Capsule contraction syndrome a concern after uncomplicated phaco

High-risk patients may require additional surgical techniques during phaco to prevent this long-term complication.

ByS. Gibran Khurshid, FRCS(Ed)

Figure 1. Dislocated IOL in fibrosed capsular bag lying on inferior retina (arrow).

A 75-year-old woman was seen for a sudden loss of vision 8 years after an uneventful cataract extraction. Her ophthalmic surgical history included phacoemulsification with implantation of foldable silicone IOL with poly-propylene haptics in the capsular bag. The diameter of capsulorrhexis was 6 to 7 mm. There was no history of trauma but she had been a high simple myope with axial length of 30 mm.

Slit-lamp biomicroscopy showed normal anterior segment but the IOL within the fibrotic bag had dislocated into the vitreous cavity and was lying on the inferior retinal surface (figure 1).

The IOL was mobile in liquefied vitreous with no other retinal problem. She underwent a pars plana vitrectomy. The IOL was floated to behind the iris with perfluorocarbon liquid and removed through corneal section and then another type of IOL was implanted into the ciliary sulcus using transscleral fixation.

Gross examination showed the IOL wrapped in the shrunken and fibrotic capsular bag (figure 2). Histopathological examination clearly revealed migration of lens epithelial cells and severe fibrotic changes in the capsular bag. Six weeks after surgery the best corrected visual acuity (BCVA) was 20/25. At 6 months the BCVA remained 20/20 with no further complication.

Discussion

Figure 2. Severely contracted and fibrosed capsular bag with IOL.

Capsular contraction syndrome is defined as an exaggerated reduction in anterior capsulotomy and capsular bag diameter after extracapsular cataract surgery (ECCE). It frequently occurs with continuous curvilinear capsulorrhexis. It can lead to extensive reduction of capsulotomy opening, malpositioning of opening and 360° zonular dehiscence and posterior dislocation of IOL with the bag. This causes significant visual disability and further need of posterior segment surgery, which can be associated with complications like retinal dialysis and detachment.

It has rarely been recognized with can-opener style of capsulectomies during ECCE, although this type of capsulectomy is not favorable during phaco. In such cases, the presence of multiple anterior capsular radial tears distributes the sphincter effect of fibrotic contraction force and results in less strain on zonules.

Conditions that predispose to capsular contraction syndrome are pseudoexfoliation, advance age, uveitis, pars planitis and myotonic muscular dystrophy. In our case there was no risk factor except that the patient was a high myope. Probably a long-term follow-up is needed to establish a definite relationship between myopia and capsular contraction syndrome.

Awareness of this newly recognized long-term complication may justify performing additional surgical techniques during phaco in high-risk patients. Maneuvers like anterior capsular nicks at the margins of capsulorrhexis after implantation of IOL, use of an IOL designed to provide maximal peripheral capsular bag expansion, use of capsular tension ring or Nd:YAG radial anterior relaxing capsulotomies within 4 weeks of cataract surgery reduce the effect of the fibrotic contraction process in the capsular bag. This lessens the chronic zonular traction that could cause spontaneous IOL dislocation and retinal detachment.

For Your Information:

S. Gibran Khurshid, FRCS(Ed), and F. Kinsella, FRCOphth, can be reached at Department of Ophthalmology, University College Hospital, Galway, Ireland; +(353) 91-524-222; fax: +(353) 91-526-637; e-mail: syedgibran@yahoo.com.

References:

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Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology. 2001;108:1727.

Rokwska E, Zarnowski T, Zagorski Z. Capsule contraction syndrome. Klin Oczna. 1999;101:375-378.