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Capsular bag distension associated with sulcus implantation of intraocular lenses
Capsular bag distension associated with sulcus implantation of intraocular lenses Orna Geyer, MD, Michaela Goldstein, MD, Levi Rothkoff, MD, Moshe Laz~r, MD
From the Department of Ophthalmology, Tel-Aviv Sourasky Medical Center and the Sackler Faculty ofMedicine, Tel Aviv University, Israel.
Chi ron Vision-Oomilens) was unintentionally implanted in the sulcus. There was a 1.5 mm overlap of the 10L optic and the anterior capsular bag opening. Sodium hyaluronate was aspirated from the eye near the end of suturing. Slitlamp examination on the first postoperative day was normal. Prednisolone acetate 1% was given topically 4 times per day. Two weeks after surgery, visual acuity was finger counting with a spherical equivalent of - 3.50 0 due to a macular scar. The eye was quiet with an intraocular pressure (lOP) of 18 mm Hg. The anterior chamber was deep and showed minimal activity. The anterior capsule was tightly applied by a fibrotic sheen ("glue") to the posterior part of the 10L optic for 360 degrees. The posterior capsule was far behind the posterior surface of the optic and the anterior capsule. The capsular bag was distended (inflated), with small pigmented particles suspended within. Treatment with topical prednisolone acetate was continued. Three weeks postoperatively, visual acuity was unchanged; however, the refraction was -2.00 0 spherical equivalent. The anterior segment was normal. The 10L had shifted posteriorly, the capsular bag inflation had disappeared, and the posterior capsule was directly behind the 10L, which was sealed to the posterior capsule. The status of the eye did not change throughout the 3 month follow-up.
None of the authors has a proprietary or financial interest in any material or method mentioned
Case 2
Reprint requests to Orna Geyer, MD, Department of Ophthalmology, Tel-Aviv Sourasky Medical Center, 6 Weizman Street, Tel-Aviv 64239, Israel
A 57-year-old man with diabetes had a nuclear and cortical cataract in the left eye and had cataract extraction using the mini-nuc technique 5 with a 5.0 mm capsulorhexis.
C
apsular bag distension is a known complication of capsulorhexis. Until now, it has been described in cases in which the intraocular lens (IOL) was implanted in the capsular bag. 1-4 To the best of our knowledge, we report this complication for the first time in eyes with a sulcus-fixated IOL.
Case Studies Casel An 80-year-old healthy woman with nuclear and cortical cataract had phacoemulsification via a temporal corneal incision in the right eye. Surgical details were as follows: a 5.0 mm capsulorhexis was performed under viscoelastic material. After phacoemulsification of the nucleus and complete cortex aspiration, sodium hyaluronate (Biolon®) was injected into the anterior chamber and the capsular bag. A singlepiece poly(methyl methacrylate) (PMMA), 21.50 diopter (D) 10L with a 13.3 mm overall length, 6.5 mm biconvex optic, and modified C-Ioops with 10 degree angulation (FLEX 652,
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J CATARACT REFRACT SURG-VOL 24. NOVEMBER 1998
CASE REPORTS: GEYER
After complete cortex aspiration, an IOL was unintentionally implanted in the sulcus. The single-piece PMMA 21.0 0 IOL had a 13.5 mm overall length, 6.5 mm biconvex optic, blue haptic of polypropylene, and modified C-Ioops with 10 degree angulation (C881M2, Optical Radiation Corp.). There was a 1.5 mm overlap of the IOL optic and the anterior capsular bag opening. No viscoelastic material was used during the procedure. Prednisolone acetate 1% was given topically 3 times per day for 2 months. The postoperative course of the eye was free of complications, and visual acuity was 20/20 with a manifest refraction of -1.00 -1.00 X 100 at 6 weeks postoperatively. The patient was lost to follow-up. Seven months after the cataract operation, the patient reappeared, reporting decreased vision in the operated eye. Visual acuity was 20/60 with a spherical equivalent of -0.75 0, and lOP was 16 mm Hg. Slitlamp examination revealed a normal, deep, and quiet anterior chamber with the same capsular bag distension and IOL appearance as described in Case 1. The posterior capsule was covered with posterior subcapsular debris. The anterior chamber was as deep as that in the fellow eye. A fibrotic sheen (glue) creeping over the anterior capsule opening was present for 360 degrees, as in Case 1. Because the posterior capsule was opaque, a 2.5 mm wide neodymium:YAG (Nd:YAG) laser posterior capsulotomy was performed. As soon as the opening was made, the capsular bag distension disappeared and the posterior capsule was directly behind the anterior capsule and IOL. One week after the Nd:YAG capsulotomy, the patient had a best corrected visual acuity of20/20 with a spherical equivalent of +0.50 D. Slitlamp examination showed a quiet and deep anterior chamber. The IOL and the anterior capsule opening were sealed by adherence to the posterior capsule. No fluid was seen between the anterior and posterior capsules. Followup 1 year later showed no changes.
