EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW RESIDENTS 110 October 2014 He presented for routine follow-up 6 weeks after he was given a ranibi- zumab injection in the left eye for diabetic macular edema. On exam, his vision was 20/70 in the right eye, down from 20/25 6 weeks prior, without improvement on pinhole, and 20/30 in the left eye. He was refracted to 20/50 in the right eye with –3.00 sphere. His in- traocular pressure, pupils, and visual fields to confrontation were normal. Slit lamp exam of the anterior segment was normal, except for distention of the posterior capsule with milky fluid located between the intraocular lens and posterior capsule (Figure 2A) with prominent Elschnig pearls (Figure 2B). Fundus exam showed moderate non-prolif- erative diabetic retinopathy without macular edema. Discussion This case was presented at UCSF Grand Rounds, and our comprehen- sive ophthalmology faculty shared the following thoughts on the case. Dr. Bloomer: "These are very inter- esting cases and the first that I have seen. I am baffled by the rarity of this entity given the sheer numbers of cataract surgeries performed." "With time, most anterior capsules become fibrotic and adhere to the lens, as anyone who has tried to explant an intraocular lens after a few months can attest. The globes that I gross in our pathology lab that are pseudophakic invariably have significant amounts of retained co - tical material in the bag along with the lens. I believe that there must be another factor other than just the presence of cortex and a fibrotic capsule that leads to this syndrome. Some but not all cases have been associated with the presence of Propionibacterium acnes. 1 I wonder if the presence of an indolent bacterial species could be enough to cause this but not enough to routinely be cultured or cause endophthalmitis after YAG capsulotomy?" Dr. Ramanathan: "We know cap- sular block syndrome (CBS) to be a problem in which there is a trapping of fluid material behind a lens or lens implant because the anterior capsule is either fused or otherwise adherent to the lens or lens im- plant." "Miyake and colleagues char- acterize these postoperative cases based on presentation early or late. 2 Early occurrences often reveal a transparent substance behind the lens implant that may be retained viscoelastic material left behind. Late occurring cases are character- ized by a milky liquefied material behind the lens implant, often along with a posterior capsular opacity. This milky white material has been noted to contain large amounts of alpha-crystalline, suggesting that it was elaborated by residual lens epithelial cells, but no evidence of gamma globulin suggestive of immune reaction." 3 "The treatment for both early and late postoperative CBS is Nd:YAG capsulotomy. Capsulotomy solves multiple problems created by CBS: 1.) It allows egress of the retained (potentially milky) material into the vitreous cavity; 2.) It allows the lens implant to move posteriorly thereby improving the refraction; 3.) It removes any associated posterior capsular opacification. Dr. Chiu: "Capsular block syndrome is an uncommon cause of late vision loss after cataract surgery. As in other cases of posterior capsular opacification, vision impairment is due to an opacified post-lenticular medium. However, on close exam- ination, the intraocular lens may be anteriorly displaced and the capsular bag will appear distended with white liquid." "Laser capsulotomy is curative and causes dissipation of the media opacity and return of the intraoc- ular lens to its baseline position. Although there may be concern for late postoperative endophthalmi- tis with release of this sequestered material, no cases have thus far been identified. Therefore, in the few cases I have encountered, I recom- mended only topical steroid after laser treatment. As these cases exem- plify, capsular block syndrome is a rare complication following cataract surgery with excellent prognosis for visual recovery." Case outcome The decreased vision was attributed to late capsular block syndrome in both cases. The first patient was treated with an intravitreal injection of aflibe cept for his wet AMD on the day of his visit and returned 2 weeks later for YAG capsulotomy to release the accumulated capsular fluid. His vision improved to 20/70. Similarly, the second patient un- derwent YAG capsulotomy and his vision improved to 20/25 without The San Francisco continued from page 109 Figure 1. Patient 1 underwent slit lamp photography (A), which showed a milky fluid between the posterior hamber intraocular lens (left arrow) and posterior capsule (right arrow). This relationship was better demonstrated with UBM (B), revealing distension of the posterior capsule posteriorly. OCT of the macula (C) showed a pigment epithelial detachment with overlying subretinal fluid which was consistent with prior exams. Figure 2. Patient 2 had slit lamp photos taken at presentation (A) that showed a clear cornea, quiet anterior chamber, and a posterior chamber intraocular lens with moderate capsular phimosis and milky white fluid in the capsular ba . Bowing of the posterior capsule away from the intraocular lens was also seen on anterior segment OCT (B). After YAG capsulotomy, no intraocular inflammation as seen, the milky fluid clea ed, and the patient's vision returned to baseline. Source (all): University of California, San Francisco