|Year : 2022 | Volume
| Issue : 3 | Page : 259-261
N Sandhya, VG Namitha
Department of Cataract Services, Giridhar Eye Institute, Ponneth Temple Road, Kadavanthra, Cochin, Kerala, India
|Date of Submission||30-Apr-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||30-May-2022|
|Date of Web Publication||22-Dec-2022|
Dr. N Sandhya
Giridhar Eye Institute, Ponneth Temple Road, Kadavanthra, Cochin - 682 020, Kerala
Source of Support: None, Conflict of Interest: None
Capsular bag distension syndrome (CBDS) is a rare complication of cataract surgery characterized by collection of turbid fluid between the posterior surface of the intraocular lens (IOL) and the posterior capsule. Here, we report a case of CBDS presenting 7 years after uneventful cataract surgery. Patient presented with blurring of vision in the right eye and his best corrected visual acuity (BCVA) was 6/9 N6. Slit lamp examination showed collection of turbid fluid between IOL and posterior capsule, and the opaque fibrosed capsulorhexis margin was adherent to the optic of IOL which was well placed within the bag. Patient underwent neodymium yttrium aluminium garnet (ND-YAG) laser posterior capsulotomy to release the fluid into the vitreous cavity. 6 weeks after the procedure his BCVA improved to 6/6 N6.
Keywords: Capsular bag distension syndrome, lacteocrumenasia, neodymium yttrium aluminium garnet laser
|How to cite this article:|
Sandhya N, Namitha V G. Lacteocrumenasia. Kerala J Ophthalmol 2022;34:259-61
| Introduction|| |
Capsular bag distension syndrome (CBDS) is a rare complication of cataract surgery reported in 0.73–1% of patients. Basically this occurs due to adherence of capsulorhexis rim to the optic of intraocular lens (IOL) preventing free flow of fluid through the anterior capsule opening with accumulation of fluid behind the IOL and distension of posterior capsule.
Lacteocrumenasia (liquified after cataract) is a type of CBDS occuring in the late postoperative period. Commonly CBDS presents with unexplained myopia, reduced vision, shallow anterior chamber and occasionally with high intraocular pressure. However these are less common in lacteocrumenasia.
| Case Report|| |
A 76-year-old male presented to us with a history of gradual diminution of vision in the right eye of 3 weeks duration, without any other ocular symptoms. He had undergone cataract surgery in right eye 7 years ago and in the left eye 5 years ago in another hospital. Postoperative period was reportedly uneventful. He was diabetic for 15 years. He did not have any other systemic illness. On examination his best corrected visual acuity (BCVA) in the right eye was 6/9, N6 and left eye was 6/6, N6. There was no myopic shift in his refraction in the right eye compared to the previous visit 2 years back.
He was pseudophakic and anterior chamber was quiet in both eyes. IOL was looking normal in left eye but in the right eye the IOL seemed to have an yellowish tinge. Intraocular pressure was within normal limits in both the eyes.
Slit lamp examination after dilatation showed a well-centred single piece IOL in the bag in the left eye. In the right eye the single piece IOL was transparent and was placed well inside the bag. The anterior capsule rim was opacified and fibrosed, and was adherent to the anterior surface of the IOL optic. There was white proliferative tissue inferiorly behind the IOL and yellowish white turbid fluid had accumulated between the posterior surface of IOL and posterior capsule [Figure 1]a and [Figure 1]b. Dilated fundus examination of the right eye was hazy due to the turbid fluid, but appeared normal. Left eye fundus was normal.
|Figure 1: (a and b) Shows the opacified anterior capsule rim adherent to the IOL optic and yellowish turbid fluid between the IOL and the posterior capsule|
Click here to view
Presence of turbid fluid between the posterior capsule and the posterior surface of IOL and a fibrosed opacified rhexis margin adherent to the optic in this patient years after cataract surgery were features typical of late onset capsular bag distension syndrome (CBDS) or lacteocrumenasia. Patient underwent neodymium yttrium aluminium garnet (ND-YAG) laser capsulotomy and the turbid fluid was released into the vitreous [Figure 2]a, [Figure 2]b, [Figure 2]c. Postprocedure he was given topical steroid eye drops (prednisolone acetate 1.0% eye drops 6 times per day for 1 week and 4 times per day for 3 weeks) and topical antiglaucoma medication (timolol maleate 0.5% twice daily for 1 month). He was reviewed at 1, 2, and 6 weeks after the procedure. Through out the follow-ups his IOP was normal. His visual acuity remained same in the initial two follow-ups due to the dispersion of fluid in the anterior vitreous but at 6 weeks his vision improved to 6/6, N6.
