- Email: [email protected]
Spontaneous closure of anterior capsule tear
CASE REPORT
Spontaneous closure of anterior capsule tear Philip T.H. Lam, FRCSEd, FRCOphth, Teresa T.Y. Lau, MBChB, MRCSEd, Srinivas K. Rao, DO, DNB, FRCSEd, Dennis S.C. Lam, MD, FRCSEd
We report a case of anterior capsule tear that was closed spontaneously by fibrotic tissue during the postoperative period. The tear was inadvertently created during intraocular lens (IOL) implantation in the capsular bag. The IOL remained stable in the postoperative period, with excellent centration and no compromise in vision. J Cataract Refract Surg 2008; 34:1992–1994 Q 2008 ASCRS and ESCRS
To protect against posterior capsule opacification, in addition to in-the-bag location of both intraocular lens (IOL) haptics,1,2 the capsulorhexis edge should cover the optic completely to provide a barrier against lens epithelial cell (LEC) migration.3,4 Although in-thebag IOL implantation can be achieved intraoperatively in the presence of a capsule tear, haptic subluxation may occur, leading to IOL decentration in the postoperative period.5 Furthermore, implantation of a singlepiece hydrophobic acrylic IOL in the ciliary sulcus could result in pigment release and secondary glaucoma.6 We report a case of spontaneous closure of an anterior capsule tear in an eye with a single-piece hydrophobic acrylic IOL. The optic edge was completely enclosed by anterior capsule fibrosis and the tissue that bridged the capsule tear. CASE REPORT A 73-year-old man with bilateral cataract had phacoemulsification and implantation of a single-piece sharp-edged hydrophobic acrylic IOL (AcrySof SA60D3 C19.0 diopter, Alcon Laboratories) in his right eye. Coaxial phacoemulsification was conducted via a 2.85 mm corneal wound at the 12 o’clock meridian. The IOL was implanted using the proprietary delivery system (Monarch II delivery system and a B cartridge, Alcon Laboratories). During IOL delivery,
Accepted for publication May 20, 2008. From the Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong SAR, China. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Philip T.H. Lam, FRCSEd, FRCOphth, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, University Eye Centre, Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, Hong Kong, China. E-mail: [email protected].
1992
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
the tip of the cartridge, which was 3.0 mm in diameter, was placed at the incision and not inserted into the anterior chamber. The IOL began to unfold when the optic was being advanced through the anterior capsule opening. The sharp posterior optic edge created a tear at the 5 o’clock meridian of the capsulorhexis edge. With the aid of an ophthalmic viscosurgical device (OVD), the optic and trailing haptic were gently dialed into the capsular bag, with the IOL’s long axis perpendicular to the tear. The OVD was then removed by gentle irrigation/aspiration under low bottle height, preventing further extension of the capsule tear. The postoperative course was uneventful. At 1 month, the visual acuity in the right eye was 0.12 logMAR (at 4 m) and 0.4 logMAR (at 31 cm). There was no excessive inflammation. The intraocular pressure ranged between 9 mm Hg and 13 mm Hg. On day 7, a bridge of LECs was observed to grow from the capsulorhexis edge across the tear (Figure 1). The tissue bridge gradually thickened, opacified, and blended into the anterior capsule fibrosis to completely enclose the edge of the optic (Figures 2 and 3). The IOL optic remained in the capsular bag with excellent centration. At 10 months, the uncorrected logMAR visual acuity was 0.1 for distance and near. The IOL was well centered. Anterior capsule opacification did not intensify, and there was no further change in the appearance of the tissue bridge.
