved from 0.48 to 0.1 logMAR.

CONCLUSIONS

Capsular block syndrome is a rare late-onset complication of cataract surgery causing a deep visual acuity decay. A precise slit-lamp examination and AS-OCT, together, avoid misdiagnosis and unnecessary surgical treatment, which may be needed in case of IOL opacity or fibrotic-like lacteocrumenasia. AS-OCT also helps in determining the treatment outcome. Immediate best-corrected visual acuity improvement is reached after a successful intervention.

Late-onset capsular bag distention syndrome resistant to laser treatment: a case report

Capsular bag distention syndrome (CBDS) or capsular block syndrome is a rare complication of cataract surgery. Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser usually is effective treatment for CBDS. Rarely, surgical intervention is required in resistant cases (as in our case). Herein, we present the case of a 58-year-old male who presented to us with this condition.

Retro-intraocular Lens Irrigation-aspiration to Prevent Capsular Block Syndrome at the Hands of Novice Surgeons

Retro-intraocular lens (IOL) irrigation-aspiration is of paramount importance in order to remove the viscoelastic substance from the retro-IOL space and to prevent any early post-operative capsular block syndrome. However, manoeuvring the IOL to reach the retro-IOL space may be difficult at the hands of novice surgeons despite the use of coaxial or bimanual irrigation-aspiration probes. We describe a simpler and safer technique in order to facilitate the removal of this retro-IOL viscoelastic substance using a 26-Gauge bent-cannula mounted on a 2-ml syringe. The fluid is injected forcefully along with sideways movement of cannula in a single-plane to displace the viscoelastic substance.

Multiquadrant versus single quadrant cortical cleaving hydrodissection during phacoemulsification of age related cataract

Purpose

To evaluate and compare single and multiquadrant hydrodissection in age related cataract.

Design

Prospective, observational case series.

Methods

In this study, 220 patients were consecutively assigned to either single (n = 110) or multiquadrant (n = 110) hydrodissection during phacoemulsification. Patients having operable cataract in the nuclear grade of 1–3 of Lens Opacities Classification System III were included in the study. After hydrodissection of the nucleus nuclei were not rotated. Parameters assessed were amount of balanced salt solution (BSS) required to accomplish the hydrodissection, nucleus emulsification time (NET), and cortical aspiration time (CAT). Ease in nucleus rotation during chopping of the nucleus, cortical aspiration (easy, difficult, or very difficult) and intraoperative surgical complications were qualitatively assessed.

Results

Average amount of BSS required in multiquadrant hydrodissection was 1.7 ml (±0.9), which was more than double the single quadrant group 0.71(±0.17), p = 0.001. No statistically significant differences were observed between the two studied groups with respect to the following parameters: mean NET (single quadrant 277 sec ± 95.5, multiquadrant 267 sec ± 98.8, p = 0.379), CAT (single quadrant 75.7 sec ± 31.2, multiquadrant 73.4sec ± 33.9p = 0.301), and total fluid required (single quadrant 154 ml ± 64.9, multiquadrant 157 ml ± 66.4p = 0.708).

Almost equal number of patients in both the groups had easy rotation of the nucleus (single quadrant: n = 105, 95.45% and multiquadrant n = 103, 93.64%) and cortical aspiration (n = 102, 92.72% both the groups). Three patients in multiquadrant group had posterior capsular rupture during hydrodissection.

Conclusions

A single quadrant hydrodissection is sufficient for the efficient removal of nucleus and cortex.

[Late capsular block syndrome]

The article describes 5 cases of capsular block syndrome (CBS). This late cataract surgery complication has not been sufficiently covered in Russian scientific literature. Diagnostics were based mainly on slit-lamp biomicroscopy and anterior segment optical coherence tomography. In all cases, examination revealed a retro-optical space filled with content of different transparency and homogeneity (transparent liquid, opaque liquid, regenerative lens material). The condition caused visual acuity to decrease in each case. Patient management included follow-ups (2 cases), yttrium-aluminum-garnet laser (YAG-laser) puncture of posterior lens capsule (1 case) or YAG-laser posterior capsulotomy (2 cases). YAG-laser treatment resulted in visual functions improvement.

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.

Clinical and experimental evaluation of new back-flow hydrodissection technique

PURPOSE

To assess the efficacy and safety of a new technique, back-flow hydrodissection.

SETTING

Hirota Eye Clinic, Yamaguchi, and Department of Ophthalmology, University of Tsukuba, Ibaraki, Japan.

DESIGN

Prospective case series and experimental study.