Discussion Capsular bag distension has been reported as a complication of capsulorhexis, endophacoemulsification, and posterior chamber 10L implantation. This syndrome is characterized by complete sealing of the anterior capsule opening against the 10L optic, inflation of the capsular bag, and displacement of the posterior capsule far behind the posterior optic surface. The bag contains a fluid with suspended particulate debris, and the complication occurs more frequently in cases in which an AcrySoflOL is implanted. 4 Although no specific treatment is recommended, Nd:YAG laser anterior capsulotomy has been shown to accelerate the resolution of the syndrome. 1-4
In previously reported cases, this postoperative complication was caused by adherence of an intact anterior capsule rim to the anterior surface of a posterior chamber 10L that had been implanted in the capsular bag. Our 2 cases are different; the syndrome developed in eyes with the lens implanted in the sulcus (i.e., located in front of the anterior rim of the capsular bag). Thus, closure of the capsular bag was induced by complete sealing of the anterior capsule opening against the posterior surface of the 10L optic. The lens characteristics and position in both patients likely precipitated the development of the syndrome. 1. The lens optic was biconvex. This allowed closer contact between the posterior surface of the 10L optic and anterior capsule rim. 2. The 10L overlapped the size of the anterior capsular bag opening by 1.5 mm, contributing to the tight closure of the bag opening. 3. The lenses were of PMMA, which is believed to be associated with the development of the fibrotic glue responsible for sealing the 10L to the anterior lens capsule. 2 The fluid in the capsular bag in Out cases contained cells that did not move and looked as though they were in suspension. This finding was similar to those described in the literature. 1,2 The nature of the liquid within the capsular bag is unknown. It was suggested that this liquid could be viscoelastic material trapped within the capsular bag or that the retained lens epithelial cells, with their proteinaceous by-products, or the retained cortex induced an osmotic gradient across the capsule that subsequently drew water into the capsular bag, causing its maximal inflation. Since the viscoelastic material is retained in the eye for the first 48 hours after surgery, it is a less likely cause in Case 1, in which the capsular bag distension was observed 2 weeks after surgery. A viscoelastic agent was not used in Case 2, eliminating its culpability in the evolution of the syndrome. Although the bag distension in Case 2 was noticed only 7 months after surgery, clinical evidence suggests that the syndrome was overlooked at the 6 week visit: (1) The refractive error changed minimally between the 6 week and 7 month follow-ups. If the syndrome had occurred after the 6 week visit, it would have been likely that the refraction at 7 months would have been more myopic than that at 6 weeks. (2) After the
J CATARACT REFRACT SURG-VOL 24, NOVEMBER 1998
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CASE REPORTS: GEYER
Nd:YAG capsulotomy relieved the distension, there was a significant hyperopic shift compared with both refractions. This shows that it is possible to miss this syndrome in the early postoperative period when the posterior capsule is clear and distended away from the IOL. If surgeons do not suspect the condition, they may not focus posteriorly and thereby detect the capsular bag. In cases of capsular bag distension reported in the literature in which lenses were inserted in the capsular bag, there was a forward shift of the IOL optic and induced myopia. In our cases, there was no observable anterior movement of the IOL. However, the hyperopic shift after the resolution of the bag distension suggests that some forward movement existed. In Case 1, the syndrome resolved with conservative treatment within a few weeks. In the second case, a posterior capsulotomy was performed, allowing the trapped fluid to migrate posteriorly; recovery was rapid. The reports in the literature recommend no treatment or the use of Nd:YAG laser punctures to the anterior capsular bag. Some precautions at the time of surgery may prevent bag distension syndrome. These include making a capsulorhexis large enough so the IOL does not
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overlap the anterior capsular bag opening, preventing tight closure of the bag, and meticulous aspiration of viscoelastic material and cortex trapped in the capsular bag. Our 2 cases indicate that capsular bag distension can be present in eyes with a sulcus-fixated IOL. We believe that capsular bag distension after cataract surgery is more common than reported and increased awareness will reveal additional cases. Neodymium:YAG laser capsulotomy can resolve cases in which conservative treatment fails.
References 1. Davison JA. Capsular bag distension after endophacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg 1990; 16:99-108 2. Holtz SJ. Postoperative capsular bag distension. J Cataract Refract Surg 1992; 18:310-317 3. Tu KL, Gaskell A. Capsular bag distension syndrome (letter). Br J Ophthalmol 1997; 81:610 4. Omar 0, Eng CT, Chang A, et al. Capsular bag distension with an acrylic intraocular lens. J Cataract Refract Surg 1996; 22:1365-1367 5. Blumenthal M. Manual ECCE; the present state of the art. Klin Monatsbl Augenheilkd 1994; 205:266-270
J CATARACf REFRACT SURG-VOL 24, NOVEMBER 1998
From the Department of Ophthalmology, Tel-Aviv Sourasky Medical Center and the Sackler Faculty ofMedicine, Tel Aviv University, Israel.