DISCUSSION Spontaneous closure of an anterior capsule tear has not been reported. We postulate the material and haptic design of this IOL contributed to this phenomenon. First, the nonangulated haptics of the single-piece design allowed apposition of the anterior capsule and the IOL surface in the immediate postoperative period. Vock et al.7 prospectively studied the gap between the anterior capsule and the IOL in 53 eyes. The gap disappeared in all eyes that received a hydrophobic IOL with nonangulated haptics but in only 42% of eyes that received a hydrophilic IOL with 10degree angulated haptics. Apposition of the anterior capsule and the hydrophobic acrylic IOL facilitated binding of these structures by fibronectin secreted 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.05.060
CASE REPORT: SPONTANEOUS CLOSURE OF ANTERIOR CAPSULE TEAR
Figure 1. Postoperative day 7: Slitlamp photograph shows lens epithelial cells that have grown from the capsulorhexis edges to the optic and have bridged the capsule tear at the 5 o’clock meridian.
extracellularly by LECs8 and allowed the LECs to migrate on the IOL surface from the capsulorhexis edges across the tear. A tissue bridge composed of LECs and fibronectin was formed. Second, the tension on the capsular bag induced by the position and design of the haptics was not sufficient to stretch or extend the capsule tear. Pandey et al.9 observed the flexible haptic design produced the smallest degree of capsular bag stretch when they compared the single-piece hydrophobic acrylic
Figure 2. Second postoperative week: Slitlamp photograph shows a tissue bridge has formed over the capsule tear.
1993
IOL with 5 other poly(methyl methacrylate) and silicone IOLs in pediatric autopsy eyes. Third, contact between the anterior capsule and the hydrophobic acrylic material led to the development of anterior capsule fibrosis in the early postoperative period.10 The degree of anterior capsule fibrosis can be regarded as diffuse, severe, or intense based on the descriptions by Vock et al.7 and Werner et al.11 The tissue bridge at the site of the tear blended with the anterior capsule fibrosis to enclose the edge of the optic completely, allowing a shrink-wrap effect to take place and avoiding IOL decentration or subluxation. To allow the capsulorhexis edge to cover the IOL optic completely, the surgeon created a relatively small, central capsulorhexis. As the IOL started to unfold while it was advanced from the tip of the cartridge at the wound before it passed through a small capsulorhexis opening, a tear could have been created by the sharp posterior edge of the IOL optic. Partial unfolding could have been prevented by using a smaller cartridge (C cartridge) for IOL delivery and inserting the tip of the cartridge into the anterior chamber. This would have required enlarging the wound and compromising wound architecture. Although the proprietary D cartridge with a smaller tip has become available lately, Alcon does not recommend its use with the SA60D3 IOL. In-the-bag IOL implantation should be the goal despite a capsule tear. With utmost care, the IOL in our case was implanted in the bag. The haptics were positioned away from the tear to prevent haptic subluxation into the ciliary sulcus, optic decentration, and pigment release in the postoperative period.
Figure 3. Sixth postoperative week: Slitlamp photograph shows the tissue bridge and the anterior capsule fibrosis completely enclose the edge of the optic. Lens epithelial cell outgrowth on the optic has disappeared.
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008
1994
CASE REPORT: SPONTANEOUS CLOSURE OF ANTERIOR CAPSULE TEAR
REFERENCES 1. Ram J, Apple DJ, Peng Q, Visessook V, Auffarth GU, Schoderbek RJ Jr, Ready EL. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part II. Choosing the correct haptic fixation and intraocular lens design to help eradicate posterior capsule opacification. Ophthalmology 1999; 106:891–900 2. Ram J, Pandey SK, Apple DJ, Werner L, Brar GS, Singh R, Chaudhary KP, Gupta A. Effect of in-the-bag intraocular lens fixation on the prevention of posterior capsular opacification. J Cataract Refract Surg 2001; 27:1039–1046 3. Peng Q, Visessook N, Apple DJ, Pandey SK, Werner L, Escobar-Gomez M, Schoderbek R, Solomon KD, Guindi A. Surgical prevention of posterior capsular opacification. Part 3: intraocular lens optic barrier effect as a second line of defence. J Cataract Refract Surg 2000; 26:198–213 4. Wejde G, Kugelberg M, Zetterstro¨m C. Position of anterior capsulorhexis and posterior capsule opacification. Acta Ophthalmol Scand 2004; 82:531–534 5. Blumenthal M, Assia E, Schochot Y. Lens anatomical principles and their technical implications in cataract surgery. Part I: the lens capsule. J Cataract Refract Surg 1991; 17:205–210 6. Uy HS, Chan PST. Pigment release and secondary glaucoma after implantation of single-piece acrylic intraocular lenses in the ciliary sulcus. Am J Ophthalmol 2006; 142:330–332 7. Vock L, Georgopoulos M, Neumayer T, Buehl W, Findl O. Effect of the hydrophilicity of acrylic intraocular lens material and haptic
8.