METHODS

For back-flow hydrodissection, the irrigation line was connected to the aspiration port of an irrigation/aspiration handpiece using a female-female connector with the irrigation port open. The balanced salt solution was irrigated from the aspiration tip opening with constant pressure, hydrodissection was performed, and the excess fluid was evacuated via the sleeve lumen. In a clinical study, 200 eyes were randomly assigned to conventional hydrodissection with an irrigation cannula or back-flow hydrodissection. In experimental studies, intraocular pressure (IOP) fluctuation and fluid dynamics in the anterior and posterior chamber were evaluated in porcine eyes.

RESULTS

The lens became freely mobile in the capsular bag in 99 (99%) of 100 eyes and in 96 (96%) of 100 eyes in the back-flow hydrodissection group and conventional hydrodissection group, respectively (P = .369). There were no between-group differences in any other surgery-related parameters, including surgical time and the complication rate. In porcine eyes, conventional hydrodissection induced a significantly larger increase in IOP than back-flow hydrodissection (P < .0001). Conventional hydrodissection immediately washed out fluorescein-stained ophthalmic viscosurgical device (OVD) from the anterior chamber, while there was little leakage of OVD from the eye with back-flow hydrodissection. The endoscopic view showed that conventional hydrodissection induced rapid and severe bulging of the posterior capsule; however, bulging was gentle and mild with back-flow hydrodissection.

CONCLUSION

Back-flow hydrodissection was safe and effective in disengaging the lens from the capsule, ensuring a freely mobile lens.

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.

Influence of irrigation dynamic pressure-assisted hydrodissection on intraocular pressure and the posterior chamber-anterior hyaloid membrane barrier during cataract surgery

PURPOSE

To evaluate the effects of irrigation dynamic pressure-assisted hydrodissection (irrigation-hydro: iH) on intraocular pressure (IOP) and the posterior chamber-anterior hyaloid membrane (PC-AHM) barrier in porcine eyes.

STUDY DESIGN

Experimental.

METHODS

In Experiment 1, IOP was recorded while irrigating the anterior chamber (AC), during iH, and during phacoemulsification and aspiration in 20 porcine eyes using bottle heights of 50, 70, and 90 cm. Under the same conditions, IOP was recorded during conventional manual cortical cleaving hydrodissection (manual hydro: mH) in 20 porcine eyes. In Experiment 2, after iH, ACs were perfused for 5 seconds with balanced salt solution containing 1.0-μm fluorescein beads in 20 porcine eyes using bottle heights of 70, 118, and 169 cm. PC-AHM barrier staining grade was evaluated by the Miyake-Apple view.

RESULTS

iH proved successful in all cases. In Experiment 1, IOP during iH was relatively stable and peak IOP was below the baseline bottle height-dependent pressure. No eyes showed a peak IOP > 75 mmHg during iH, but 8 eyes showed a peak IOP > 75 mmHg during mH. In Experiment 2, neither AHT nor ruptured capsules were observed at any bottle height.

CONCLUSION

Unlike mH, IOP during iH was relatively stable without any high peak IOP. Thus, iH offers a simple technique for reducing peak IOP and avoiding disturbance of the PC-AHM barrier.

The safety and efficacy of phaco-sleeve irrigation-assisted hydrodissection during femtosecond laser-assisted cataract surgery

Femtosecond laser-assisted cataract surgery (FLACS) changes the intraoperative environment due to the generation of intracapsular gas that induces a high intracapsular volume. Manual hydrodissection (mH) may induce high intracapsular pressure (ICP) and additional intracapsular volume, thereby leading to capsular block syndrome (CBS). Since the phaco-sleeve irrigation-assisted hydrodissection (iH) technique is used to initially groove and split the lens and remove the intracapsular gas, this can reduce the intracapsular volume while bypassing the intracapsular lens prior to the hydrodissection. As iH uses the phaco tip to intentionally vacuum the intraocular fluid for use in inducing the irrigation jet from the sleeve side holes, the ICP cannot surpass the set irrigation pressure, thereby avoiding CBS. Using this technique, we performed FLACS without CBS in 310 cataract eyes. Our findings suggest that the iH technique may be beneficial for patients by preventing CBS during FLACS.

Two cases of very late-onset capsular bag distension syndrome

Purpose

We present two cases of late-onset capsular bag distension syndrome (CBDS).

