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.

Assessment of Corneal and Lens Density in Children With Celiac Disease

PURPOSE

To assess the early changes of corneal and lens density in a pediatric population with celiac disease.

METHODS

One hundred one patients were included in this observational and prospective study. Patients with celiac disease formed the celiac disease group. Healthy individuals with no medical history formed the control group. Corneal and lens density were assessed with Pentacam HR (Oculus Optikgeräte GmbH, Wetzlar, Germany).

RESULTS

The mean lens and corneal density outcomes in all zones did not differ between groups (P > .05 for each). Maximum lens density outcome was significantly higher in the celiac disease group than in the control group (P = .028). The mean corneal density at the peripheral cornea was significantly higher in females than males in the celiac disease group (P < .05 for each). Compliance with a gluten-free diet, body mass index, and histological classification of celiac disease had no significant effect on lens and corneal density in patients with celiac disease (P > .05 for each).

CONCLUSIONS

Celiac disease did not affect the mean lens and corneal density in this pediatric population, but higher maximum lens density in patients with celiac disease and higher peripheral corneal density in female patients with celiac disease may indicate early stages of ocular involvement of celiac disease. [J Pediatr Ophthalmol Strabismus. 2019;56(6):402-406.].

Late postoperative capsular bag distension syndrome

PURPOSE

Capsular bag distension syndrome is to be seen as a relatively rare complication after cataract surgery.

MATERIALS AND METHODS

We describe our experience of late-onset capsular bag distension syndrome with one case onset 4 years after cataract surgery. Nowadays diagnostic imaging methods were used. The literature was reviewed to summarize the diagnosis, classification, use of diagnostic aids, and the current treatments for the capsular bag distension syndrome. Visual acuity was assessed using the ETDRS (Early Treatment Diabetic Retinopathy Study) chart.

DISCUSSION

A 72-year-old woman presented with decreased visual acuity and blurred vision 4 years after phacoemulsification with continuous curvilinear capsulorhexis (CCC) and in-the-bag IOL implantation. After the slit lamp examination, patient was investigated with Scheimpflug camera (OCULUS Pentacam HR) and anterior segment spectral domain OCT (Optovue, Avanti RTVue XR), which confirmed the diagnosis of capsular block syndrome. Aspiration of the turbid fluid behind the lens and capsular bag lavage resulted in resolution of her symptoms. Aspirated fluid was examined. We have observed no CBS recurrence.

CONCLUSION

CBS is the relatively rare complication of the standard cataract surgery, which can occur during surgery and in a postoperative period. CBS can be solved successfully after regular diagnosis using modern imaging methods.

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.

CANDIDA ENDOPHTHALMITIS FROM THE REACTIVATION OF A DORMANT LENTICULAR FUNGAL ABSCESS IN A PREMATURE INFANT

BACKGROUND/PURPOSE

To report a case of fungal endophthalmitis from reactivation of a dormant lenticular fungal abscess in a severely premature infant.

METHODS

Single retrospective case report.

RESULTS

A female born at 23 and 6/7 weeks and weighing 620 g was diagnosed at age 29 weeks post menstrual age with persistent tunica vasculosa lentis, lenticular opacity, and aggressive posterior retinopathy of prematurity, and received bilateral intravitreal injection of bevacizumab. At the time of injection she was receiving systemic antibiotics for sepsis and fungemia. The retinopathy of prematurity regressed, as did the tunica vasculosa lentis, but a small plaque remained on the lens. At 5.5 months of age, patient presented with hypopyon and elevated intraocular pressure. Culture of intraocular fluid demonstrated Candida albicans.

CONCLUSION

Candida lenticular abscess is a rare complication of systemic fungemia in premature infants. Bevacizumab-induced regression of tunica vasculosa lentis may have decreased the ability of systemically administered antifungal medications to reach the colonized lens.

An Overview of the Eye in Diabetes

The three papers in this symposium are based on presentations to an RSM meeting on the Diabetic Eye, held on 9 April 2003. The matter is particularly topical because the National Service Framework for Diabetes calls for a high-quality retinal screening programme. After a review of the various ophthalmic conditions likely to be encountered in diabetic patients (A Negi, S A Vernon) we proceed to the most important, diabetic retinopathy, with a discussion of screening methods (D M Squirrell, J F Talbot) and an account of laser treatments (J G F Dowler). Colour versions of the clinical photographs are available online [www.jrsm.org]. Publication was coordinated by Professor Susan Lightman, of Moorfields Eye Hospital, London, UK.

