|Year : 2019 | Volume
| Issue : 1 | Page : 71-73
Early postoperative capsular block syndrome
Venkatesh Sugantharaj, Machireddy R Shekharreddy, Shruti P Hegde
Department of Ophthalmology, Shri Sathya Sai Medical College and Research Institute, Ammapettai, Tamil Nadu, India
|Date of Web Publication||10-Jun-2019|
Prof. Venkatesh Sugantharaj
Department of Ophthalmology, Shri Sathya Sai Medical College and Research Institute, Tiruporur-Guduvanchery Main Road, Ammapettai, Chengalpet Taluk, Nellikuppam, Kancheepuram - 603 108, Tamil Nadu
Source of Support: None, Conflict of Interest: None
We report a case of early postoperative capsular block syndrome (CBS) in a patient who presented with moderate blurring of vision and mild periorbital pain in his first postoperative visit (the 5th postoperative day). The unaided visual acuity (VA) was 6/24 and the best-corrected VA was 6/6 with −1.0D Sph/−0.50cylx 140. The anterior chamber was shallow (anterior chamber depth: 2.6 mm), and the intraocular pressure was 24 mmHg. Slit-lamp examination revealed an “in-the-bag” intraocular lens (IOL) with a 360° anterior capsular overlap and a distended capsular bag with an optically clear space between the IOL optic and the posterior capsule. A diagnosis of early postoperative CBS was made, and the retro-optic fluid was drained by making a Nd:YAG opening on the anterior capsule inferior and peripheral to the optic. Posttreatment unaided VA improved to 6/6–2 improving further to 6/5 with −0.50 × 140. This case is presented to highlight that early postoperative CBS can easily be missed if not looked for and can account for a postoperative refractive surprise that is easily correctable.
Keywords: Early postoperative capsular block syndrome, Nd:YAG laser anterior capsulotomy, postoperative refractive surprise
|How to cite this article:|
Sugantharaj V, Shekharreddy MR, Hegde SP. Early postoperative capsular block syndrome. TNOA J Ophthalmic Sci Res 2019;57:71-3
| Introduction|| |
The implantation of an “in-the-bag” intraocular lens (IOL) through a well-centered 5.00–5.5 mm rhexis is easily achievable today which allows for a 360° overlap of the optic of the IOL by the anterior capsule. This maneuver facilitates a good “shrink-wrap effect” of the IOL and reduces the incidence of intermediate or late posterior capsular opacification as well as provides a stable effective lens position. However, in such a situation, it is imperative to wash out all the viscoelastic from behind the IOL within the capsular bag. Failure to do so will cause the retained viscoelastic to swell in the postoperative period by drawing in the aqueous from the surroundings, through an osmotic gradient, leading to a progressive myopia and shallowing of the anterior chamber with an associated increase in the intraocular pressure (IOP) leading to an early postoperative capsular block syndrome (CBS).
| Case Report|| |
A 62-year-old male patient underwent uneventful phacoemulsification in the right eye, with the implantation of an “in-the-bag” hydrophobic acrylic IOL, through a 5.0-mm continuous curvilinear capsulorrhexis (CCC) which was well centered [Figure 1].
|Figure 1: “In-the-bag” intraocular lens with 360° anterior capsular overlap over the optic at the end of surgery|
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On the first postoperative visit, which was on the 5th postoperative day, the unaided visual acuity (VA) was 6/24 improving to 6/6 with a −1.0DS/0.50dcx 140. The anterior chamber was shallower in the right eye compared to its fellow and was measured at 2.6 mm. The IOP was slightly elevated at 24.0 mmHg. Methylcellulose 2% was used as the viscoelastic agent during the phacoemulsification surgery and for the implantation of the IOL. The IOL power was calculated using the SRK/T formula, the axial length measured by immersion ultrasound, and the keratometric values obtained by auto-K values.
