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Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 48-49

Overcoming challenges of capsulotomy in anterior lenticonus: Femtosecond laser capsulotomy and Zepto precision pulse capsulotomy approach

Cataract and Refractive Surgery Services, L V Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad, Telangana, India

Date of Submission15-Apr-2020
Date of Acceptance15-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Pratik Gogri
L V Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1003_20

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Keywords: Alport syndrome, anterior lenticonus, femtosecond laser capsulotomy, zepto precision pulse capsulotomy

How to cite this article:
Gogri P, Madia T, Bhalerao S. Overcoming challenges of capsulotomy in anterior lenticonus: Femtosecond laser capsulotomy and Zepto precision pulse capsulotomy approach. Indian J Ophthalmol Case Rep 2021;1:48-9

How to cite this URL:
Gogri P, Madia T, Bhalerao S. Overcoming challenges of capsulotomy in anterior lenticonus: Femtosecond laser capsulotomy and Zepto precision pulse capsulotomy approach. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Mar 2];1:48-9. Available from: https://www.ijoreports.in/text.asp?2021/1/1/48/305468

A 19-year-old gentleman presented with symptoms of gradual, progressive, painless diminution of vision in both eyes for last 3 years. On examination, his corrected distance visual acuity (CDVA) was 20/200 in both eyes. Retinoscopy revealed a central oil droplet reflex in both eyes [Figure 1]a. Anterior segment examination was essentially within normal limits except for central nipple like protrusion in the anterior lens capsule with clear underlying lens [Figure 1]b. Anterior segment optical coherence tomography (OCT, Carl Zeiss Meditec, California, USA) imaging of both eyes was also suggestive of the anterior lenticonus [Figure 1]c. Retinal examination revealed no significant findings. Audiometry was suggestive of bilateral sensorineural deafness. There was medical history of chronic renal disease. Based on the corroborative findings, diagnosis of bilateral anterior lenticonus in Alport syndrome was made. The visual acuity deterioration appeared to be due to the development of bilateral anterior lenticonus. Clear lens extraction with IOL implantation was performed sequentially in both eyes.
Figure 1: Anterior Lenticonus (a) Retroillumination image showing oil droplet reflex, (b) Slit view of the lens showing the central bulge in the anterior capsule, (c) Optical coherence tomography image showing the anterior lens capsule bulge with underlying clear lens

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The femtosecond laser (Catalys Precision Laser System, Abbott Laboratories Inc., IL) capsulotomy was planned to create a capsulorhexis of size 5 mm via scanned capsule center. The software was not able to automatically detect the anterior lens capsule due to the central protrusion of the lenticonus. Hence, the anterior lens capsule plane was manually selected before the laser delivery [Figure 2]. In view of the high astigmatism in the right eye, femtosecond laser-assisted anterior penetrating arcuate incision was also done. Clear lens extraction with foldable IOL was done in the left eye 4 weeks later. Zepto Precision Pulse Capsulotomy (PPC) (Mynosys, Fremont, California) was used to make capsulotomy in the left eye which resulted in a complete free floating capsulorhexis [Figure 3]. Rest of the surgery was uneventful with a single-piece hydrophobic IOL implantation in the bag. The postoperative recovery was uneventful. The uncorrected distance visual acuity (UDVA) at 1 week in right eye and left eye was 20/25 and 20/20, respectively. Slit-lamp biomicroscopy examination revealed in situ posterior chamber IOL in both eyes.
Figure 2: Manual marking of the anterior lens capsule plane on the planning module of the femtosecond laser platform

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Figure 3: Zepto Precision Pulse Capsulotomy probe in the LE

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  Discussion Top

Anterior lenticonus develops in Alport syndrome due to protrusion of the lens through the weak and thin part of the anterior lens capsule. Even without any co-existing cataractous changes, it causes progressive visual deterioration and significant changes on the aberration profile, hence surgical intervention is required for visual rehabilitation of these patients.[1] Clear lens extraction with in-the-bag IOL implantation has been shown to be good option for improving the visual acuity.[1]

The abnormal elasticity of the anterior capsule during phacoemulsification in anterior lenticonus was described by Aslanzadeh et al.[2] John et al. reported the anterior capsule to be tough and difficult to puncture with the cystotome.[3] It has been well documented in literature that anterior lenticonus due to Alport syndrome is associated with increased capsular fragility.[4] Hence manual CCC in these patients is challenging. Various techniques of automated capsulotomy thus have a role to play in anterior lenticonus. Femtosecond laser capsulotomy helps us to overcome these difficulties by providing an automated circular well centered rhexis. But it must be noted that the software was notable to detect the anterior capsule plane which had to be selected manually on the OCT image. Not to forget the added advantage of astigmatism correction with the help of femtosecond arcuate incisions. Everything said, the economic constraints of the additional usage of femtosecond laser can be prohibitive to its usage in all patients. Due to the cost factor, the patient did not want to opt for femtosecond laser-assisted cataract surgery (FLACS) for the left eye. Hence, we used Zepto PPC for the left eye. Thompson et al. have shown in cadaveric eyes that the strength of PPC capsulotomy edge is stronger than femtosecond capsulotomy or manual CCC.[5] Apart from the cost benefit, Zepto PPC also provides logistical advantage of being able to do intraoperatively in the same room. The disadvantage of Zepto PPC is that it cannot help us to make corneal incisions or lens fragmentation or astigmatism correction.

To the best of our knowledge, this is the first case report in literature highlighting the use of Zepto PPC in a case of anterior lenticonus associated with Alport syndrome. The Zepto PPC provided a circular, precise, appropriately sized free floating anterior capsulotomy. The femtosecond laser capsulotomy, although with a few modifications, was also able to provide a well centered anterior capsulotomy. Both these procedures are helpful for cataract surgery in challenging cases like anterior lenticonus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

John ME, Noblitt RL, Coots SD, Boleyn KL, Ballew C. Clear lens extraction and intraocular lens implantation in a patient with bilateral anterior lenticonus secondary to Alport's syndrome. J Cataract Refract Surg 1994;20:652-5.  Back to cited text no. 1
Savige J, Sheth S, Leys A, Nicholson A, Mack HG, Colville D. Ocular features in Alport syndrome: Pathogenesis and clinical significance. Clin J Am Soc Nephrol 2015;10:703-9.  Back to cited text no. 2
Aslanzadeh GA, Gharabaghi D, Naderi N. Clear lens phacoemulsification in the anterior lenticonus due to Alport Syndrome: Two case reports. J Med Case Rep 2008;2:178.  Back to cited text no. 3
Kato T, Watanabe Y, Nakayasu K, Kanai A, Yajima Y. The ultrastructure of the lens capsule abnormalities in Alport's syndrome. Jpn J Ophthalmol 1998;42:401-5.  Back to cited text no. 4
Thompson VM, Berdahl JP, Solano JM, Chang DF. Comparison of manual, femtosecond laser, and precision pulse capsulotomy edge tear strength in paired human cadaver eyes. Ophthalmology 2016;123:265-74.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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