Complications in posterior chamber lens implantation

Posterior chamber lens implantations may be accompanied by intraocular operative complications, such as miosis, rupture of posterior capsule, incomplete capsulectomy, vitreous loss, or remaining lens material and some more. Postoperative complications can be a pupillary block, narrow anterior chamber, uveitis, lens or vitreous material in the anterior chamber, endophthalmitis, keratopathy or difficulties caused by malposition of the lens. As late sequelae of the intraocular lens implantation procedure secondary membranes can be observed as well as corneal edema, cystoid macular edema or retinal detachment.

Choroid plexus in the eye: a case study

PURPOSE

The purpose of this report is to describe a pediatric case of total retinal detachment (RD) with secondary glaucoma in the setting of posterior coloboma with the metaplastic retinal pigment epithelium showing abrupt transition to choroid plexus tissue.

METHODS

Retrospective case report.

RESULTS

A 3-month-old patient presented with leukocoria and enlarged right eye. She was found to have a funnel RD with anterior displacement of lens-iris diaphragm and secondary glaucoma. Orbital imaging ruled out retinoblastoma, and posterior coloboma was identified. Intraocular pressures remained significantly elevated despite maximal medical therapy on glaucoma drops and transscleral cycloablation, and the eye was enucleated for comfort. Histologic analysis confirmed neovascularization of the iris, total RD, and posterior coloboma with the associated metaplastic retinal pigment epithelium showing abrupt transition to choroid plexus tissue.

CONCLUSION

This is the first reported case of choroid plexus in the human eye. A close association of choroid plexus with coloboma and RD raises possibility that this tissue may have functionally contributed to pathogenesis of RD by secreting cerebrospinal fluid within subretinal space.

Cataract extraction outcomes and the prevalence of zonular insufficiency in retinitis pigmentosa

PURPOSE

To examine surgical outcomes in patients with retinitis pigmentosa (RP) undergoing phacoemulsification cataract extraction.

DESIGN

Retrospective observational case series.

PATIENTS AND METHODS

In this single-institution study of consecutive RP patients who underwent phacoemulsification cataract extraction and intraocular lens implantation by a single surgeon between 2002 and 2012, preoperative, intraoperative, and postoperative records were analyzed with attention to best-corrected visual acuity (BCVA), lens and zonular status, capsular tension ring use, incidence of posterior capsular opacification and neodymium-doped yttrium-aluminum-garnet (YAG) laser capsulotomy, and surgical complications.

RESULTS

Eighty eyes of 47 RP patients (21 male) underwent cataract surgery during the study period at an average age of 48.9 years (range, 31-78 years). Mean follow-up time was 23.3 months (range, 1 day - 95 months). Posterior subcapsular cataracts were present in 97.5% of patients. Mean BCVA improved from 20/340 (logarithm of the minimal angle of resolution [logMAR] 1.23) to 20/129 (0.81) within 3 months of surgery, P < .0001. Eyes with a preoperative vision of 20/40 to 20/200 (47 eyes) improved from a mean of 20/81 (logMAR 0.61) preoperatively to 20/43 (0.33), P < .0001, postoperatively. Posterior capsule opacification occurred in 66 eyes (82.5%), and 42 eyes (52.5%) underwent a YAG laser capsulotomy at a mean of 10.8 months after surgery. Fifteen eyes (18.8%) of 10 patients (21.3%) had signs of phacodonesis (3 eyes noted preoperatively, 8 intraoperatively, and 4 postoperatively). One patient had bilateral dislocated in-the-bag intraocular lenses at 5.5 years and 6 years after surgery.

CONCLUSION

Cataract surgery yields significantly improved Snellen visual acuity in a majority of RP patients with a preoperative vision of 20/200 or better. Conversely, patients with a preoperative visual acuity of 20/400 or worse generally have more limited objective improvements, likely because of macular involvement, but usually report noticeable subjective improvement. A high prevalence of zonular instability is seen in RP patients undergoing cataract extraction. It is therefore important to conduct a careful preoperative assessment of lens stability with preparation for adjunctive methods that augment intraoperative and postoperative lens stabilization.