9.
10.
11.
angulation on anterior capsule opacification. Br J Ophthalmol 2007; 91:476–480 Linnola RJ, Werner L, Pandey SK, Escobar-Gomez M, Znoiko SL, Apple DJ. Adhesion of fibronectin, vitronectin, laminin, and collagen type IV to intraocular lens materials in pseudophakic human autopsy eyes. Part 1: histological sections. J Cataract Refract Surg 2000; 26:1792–1806 Pandey SK, Werner L, Wilson ME Jr, Izak AM, Apple DJ. Capsulorhexis ovaling and capsular bag stretch after rigid and foldable intraocular lens implantation; experimental study in pediatric human eyes. J Cataract Refract Surg 2004; 30:2183–2191 Miyake K, Ota I, Miyake S, Maekubo K. Correlation between intraocular lens hydrophilicity and anterior capsule opacification and aqueous flare. J Cataract Refract Surg 1996; 22:764–769 Werner L, Pandey SK, Apple DJ, Escobar-Gomez M, McLendon L, Macky TA. Anterior capsule opacification; correlation of pathologic findings with clinical sequelae. Ophthalmology 2001; 108:1675–1681
First author: Philip T.H. Lam, FRCSEd, FRCOphth Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, University Eye Centre, Hong Kong Eye Hospital
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008
Spontaneous closure of anterior capsule tear Philip T.H. Lam, FRCSEd, FRCOphth, Teresa T.Y. Lau, MBChB, MRCSEd, Srinivas K. Rao, DO, DNB, FRCSEd, Dennis S.C. Lam, MD, FRCSEd
We report a case of anterior capsule tear that was closed spontaneously by fibrotic tissue during the postoperative period. The tear was inadvertently created during intraocular lens (IOL) implantation in the capsular bag. The IOL remained stable in the postoperative period, with excellent centration and no compromise in vision. J Cataract Refract Surg 2008; 34:1992–1994 Q 2008 ASCRS and ESCRS
To protect against posterior capsule opacification, in addition to in-the-bag location of both intraocular lens (IOL) haptics,1,2 the capsulorhexis edge should cover the optic completely to provide a barrier against lens epithelial cell (LEC) migration.3,4 Although in-thebag IOL implantation can be achieved intraoperatively in the presence of a capsule tear, haptic subluxation may occur, leading to IOL decentration in the postoperative period.5 Furthermore, implantation of a singlepiece hydrophobic acrylic IOL in the ciliary sulcus could result in pigment release and secondary glaucoma.6 We report a case of spontaneous closure of an anterior capsule tear in an eye with a single-piece hydrophobic acrylic IOL. The optic edge was completely enclosed by anterior capsule fibrosis and the tissue that bridged the capsule tear. CASE REPORT A 73-year-old man with bilateral cataract had phacoemulsification and implantation of a single-piece sharp-edged hydrophobic acrylic IOL (AcrySof SA60D3 C19.0 diopter, Alcon Laboratories) in his right eye. Coaxial phacoemulsification was conducted via a 2.85 mm corneal wound at the 12 o’clock meridian. The IOL was implanted using the proprietary delivery system (Monarch II delivery system and a B cartridge, Alcon Laboratories). During IOL delivery,
Accepted for publication May 20, 2008. From the Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong SAR, China. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Philip T.H. Lam, FRCSEd, FRCOphth, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, University Eye Centre, Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, Hong Kong, China. E-mail: [email protected].