Observations

Two female patients were referred with decreased visual acuity and blurred vision. They had both undergone uncomplicated phacoemulsification and intraocular lens implantation into the capsular bag, seven and 13 years prior.Slit-lamp biomicroscopy and anterior segment optical coherence tomography demonstrated milky fluid between the intraocular lens and posterior capsules, consistent with late-onset capsular bag distension syndrome. A 25-gauge pars plana vitrectomy surgery was performed on each patient.This turbid retrolental fluid was successfully aspirated with posterior capsulotomy using 25-gauge pars plana vitrectomy surgery.

Conclusions and importance

Late-onset capsular bag distension syndrome may occur up to 13 years following cataract surgery; the longest reported duration of onset. Anterior segment optical coherence tomography is useful in aiding diagnosis. Management with vitrectomy surgery has the advantages of complete clearance of the turbid fluid and microbial and pathological testing.

Bilateral early capsular block syndrome following implantation of the new trifocal toric lens

A young patient underwent phacoemulsification with endocapsular implantation of trifocal toric lens in both eyes (AT LISA tri toric 939 MP, Carl-Zeiss, Germany). One-week postsurgery, he developed capsular block syndrome (CBS) in both eyes. There was deterioration of uncorrected visual acuity at 1-week postsurgery, with a myopic shift of 2.5 diopters (D) in the right eye and 2.0 D in the left eye. The intraocular pressure was only elevated in the left eye. Neodymium: yttrium-aluminum-garnet laser posterior capsulotomy resolved the block successfully in both eyes. A thick lens with a plate haptic design may have contributed to the early CBS.

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.

Irrigation dynamic pressure-assisted hydrodissection during cataract surgery

The irrigation dynamic pressure-assisted hydrodissection technique (irrigation-hydro [iH]) does not require performing manual hydrodissection using a syringe and cannula to achieve cortical-capsular cleavage during cataract surgery. Since the iH technique uses the phaco tip to intentionally vacuum the intraocular fluid in order to induce the irrigation dynamic pressure for cortical-capsular cleavage, there is a reduction in the intraocular pressure (IOP) from the bottle-height-dependent hydrostatic pressure. Thus, since the peak irrigation pressure derived from the phaco tip sleeve will be limited by the height of the irrigation fluid bottle, this is advantageous in helping to avoid excessively high IOP during cortical-capsular hydrodissection. Using this technique, we were able to effectively perform phacoemulsification without complications in 607 of 609 cataract eyes. Our findings show that utilization of the iH technique would be of benefit to patients, as it prevents high-pressure hydrodissection-related complications, such as capsular block syndrome and tears in the anterior hyaloid membrane during cataract surgery.

Use of the phaco tip technique for lens cleavage and removal during cataract surgery

Use of the phaco tip technique for lens cleavage and removal does not require manual hydrodissection using a syringe and cannula, or cortical removal using an irrigation/aspiration tip. The phaco tip is the only surgical instrument required for this technique. Its advantages include maintaining a stable intraocular pressure during cortical cleaving hydrodissection and lens removal, which includes the cortex.

A Case Report of Preoperative, Intraoperative, and Postoperative Anterior Chamber Shallowing Resulting from Different Mechanisms

A 54-year-old woman with an epiretinal membrane in her left eye accompanied by a shallow anterior chamber due to primary angle closure glaucoma underwent vitrectomy and cataract surgery. During the cataract surgery, immediately after the ultrasonic tip had been removed from the anterior chamber, anterior chamber flattening occurred. An intraoperative fundus examination showed the development of acute intraoperative choroidal effusion. Postoperatively, the anterior chamber remained shallow even after the choroidal detachment had subsided; capsular bag distension seen by ultrasound biomicroscopy suggested the development of early postoperative capsular block syndrome. After neodymium:yttrium-aluminium-garnet laser capsulotomy, the anterior chamber deepened. Depending on the perioperative period, the mechanism of a flat anterior chamber can change, and understanding the underlying mechanisms is required for appropriate treatment.

A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector

We report a case of delayed onset capsular block syndrome in a patient 6 years after undergoing cataract surgery. Ocular examination revealed marked diminution of vision accompanied with a collection of milky fluid between the intraocular lens and posterior capsule. To treat and to understand the pathology of the condition, aspiration of fluid using 25-gauge vitrector through pars plana was done, and contents sent for microbiological analysis which did not reveal any growth. Postoperative period was uneventful with the absence of intraocular inflammation and excellent visual recovery.

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.

Liquefied after cataract and its surgical treatment

Aims:

To describe liquefied after cataract (LAC) and its surgical management following an uneventful phacoemulsification with posterior chamber in-the-bag intraocular lens (IOL) implantation and continuous curvilinear capsulorrhexis (CCC).

Design:

Interventional case series.