Lenticular meridional astigmatism secondary to iris mesectodermal leiomyoma

A 61-year-old African American man presented with decreased vision of 2 months duration. Examination revealed a significant lenticular astigmatism and sectoral cataract as a result of an amelanotic iris lesion. Slitlamp optical coherence tomography (OCT) revealed angle crowding. An excisional biopsy was performed along with phacoemulsification in the right eye, with intraocular lens implantation for meridional lenticular astigmatism. Histopathology and histoimmunochemistry confirmed a diagnosis of uveal mesectodermal leiomyoma. Lenticular astigmatism may be a subtle sign of an anterior segment tumor. Anterior segment slitlamp OCT is an effective tool in diagnosing as well as monitoring small interval changes in these types of tumors.

[Ocular findings in Nijmegen breakage syndrome]

Nijmegen Breakage Syndrome (NBS) is a genomic instability disease caused by inherited mutations in the NBN/NBS1 gene. The clinical symptoms of NBS are: primary microcephaly, characteristic facial appearance, recurring respiratory tract infections caused by immune deficiency and extremely high risk of cancer development at early age.

PURPOSE

The aim of the study was to assess the vision organ in patients with NBS.

MATERIAL AND METHODS

Ophthalmological examination of 10 NBS patients was performed. The visual acuity, refractive errors, anterior and posterior segment of the eye ball test, tonometry and biometry were assessed.

RESULTS

Serious pathology of the sight organ in the study group were found, including upward slanting of the palpebral fissures, reduced visual acuity, small eyes, small cornea diameter, lens opacity, refractive errors.

CONCLUSIONS

The patients with Nijmegen breakage syndrome have significant sight organ abnormalities. These pathologies require long-term ophthalmologic care.

Phacoemulsification in vitrectomized eyes: results using a 'phaco chop' technique

PURPOSE

To evaluate the intraoperative and early postoperative complications of phacoemulsification using a 'phaco chop' technique in previously vitrectomized eyes.

METHODS

A prospective interventional case series. Seventy-five previously vitrectomized eyes of 73 consecutive patients underwent phacoemulsification using a 'phaco chop' technique via clear corneal incision. Patients were observed for any intraoperative or early postoperative complications.

RESULTS

Fifty-four eyes (72%) had predominant nuclear sclerosis or posterior subcapsular cataract. The intraoperative findings included intraoperative miosis [seen in 21 eyes (28%)] and posterior capsule plaques [in 15 eyes (20%)]. No other significant intraoperative complication (posterior capsule rupture, zonular lysis or dropped nuclei) was observed. In the early postoperative period, one patient had massive serous choroidal detachment, which resolved with conservative treatment. Mean preoperative visual acuity (LogMar scale) was 0.74, which improved to 0.36 postoperatively (p < 0.001).

CONCLUSION

Phacoemulsification using a 'phaco chop' technique is a safe procedure in vitrectomized eyes.

Phacoemulsification and intraocular lens implantation in Alport syndrome with anterior lenticonus

Eleven eyes of 6 patients with Alport syndrome had phacoemulsification with implantation of a single-piece acrylic hydrophobic intraocular lens (IOL) (AcrySof SA6OAT, Alcon) because of anterior lenticonus. All patients had excellent visual acuity after surgery. We recommend phacoemulsification with IOL implantation as a safe and effective procedure in patients with anterior lenticonus secondary to Alport syndrome.

Traumatic lenticular abscess: clinical description and outcome

PURPOSE

To analyze cases with posttraumatic lenticular abscess and study the etiology, clinical presentation, management, and outcome.

DESIGN

Retrospective case series.

METHODS

Seventeen eyes of 17 patients with traumatic lenticular abscesses were managed with extracapsular cataract extraction after aspirating the abscess.

RESULTS

The mean age of the patients was 40.3 years, and males constituted 82%. The mean time to presentation after injury was 14.35 days (range, one to 60 days), and the patients had a mean follow-up of 125.94 days (range, 21 to 300 days). Culture of the lenticular abscess revealed bacterial growth in eight cases (47%) and fungi in four cases (23.5%). In five (29.4%) cases, culture was negative. Staphylococcus epidermidis grew in seven cases (41%). Thirteen eyes (77%) had best-corrected visual acuity better than 20/120.