1992
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
the tip of the cartridge, which was 3.0 mm in diameter, was placed at the incision and not inserted into the anterior chamber. The IOL began to unfold when the optic was being advanced through the anterior capsule opening. The sharp posterior optic edge created a tear at the 5 o’clock meridian of the capsulorhexis edge. With the aid of an ophthalmic viscosurgical device (OVD), the optic and trailing haptic were gently dialed into the capsular bag, with the IOL’s long axis perpendicular to the tear. The OVD was then removed by gentle irrigation/aspiration under low bottle height, preventing further extension of the capsule tear. The postoperative course was uneventful. At 1 month, the visual acuity in the right eye was 0.12 logMAR (at 4 m) and 0.4 logMAR (at 31 cm). There was no excessive inflammation. The intraocular pressure ranged between 9 mm Hg and 13 mm Hg. On day 7, a bridge of LECs was observed to grow from the capsulorhexis edge across the tear (Figure 1). The tissue bridge gradually thickened, opacified, and blended into the anterior capsule fibrosis to completely enclose the edge of the optic (Figures 2 and 3). The IOL optic remained in the capsular bag with excellent centration. At 10 months, the uncorrected logMAR visual acuity was 0.1 for distance and near. The IOL was well centered. Anterior capsule opacification did not intensify, and there was no further change in the appearance of the tissue bridge.
DISCUSSION Spontaneous closure of an anterior capsule tear has not been reported. We postulate the material and haptic design of this IOL contributed to this phenomenon. First, the nonangulated haptics of the single-piece design allowed apposition of the anterior capsule and the IOL surface in the immediate postoperative period. Vock et al.7 prospectively studied the gap between the anterior capsule and the IOL in 53 eyes. The gap disappeared in all eyes that received a hydrophobic IOL with nonangulated haptics but in only 42% of eyes that received a hydrophilic IOL with 10degree angulated haptics. Apposition of the anterior capsule and the hydrophobic acrylic IOL facilitated binding of these structures by fibronectin secreted 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.05.060
CASE REPORT: SPONTANEOUS CLOSURE OF ANTERIOR CAPSULE TEAR
Figure 1. Postoperative day 7: Slitlamp photograph shows lens epithelial cells that have grown from the capsulorhexis edges to the optic and have bridged the capsule tear at the 5 o’clock meridian.
extracellularly by LECs8 and allowed the LECs to migrate on the IOL surface from the capsulorhexis edges across the tear. A tissue bridge composed of LECs and fibronectin was formed. Second, the tension on the capsular bag induced by the position and design of the haptics was not sufficient to stretch or extend the capsule tear. Pandey et al.9 observed the flexible haptic design produced the smallest degree of capsular bag stretch when they compared the single-piece hydrophobic acrylic
Figure 2. Second postoperative week: Slitlamp photograph shows a tissue bridge has formed over the capsule tear.
1993
IOL with 5 other poly(methyl methacrylate) and silicone IOLs in pediatric autopsy eyes. Third, contact between the anterior capsule and the hydrophobic acrylic material led to the development of anterior capsule fibrosis in the early postoperative period.10 The degree of anterior capsule fibrosis can be regarded as diffuse, severe, or intense based on the descriptions by Vock et al.7 and Werner et al.11 The tissue bridge at the site of the tear blended with the anterior capsule fibrosis to enclose the edge of the optic completely, allowing a shrink-wrap effect to take place and avoiding IOL decentration or subluxation. To allow the capsulorhexis edge to cover the IOL optic completely, the surgeon created a relatively small, central capsulorhexis. As the IOL started to unfold while it was advanced from the tip of the cartridge at the wound before it passed through a small capsulorhexis opening, a tear could have been created by the sharp posterior edge of the IOL optic. Partial unfolding could have been prevented by using a smaller cartridge (C cartridge) for IOL delivery and inserting the tip of the cartridge into the anterior chamber. This would have required enlarging the wound and compromising wound architecture. Although the proprietary D cartridge with a smaller tip has become available lately, Alcon does not recommend its use with the SA60D3 IOL. In-the-bag IOL implantation should be the goal despite a capsule tear. With utmost care, the IOL in our case was implanted in the bag. The haptics were positioned away from the tear to prevent haptic subluxation into the ciliary sulcus, optic decentration, and pigment release in the postoperative period.