|Figure 2: (a-c) Shows the transparent IOL, disappearance of yellowish turbid fluid, posterior capsule opening and the whitish proliferation inferiorly behind the IOL|
Click here to view
| Discussion|| |
CBDS is a rare complication of cataract surgery with a reported incidence of <1% among those who have undergone phacoemulsification with posterior chamber IOL implantation. A large retrospective study found that eyes with axial length >25mm, and patients who received 4 Haptic posterior chamber intra ocular lenses (PC-IOLs) had increased risk of CBDS. Retained ophthalmic visco elastic devices, inadequate subincisional cortical cleaning, IOLs with soft haptics and biconvex designs, postoperative inflammation, capsular fibrosis, and smaller capsulorhexis are all known to predispose to this condition.
Based on the onset, Miyake et al. has classified CBDS into three types, intraoperative, early postoperative, and late postoperative [Table 1]. Based on the pathology Kim and Shin classified it into fibrotic, inflammatory, and noncellular types [Table 2]. The intraoperative CBDS occurs following rapid hydrodissection with accumulation of fluid behind the nucleus. Early postoperative CBDS presents itself within 1–15 days of cataract surgery, due to viscoelastic substance being trapped between the IOL and the posterior capsule. This often leads to myopic shift in refraction, raised IOP, and shallow anterior chamber owing to anterior displacement of IOL optic. This is the noncellular type in Kim and Shin classification.
Late onset CBDS commonly occurs 3–8 years after cataract surgery, sometimes it has been reported as late as 13 years postsurgery. Here lens epithelial cells proliferate and undergo metaplastic changes and produce collagen and extracellular matrix which accumulate within the capsular bag. Features such as raised IOP, shallow AC, and myopic shift are less common in late onset type due to the fibrosis and adhesion of the capsulorhexis rim to the optic of the IOL which prevents its anterior displacement. This is the fibrotic type of CBDS. This has been substantiated in the studies done by Landa et al. and Pinarci et al., where they found a difference of only 0.50D change in refraction posttreatment.
Electrophoresis done on the contents of capsular bag found high amounts α and β crystalline and small amounts of albumin and calcium. The absence of γ globulins in the contents pointed out the fact that there is no role for immunological mechanism in the pathogenesis of CBDS. Isolated case reports revealed a possible role for propionibacterium acne. The diagnosis of CBDS is clinical, however anterior segment OCT, ultrasound biomicroscopy, and schiempflug imaging help in diagnosing and visualizing the pathology.
The widely used treatment approach for CBDS is posterior capsulotomy with ND-YAG laser. This creates a path to disperse the contents into vitreous cavity, resulting in improvement in visual acuity. It has minimal collateral effects, low complication rates, and is relatively less expensive. Other treatment options include anterior capsulotomy especially if the opening is small and fibrosed and slit lamp or pars plana needling. The fluid, cortical material, and opacified posterior capsule can also be removed surgically through the anterior or posterior approach.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lens and Cataract, Section 11. Basic and Clinical Science Course. Chapter 8. San Francisco: American Academy of Ophthalmology; 2014. p. 213.
Kim HK, Shin JP. Capsular block syndrome after cataract surgery: Clinical analysis and classification. J Cataract Refract Surg 2008;34:357-63.
Miyake K, Ota I, Ichihashi S, Miyake S, Tanaka Y, Terasaki H. New classification of capsular block syndrome. J Cataract Refract Surg 1998;24:1230-4.
Landa G, Hoffman P, Pollack A, Bukelman A, Leiba H, Marcovich A. Outcome of posterior capsulotomy in late capsular block syndrome with posterior capsular opacification. Clin Exp Ophthalmol 2006;34:866-9.
Pinarci EY, Bayar SA, Sizmaz S, Canan H, Yilmaz G. Late capsular block syndrome presenting with posterior capsule opacification. J Cataract Refract Surg 2012;38:672-6.
Eifrig DE. Capsulorhexis-related lacteocrumenasia. J Cataract Refract Surg 1997;23:450-4
Kollias AN, Vogel MA, de Kaspar HM, Lackerbauer CA, Grueterich M. Propionibacterium acnes in capsular bag distension syndrome. J Cataract Refract Surg 2010;36:167-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2]