Materials and Methods:

Eleven patients with LAC, following uneventful phacoemulsification with CCC and in-the-bag IOL implantation were enrolled. After the basic slit lamp examination, each case was investigated with Scheimpflug photography and ultrasound biomicroscopy (UBM). Each case was treated with capsular lavage. Biochemical composition of the milky fluid was evaluated and ring of anterior capsular opacity (ACO) was examined under electron microscope.

Results:

All 11 cases presented with blurring of vision after 6-8 years of cataract surgery with IOL implantation. All cases had IOL microvacuoles, 360° anterior capsule, and anterior IOL surface touch along with ACO, ring of Soemmering, and posterior capsule distension filled with opalescent milky fluid with whitish floppy or crystalline deposits. Biochemically, the milky fluid contained protein (800 mg/dl), albumin (100 mg/dl), sugar (105 mg/dl), and calcium (0.13%) and was bacteriologically sterile. Histologically, the dissected ACO showed fibrous tissue. All cases were successfully treated with capsular lavage with good visual recovery and with no complication. There was no recurrence of LAC during 2 years postoperative follow-up in any of the cases.

Conclusions:

LAC is a late complication of standard cataract surgery. It may be a spectrum of capsular bag distension syndrome (CBDS) without shallow anterior chamber and secondary glaucoma. Capsular bag lavage is a simple and effective treatment for LAC and a safe alternative to neodymium-doped yttrium aluminum garnet (Nd-YAG) capsulotomy.

LATE-ONSET CAPSULAR BAG DISTENSION SYNDROME: A REPORT OF TWO CASES

Capsular bag distension syndrome is a very rare complication of cataract surgery. Most cases occur after uneventful phacoemulsification with continuous curvilinear capsulorhexis and implantation of an intraocular lens in the capsular bag. The entity presents with reduction of visual acuity and myopic shift in the early-to-late postoperative period. Characteristic findings include the distension of the capsular bag due to the accumulation of milky material and the forward displacement of the intraocular lens. We present two cases with an unusually delayed presentation of 6 and 8 years respectively following phacoemulsification, and describe their successful management with Nd:YAG laser posterior capsulotomy.

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.

Nonarteritic ischemic optic neuropathy developed after capsular block syndrome

A 65-year-old man developed capsular block syndrome in the early postoperative period, following phacoemulsification surgery. After neodymium-doped yttrium aluminum garnet (Nd:YAG) laser anterior capsulotomy, the intraocular pressure remained elevated for 4 days despite antiglaucomatous medication. On the postoperative fifth day, nonarteritic ischemic optic neuropathy was diagnosed. To the best of our knowledge, this is the first report of a case with nonarteritic ischemic optic neuropathy associated with early postoperative capsular block syndrome after phacoemulsification surgery.

Optical coherence tomography for an in-vivo study of posterior-capsule-opacification types and their influence on the total-pulse energy required for Nd:YAG capsulotomy: a case series

Background

Posterior capsule opacification (PCO) is the most common post-operative complication associated with cataract surgery and is mostly treated with Nd:YAG laser capsulotomy. Here, we demonstrate the use of high-resolution spectral-domain optical coherence tomography (OCT) as a technique for PCO analysis. Additionally, we evaluate the influence of PCO types and the distance between the intraocular lens (IOL) and the posterior capsule (PC), i.e., the IOL/PC distance, on the total-pulse energy required for the Nd:YAG laser posterior capsulotomy.

Methods

47 eyes with PCO scheduled for the Nd:YAG procedure were examined and divided into four categories: fibrosis, pearl, mixed type and late-postoperative capsular bag distension syndrome. Using custom-made computer software for OCT image analysis, the IOL/PC distances in two dimensions were measured. The IOL/PC distances were compared with those of a control group of 15 eyes without PCO. The influence of the different PCO types and the IOL/PC distance on the total-pulse energy required for the Nd:YAG procedure was analyzed.

Results

The total-pulse energy required for a laser capsulotomy differs significantly between PCO types (p = 0.005, Kruskal-Wallis test). The highest energy was required for the fibrosis PCO type, followed by mixed, pearl and late-postoperative capsular bag distension syndrome. The IOL/PC distance also significantly influenced the total-pulse energy required for laser capsulotomy (p = 0.028, linear regression). Lower total-pulse energy was expected for a larger IOL/PC distance.

Conclusions

Our study indicates that the PCO types and the IOL/PC distance influence the total-pulse energy required for Nd:YAG capsulotomy. The presented OCT method has the potential to become an additional tool for PCO characterization. Our results are important for a better understanding of the photodisruptive mechanisms in Nd:YAG capsulotomy.