Figure 3. Sixth postoperative week: Slitlamp photograph shows the tissue bridge and the anterior capsule fibrosis completely enclose the edge of the optic. Lens epithelial cell outgrowth on the optic has disappeared.
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008
1994
CASE REPORT: SPONTANEOUS CLOSURE OF ANTERIOR CAPSULE TEAR
REFERENCES 1. Ram J, Apple DJ, Peng Q, Visessook V, Auffarth GU, Schoderbek RJ Jr, Ready EL. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part II. Choosing the correct haptic fixation and intraocular lens design to help eradicate posterior capsule opacification. Ophthalmology 1999; 106:891–900 2. Ram J, Pandey SK, Apple DJ, Werner L, Brar GS, Singh R, Chaudhary KP, Gupta A. Effect of in-the-bag intraocular lens fixation on the prevention of posterior capsular opacification. J Cataract Refract Surg 2001; 27:1039–1046 3. Peng Q, Visessook N, Apple DJ, Pandey SK, Werner L, Escobar-Gomez M, Schoderbek R, Solomon KD, Guindi A. Surgical prevention of posterior capsular opacification. Part 3: intraocular lens optic barrier effect as a second line of defence. J Cataract Refract Surg 2000; 26:198–213 4. Wejde G, Kugelberg M, Zetterstro¨m C. Position of anterior capsulorhexis and posterior capsule opacification. Acta Ophthalmol Scand 2004; 82:531–534 5. Blumenthal M, Assia E, Schochot Y. Lens anatomical principles and their technical implications in cataract surgery. Part I: the lens capsule. J Cataract Refract Surg 1991; 17:205–210 6. Uy HS, Chan PST. Pigment release and secondary glaucoma after implantation of single-piece acrylic intraocular lenses in the ciliary sulcus. Am J Ophthalmol 2006; 142:330–332 7. Vock L, Georgopoulos M, Neumayer T, Buehl W, Findl O. Effect of the hydrophilicity of acrylic intraocular lens material and haptic
8.
9.
10.
11.
angulation on anterior capsule opacification. Br J Ophthalmol 2007; 91:476–480 Linnola RJ, Werner L, Pandey SK, Escobar-Gomez M, Znoiko SL, Apple DJ. Adhesion of fibronectin, vitronectin, laminin, and collagen type IV to intraocular lens materials in pseudophakic human autopsy eyes. Part 1: histological sections. J Cataract Refract Surg 2000; 26:1792–1806 Pandey SK, Werner L, Wilson ME Jr, Izak AM, Apple DJ. Capsulorhexis ovaling and capsular bag stretch after rigid and foldable intraocular lens implantation; experimental study in pediatric human eyes. J Cataract Refract Surg 2004; 30:2183–2191 Miyake K, Ota I, Miyake S, Maekubo K. Correlation between intraocular lens hydrophilicity and anterior capsule opacification and aqueous flare. J Cataract Refract Surg 1996; 22:764–769 Werner L, Pandey SK, Apple DJ, Escobar-Gomez M, McLendon L, Macky TA. Anterior capsule opacification; correlation of pathologic findings with clinical sequelae. Ophthalmology 2001; 108:1675–1681
First author: Philip T.H. Lam, FRCSEd, FRCOphth Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, University Eye Centre, Hong Kong Eye Hospital
J CATARACT REFRACT SURG - VOL 34, NOVEMBER 2008