Chi ron Vision-Oomilens) was unintentionally implanted in the sulcus. There was a 1.5 mm overlap of the 10L optic and the anterior capsular bag opening. Sodium hyaluronate was aspirated from the eye near the end of suturing. Slitlamp examination on the first postoperative day was normal. Prednisolone acetate 1% was given topically 4 times per day. Two weeks after surgery, visual acuity was finger counting with a spherical equivalent of - 3.50 0 due to a macular scar. The eye was quiet with an intraocular pressure (lOP) of 18 mm Hg. The anterior chamber was deep and showed minimal activity. The anterior capsule was tightly applied by a fibrotic sheen ("glue") to the posterior part of the 10L optic for 360 degrees. The posterior capsule was far behind the posterior surface of the optic and the anterior capsule. The capsular bag was distended (inflated), with small pigmented particles suspended within. Treatment with topical prednisolone acetate was continued. Three weeks postoperatively, visual acuity was unchanged; however, the refraction was -2.00 0 spherical equivalent. The anterior segment was normal. The 10L had shifted posteriorly, the capsular bag inflation had disappeared, and the posterior capsule was directly behind the 10L, which was sealed to the posterior capsule. The status of the eye did not change throughout the 3 month follow-up.
None of the authors has a proprietary or financial interest in any material or method mentioned
Case 2
Reprint requests to Orna Geyer, MD, Department of Ophthalmology, Tel-Aviv Sourasky Medical Center, 6 Weizman Street, Tel-Aviv 64239, Israel
A 57-year-old man with diabetes had a nuclear and cortical cataract in the left eye and had cataract extraction using the mini-nuc technique 5 with a 5.0 mm capsulorhexis.
C
apsular bag distension is a known complication of capsulorhexis. Until now, it has been described in cases in which the intraocular lens (IOL) was implanted in the capsular bag. 1-4 To the best of our knowledge, we report this complication for the first time in eyes with a sulcus-fixated IOL.
Case Studies Casel An 80-year-old healthy woman with nuclear and cortical cataract had phacoemulsification via a temporal corneal incision in the right eye. Surgical details were as follows: a 5.0 mm capsulorhexis was performed under viscoelastic material. After phacoemulsification of the nucleus and complete cortex aspiration, sodium hyaluronate (Biolon®) was injected into the anterior chamber and the capsular bag. A singlepiece poly(methyl methacrylate) (PMMA), 21.50 diopter (D) 10L with a 13.3 mm overall length, 6.5 mm biconvex optic, and modified C-Ioops with 10 degree angulation (FLEX 652,
1538
J CATARACT REFRACT SURG-VOL 24. NOVEMBER 1998
CASE REPORTS: GEYER
After complete cortex aspiration, an IOL was unintentionally implanted in the sulcus. The single-piece PMMA 21.0 0 IOL had a 13.5 mm overall length, 6.5 mm biconvex optic, blue haptic of polypropylene, and modified C-Ioops with 10 degree angulation (C881M2, Optical Radiation Corp.). There was a 1.5 mm overlap of the IOL optic and the anterior capsular bag opening. No viscoelastic material was used during the procedure. Prednisolone acetate 1% was given topically 3 times per day for 2 months. The postoperative course of the eye was free of complications, and visual acuity was 20/20 with a manifest refraction of -1.00 -1.00 X 100 at 6 weeks postoperatively. The patient was lost to follow-up. Seven months after the cataract operation, the patient reappeared, reporting decreased vision in the operated eye. Visual acuity was 20/60 with a spherical equivalent of -0.75 0, and lOP was 16 mm Hg. Slitlamp examination revealed a normal, deep, and quiet anterior chamber with the same capsular bag distension and IOL appearance as described in Case 1. The posterior capsule was covered with posterior subcapsular debris. The anterior chamber was as deep as that in the fellow eye. A fibrotic sheen (glue) creeping over the anterior capsule opening was present for 360 degrees, as in Case 1. Because the posterior capsule was opaque, a 2.5 mm wide neodymium:YAG (Nd:YAG) laser posterior capsulotomy was performed. As soon as the opening was made, the capsular bag distension disappeared and the posterior capsule was directly behind the anterior capsule and IOL. One week after the Nd:YAG capsulotomy, the patient had a best corrected visual acuity of20/20 with a spherical equivalent of +0.50 D. Slitlamp examination showed a quiet and deep anterior chamber. The IOL and the anterior capsule opening were sealed by adherence to the posterior capsule. No fluid was seen between the anterior and posterior capsules. Followup 1 year later showed no changes.