The reason for this postoperative refractive surprise was not initially understood, until we noticed that there was a distension of the capsular bag and a clear space behind the optic of the IOL and the posterior capsule, under slit-lamp examination [Figure 2] and [Figure 3]. The optic of the IOL was pushed anteriorly against the anterior capsule with a 360° overlap of the anterior capsule over the optic of the IOL.
|Figure 2: The blue arrow shows the accumulation of optically clear fluid in the retro-lenticular space, distending the capsular bag and pushing the IOL forward|
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|Figure 3: Another case of CBS. The blue arrow shows cellular debris in the retro- lenticular space|
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A diagnosis of early postoperative CBS was made. The retro-optic fluid was drained in the outpatient department, by making a Nd:YAG laser puncture (0.9 mj) on the anterior capsule peripheral to the optic in the inferior portion of the anterior capsule [Figure 4]. This was achieved without compromising the edge of the CCC. This leads to an immediate draining of the fluid from the retro-optic space within the capsular bag to the anterior chamber. The capsular bag distension was relieved, and the optic of the IOL came to rest in close approximation to the posterior capsule [Figure 5]. The patient was observed for a period of 2 h before being sent home.
|Figure 4: The white arrow points to the stellate opening in the anterior capsule after performing a Nd-Yag capsulotomy|
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|Figure 5: Resolution of the CBS. The blue arrow shows the collapsed retro- lenticular space and the backward movement of the IOL|
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Within 1-h posttreatment, the anterior chamber deepened to 3.1 mm, and the unaided VA improved to 6/6–1, further improving to 6/5 with −0.50DCx 140. The IOP at the end of 2 h was 26 mmHg, and the patient was sent home on tablet acetazolamide 250 mg to be taken stat and one at night and asked to report the next day.
On the following day, the unaided VA was 6/6, the IOP was 16 mmHg, the AC depth was 3.1 mm. Slit-lamp examination showed a small star-shaped opening on the anterior capsule peripheral to the optic inferiorly, not compromising the rhexis margin, good overlap of the optic with the anterior capsule, and a flat capsular bag with the optic resting against the posterior capsule.
| Discussion|| |
The incidence of CBS is about 0.73%. Dr. Kim reported a classification of three types of early postoperative CBS based on the clarity of the accumulated fluid in the capsular bag as:
They also reported that a longer axial length of >25.0 mm increased the risk for CBS as well as the IOL material and design. In their study, the “Akreos Adapt” IOL of B and L had a higher incidence of early postoperative CBS.
CBS could occur in three scenarios:
- Intraoperative CBS during cortical cleaving hydrodissection or during femtosecond laser-assisted cataract surgery
- Early-onset postoperative CBS during the early postoperative period usually within a week of surgery
- Late-onset postoperative CBS which occurs months to years after phacoemulsification surgery due to the progressive accumulation of liquified lens epithelial cells, also known as “Lacteocrumenasia.”
Early-onset postoperative CBS can present with a gradual progressive myopia, progressive shallowing of the anterior chamber depth, and gradual elevation of the IOP. It can present as a postoperative refractive surprise and one should be aware of this as the management is quite simple.
Dr. Durak reported that spontaneous resolution was rare, and this occurs usually within a month. The treatment of choice is to dilate the pupils and perform a Nd:YAG anterior capsulotomy peripheral to the optic of the IOL in the inferior portion. A single shot of low energy (0.9 − 1.5 mj) would suffice to successfully puncture the anterior capsule. If pupillary dilation is inadequate and the periphery of the anterior capsule is not visualized, Dr. Durak recommends a Nd:YAG laser posterior capsulotomy. However, performing a laser posterior capsulotomy so early in the postoperative period could lead to an increased risk of cystoid macular edema and rhegmatogenous retinal detachments.
In such cases, it is advisable to perform a small mid-peripheral iridotomy with the Nd:YAG laser and perform the anterior capsulotomy through this opening. Care is taken to avoid disruption of the edge of the capsulorrhexis margin while making this laser puncture, to prevent late decentration of the IOL. The fluid that has accumulated behind the optic of the IOL within the capsular bag then oozes out through the opening in the anterior capsule and within an hour the IOL settles back against the posterior capsule and the induced myopic refraction regresses. Dr. Baikoff suggests, based on anterior segment optical coherence tomography observations, that a posterior movement of 448 microns corrects for −0.75 DS of myopia. A watch is kept on IOP elevation, and the patient is put on oral tablet acetazolamide for a day.
| Conclusion|| |
Early postoperative CBS occurs in <1% of uneventful phacoemulsification surgeries. The importance for its detection lies in the fact that it can present as a postoperative refractive surprise or persistent postoperative elevation of IOP. This condition is easily detected under the slit lamp, and the management is effectively achieved by a simple anterior Nd:YAG laser capsulotomy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]