CONCLUSIONS

Surgical removal of the abscess, with systemic and local antimicrobial treatment is effective in cases of posttraumatic intralenticular abscess.

Late-onset hyaloideocapsular block syndrome

PURPOSE

To report an unusual cause of decreased vision in an aphakic patient.

DESIGN

Interventional case report.

PARTICIPANT

One patient.

INTERVENTION

An 80-year-old woman presented with a myopic shift and decreased visual acuity in the left eye 16 years after extracapsular cataract extraction (ECCE) without intraocular lens (IOL) implantation. Slit-lamp examination after pupil dilation revealed a milky fluid accumulation between the posterior lens capsule and the anterior hyaloid membrane. A neodymium:yttrium-aluminium-garnet (Nd:YAG) laser hyaloidotomy was performed on the anterior hyaloid membrane.

MAIN OUTCOME MEASURES

Refraction and best-corrected visual acuity.

RESULTS

The Nd:YAG laser hyaloidotomy allowed the trapped fluid to flow into the vitreous cavity. The myopic shift disappeared immediately and visual acuity improved.

CONCLUSIONS

To our knowledge, this is the first report of a late-onset hyaloideocapsular block syndrome after ECCE without IOL implantation.

Measurement of anterior lens growth after acute primary angle-closure glaucoma

BACKGROUND

To evaluate rates of intraoperative posterior capsule complications in manual small-incision cataract surgery of eyes with and without pseudoexfoliation syndrome in terms of cataract maturity level.

METHODS

We identified patients who had undergone manual small-incision cataract surgery between January 1997 and October 2003 from a review of patient charts. Preoperative data collected were cataract maturity level, best corrected visual acuity, and intraoperative posterior capsule complications as documented in the surgical report, namely (1) posterior capsule rupture or zonulolysis, or both, and (2) vitreous loss.

RESULTS

Two hundred and twenty-five eyes of 187 patients met the study criteria, of which 99 eyes had pseudoexfoliation syndrome (group 1) and 126 did not (group 2). Intraoperative posterior capsule complications occurred in 18 eyes (18%) in group 1 and 7 eyes (5.5%) in group 2 (difference was significant at p=0.003). The rate of capsular complications was significantly higher in both groups for eyes with preoperative visual acuity worse than 20/200 than for eyes with 20/200 or better. The number of eyes with visual acuity worse than 20/200 (counting fingers, hand motion, or light perception) was 70 (70%) in group 1 and 63 (50%) in group 2. Mature or brunescent cataract occurred in 49.5% of group 1 eyes and 26% of group 2 eyes.

INTERPRETATION

In manual small-incision cataract surgery, pseudoexfoliation syndrome has an increased intraoperative posterior capsule complication rate that increases as the level of cataract maturity increases and the preoperative visual acuity decreases.

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.

Persistent endocapsular hematoma following uneventful phacoemulsification and clear corneal incision cataract surgery

We report the first case of persistent endocapsular hematoma following uneventful phacoemulsification and intraocular lens surgery through a clear corneal incision.

Capsular block syndrome presenting with a hyperopic shift

We report a case of late postoperative capsular block syndrome presenting with a hyperopic shift and discuss possible causes of this unusual presentation.

Traumatic rupture of the posterior capsule resulting in complete posterior prolapse of the lens with subsequent resolution of high myopia

Uncomplicated isolated breach of the posterior capsule following a blunt forehead trauma has rarely been reported. We report the first case of a patient with high myopia who, after minor forehead trauma, developed an isolated rupture of the posterior capsule with probable complete prolapse of the crystalline lens into the vitreous cavity, leading to spontaneous correction of the patient's high axial myopia.

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.

Phacoemulsification and lens-iris diaphragm retropulsion syndrome

Lens-iris diaphragm retropulsion syndrome is mainly caused by a reverse pupillary block as a result of a defect or laxity in the zonular apparatus. It is characterized by a posterior displacement of the lens-iris diaphragm with posterior iris bowing, pupil dilation, and pain. The authors describe a new management technique using an iris hook retractor to lift the iris to relieve the pupillary block.