Discussion Capsular bag distension has been reported as a complication of capsulorhexis, endophacoemulsification, and posterior chamber 10L implantation. This syndrome is characterized by complete sealing of the anterior capsule opening against the 10L optic, inflation of the capsular bag, and displacement of the posterior capsule far behind the posterior optic surface. The bag contains a fluid with suspended particulate debris, and the complication occurs more frequently in cases in which an AcrySoflOL is implanted. 4 Although no specific treatment is recommended, Nd:YAG laser anterior capsulotomy has been shown to accelerate the resolution of the syndrome. 1-4
In previously reported cases, this postoperative complication was caused by adherence of an intact anterior capsule rim to the anterior surface of a posterior chamber 10L that had been implanted in the capsular bag. Our 2 cases are different; the syndrome developed in eyes with the lens implanted in the sulcus (i.e., located in front of the anterior rim of the capsular bag). Thus, closure of the capsular bag was induced by complete sealing of the anterior capsule opening against the posterior surface of the 10L optic. The lens characteristics and position in both patients likely precipitated the development of the syndrome. 1. The lens optic was biconvex. This allowed closer contact between the posterior surface of the 10L optic and anterior capsule rim. 2. The 10L overlapped the size of the anterior capsular bag opening by 1.5 mm, contributing to the tight closure of the bag opening. 3. The lenses were of PMMA, which is believed to be associated with the development of the fibrotic glue responsible for sealing the 10L to the anterior lens capsule. 2 The fluid in the capsular bag in Out cases contained cells that did not move and looked as though they were in suspension. This finding was similar to those described in the literature. 1,2 The nature of the liquid within the capsular bag is unknown. It was suggested that this liquid could be viscoelastic material trapped within the capsular bag or that the retained lens epithelial cells, with their proteinaceous by-products, or the retained cortex induced an osmotic gradient across the capsule that subsequently drew water into the capsular bag, causing its maximal inflation. Since the viscoelastic material is retained in the eye for the first 48 hours after surgery, it is a less likely cause in Case 1, in which the capsular bag distension was observed 2 weeks after surgery. A viscoelastic agent was not used in Case 2, eliminating its culpability in the evolution of the syndrome. Although the bag distension in Case 2 was noticed only 7 months after surgery, clinical evidence suggests that the syndrome was overlooked at the 6 week visit: (1) The refractive error changed minimally between the 6 week and 7 month follow-ups. If the syndrome had occurred after the 6 week visit, it would have been likely that the refraction at 7 months would have been more myopic than that at 6 weeks. (2) After the
J CATARACT REFRACT SURG-VOL 24, NOVEMBER 1998
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CASE REPORTS: GEYER
Nd:YAG capsulotomy relieved the distension, there was a significant hyperopic shift compared with both refractions. This shows that it is possible to miss this syndrome in the early postoperative period when the posterior capsule is clear and distended away from the IOL. If surgeons do not suspect the condition, they may not focus posteriorly and thereby detect the capsular bag. In cases of capsular bag distension reported in the literature in which lenses were inserted in the capsular bag, there was a forward shift of the IOL optic and induced myopia. In our cases, there was no observable anterior movement of the IOL. However, the hyperopic shift after the resolution of the bag distension suggests that some forward movement existed. In Case 1, the syndrome resolved with conservative treatment within a few weeks. In the second case, a posterior capsulotomy was performed, allowing the trapped fluid to migrate posteriorly; recovery was rapid. The reports in the literature recommend no treatment or the use of Nd:YAG laser punctures to the anterior capsular bag. Some precautions at the time of surgery may prevent bag distension syndrome. These include making a capsulorhexis large enough so the IOL does not
1540
overlap the anterior capsular bag opening, preventing tight closure of the bag, and meticulous aspiration of viscoelastic material and cortex trapped in the capsular bag. Our 2 cases indicate that capsular bag distension can be present in eyes with a sulcus-fixated IOL. We believe that capsular bag distension after cataract surgery is more common than reported and increased awareness will reveal additional cases. Neodymium:YAG laser capsulotomy can resolve cases in which conservative treatment fails.
References 1. Davison JA. Capsular bag distension after endophacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg 1990; 16:99-108 2. Holtz SJ. Postoperative capsular bag distension. J Cataract Refract Surg 1992; 18:310-317 3. Tu KL, Gaskell A. Capsular bag distension syndrome (letter). Br J Ophthalmol 1997; 81:610 4. Omar 0, Eng CT, Chang A, et al. Capsular bag distension with an acrylic intraocular lens. J Cataract Refract Surg 1996; 22:1365-1367 5. Blumenthal M. Manual ECCE; the present state of the art. Klin Monatsbl Augenheilkd 1994; 205:266-270
J CATARACf REFRACT SURG-VOL 24, NOVEMBER 1998