Femtosecond-laser assisted cataract surgery: a review

Introduced in 2008, the femtosecond laser is a promising new technological advance which plays an ever increasing role in cataract surgery where it automates the three main surgical steps: corneal incision, capsulotomy and lens fragmentation. The proven advantages over manual surgery are: a better quality of incision with reduced induced astigmatism; increased reliability and reproducibility of the capsulotomy with increased stability of the implanted lens; a reduction in the use of ultrasound. Regarding refractive results or safety, however, no prospective randomized study to date has shown significant superiority compared with standard manual technique. The significant extra cost generated by this laser, undertaken by the patient, is a limiting factor for both its use and study. This review outlines the potential benefits of femtosecond-laser-assisted cataract surgery due to the automation of key steps and the safety of this new technology.

Capsular block syndrome: a case report and literature review

PURPOSE

To report the case of a patient who developed late capsular block syndrome and to review the current literature regarding this complication of phacoemulsification procedures.

METHODS

The literature was reviewed to summarize the diagnosis, classification, use of diagnostic aids, and the current treatments for this complication.

RESULTS

A 69-year-old patient complained of decreased visual acuity 11 months after undergoing phacoemulsification. She was found to have a secondary myopization. Anterior segment ultrabiomicroscopy confirmed the diagnosis of capsular block syndrome. The patient underwent neodymium-doped yttrium aluminum garnet (Nd:YAG) laser posterior capsulotomy, which resulted in complete resolution of her symptoms.

CONCLUSION

CAPSULAR BLOCK SYNDROME IS A FAIRLY RARE COMPLICATION OF PHACOEMULSIFICATION PROCEDURES THAT, DEPENDING PRIMARILY ON THE TIMING OF ITS OCCURRENCE FOLLOWING SURGERY, CAN DEVELOP INTO ONE OF THE THREE FOLLOWING POSSIBLE CLINICAL SCENARIOS: intraoperatory, early postoperatory, and late postoperatory. In this patient, Nd:YAG laser capsulotomy was shown to be a safe and effective treatment option for this type of complication.

Hydrodissection-free phacoemulsification surgery: mechanical cortical cleaving dissection

We describe hydrodissection-free phacoemulsification surgery (hydro-free phaco), which eliminates conventional cortical-cleaving hydrodissection during cataract surgery. To replace hydrodissection, we devised a mechanical cortical-cleaving dissection technique that is performed during phacoemulsification. The new technique prevents the high pressure within the endocapsular space or the posterior chamber-anterior hyaloid membrane barrier area that is common with hydrodissection. This reduces hydrodissection-related complications such as posterior capsule rupture, anterior hyaloid membrane tear, extension of zonule fracture, and pseudoexpulsive hemorrhage. Using this technique, phacoemulsification was performed effectively without complications in 547 of 550 cataract eyes. We propose this technique to prevent hydrodissection-related complications in eyes with a high risk for complications.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

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.

Safety of hydroimplantation: a foldable intraocular lens implantation without the use of an ophthalmic viscosurgical device

PURPOSE

To compare the safety of a single-piece, foldable intraocular lens (IOL) hydroimplantation with that of a standard implantation using an ophthalmic viscosurgical device (OVD).

METHODS

One hundred consecutive patients with bilateral age-related cataract surgery were enrolled into a prospective double-blind study. Each patient's first eye was randomly assigned to a standard implantation technique with an OVD or the hydroimplantation technique, while the fellow eye received the opposite technique. The main outcomes measured were endothelial cell loss, postoperative changes of intraocular pressure (IOP), and the frequency of complications.

RESULTS

The reduction of endothelial cell density 1 month and 6 months after the surgery was 9.76% ± 13.5%, 10.7% ± 12.6%, respectively, in group A (OVD) and 9.07% ± 12.7%, 9.13% ± 13.7%, respectively, in group B (hydroimplantation). The differences were not statistically significant. The mean IOP 2 hours after surgery was 10.19 ± 6.78 mm Hg in group A and 9.92 ± 7.01 mm Hg in group B. Twenty-four hours and 1 month after surgery, the mean IOP was 14.52 ± 5.59 mm Hg and 13.21 ± 3.5 mm Hg, respectively, in group A, and 15.45 ± 5.77 mm Hg and 13.1 ± 3.44 mm Hg, respectively, in group B. The differences between groups A and B were not statistically significant.

CONCLUSIONS

The hydroimplantation technique is a safe technique for single-piece foldable IOL implantation. There was no increase in intraoperative and postoperative complications compared with the standard implantation technique using an OVD.

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.