• Users Online: 2152
  • Print this page
  • Email this page

 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 77-79

A rare case of complete anterior capsular occlusion following phacoemulsification with acrylic intraocular lens and capsular tension ring implantation in pseudoexfoliation syndrome

Department of Ophthalmology, D.D. Eye Institute, Kota, Rajasthan, India

Date of Submission18-Jul-2022
Date of Acceptance03-Nov-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Anamika Das
B1 Berry's Avenue, Opp Radhakrishna Park Society, Near Akota Stadium, Akota, Vadodara - 390 020, Gujarat
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1755_22

Rights and Permissions

A 72-year-old man presented with bilateral brunescent cataract with pseudoexfoliation syndrome and subtle phacodonesis. He underwent right eye phacoemulsification with a 5-mm continuous curvilinear capsulorrhexis and implantation of an acrylic hydrophilic intraocular lens (IOL) with a polymethyl methacrylate (PMMA) capsular tension ring (CTR). Six months postoperatively, anterior capsule fibrosis and complete closure of the capsulorhexis opening were noted. A neodymium: YAG (Nd: YAG) laser anterior capsulotomy was performed for visual recovery. The centripetal forces of capsular fibrosis after cataract surgery may exceed the centrifugal resistance of the standard CTR in patients with pseudoexfoliation. Such patients must be frequently monitored postoperatively. A Nd: YAG laser anterior capsulotomy is a safe and effective option to manage even thick membranous anterior capsular occlusion. This is a unique case report since anterior capsular fibrosis and complete occlusion despite CTR in situ are extremely rare (reported only once to the best of our knowledge).

Keywords: Capsular contraction syndrome, capsular fibrosis, capsular occlusion, pseudoexfoliation syndrome

How to cite this article:
Mathur V, Das A. A rare case of complete anterior capsular occlusion following phacoemulsification with acrylic intraocular lens and capsular tension ring implantation in pseudoexfoliation syndrome. Indian J Ophthalmol Case Rep 2023;3:77-9

How to cite this URL:
Mathur V, Das A. A rare case of complete anterior capsular occlusion following phacoemulsification with acrylic intraocular lens and capsular tension ring implantation in pseudoexfoliation syndrome. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:77-9. Available from: https://www.ijoreports.in/text.asp?2023/3/1/77/368167

Phacoemulsification has emerged as the least traumatic procedure for cataract extraction for ophthalmologists. A continuous curvilinear capsulorrhexis of adequate size is essential for phaco procedure and for correct intraocular lens (IOL) centration and is the most common technique for anterior capsule opening. Shrinkage of the anterior capsular opening postoperatively is termed as capsular contraction syndrome (CCS) and is a known complication after continuous curvilinear capsulorrhexis. Pseudoexfoliation syndrome is identified as a predisposing factor.[1],[2] Capsular contraction can be of a variable degree and in predisposing conditions, can lead to a rare phenomenon of complete closure of anterior capsule opening. A polymethyl methacrylate (PMMA) capsular tension ring (CTR) can prevent postoperative capsular contraction to an extent by maintaining the circular contour of the capsular bag in eyes with zonular weakness.[3] To the best of our knowledge, complete occlusion of the anterior capsule opening despite the use of acrylic IOL and PMMA CTR has been rarely reported before.

We report a case of capsular contraction with complete occlusion in the presence of a PMMA CTR.

  Case Report Top

A 72-year-old male presented with diminished vision in both eyes. The unaided visual acuity was 2/60 in right eye (RE) and 6/36 in left eye (LE), with no improvement in RE and a best corrected visual acuity of 6/12 with − 3.0 D (spherical) in LE. The intraocular pressure was 17 and 14 mmHg, respectively. Slit-lamp examination showed a dense brunescent cataract with thick posterior plate in RE and grade 2 nuclear sclerosis in LE. In both eyes, signs of pseudoexfoliation and inadequate pupillary dilation (5 mm) were noted. Phacodonesis was evident in RE.

The patient underwent RE phacoemulsification with a 5.5-mm complete curvilinear capsulorrhexis. Intraoperatively, lax zonules were noted during irrigation and aspiration, owing to pseudoexfoliation syndrome; therefore, a PMMA CTR (auroring) was implanted [Figure 1] after complete cortical removal followed by an acrylic hydrophilic IOL. Lens epithelial cell (LEC) polishing was done from the undersurface of anterior capsule nasally. There were no intraoperative complications.
Figure 1: Insertion of capsular tension ring (auroring).

Click here to view

Postoperatively, prednisolone eye drops (1%) was started four hourly and tapered over 1 month. Visual acuity for distance on the seventh postoperative day was noted to be 6/6 in the operated eye.

Six months later, the patient presented with markedly reduced visual acuity of 5/60 in the operated eye. On slit-lamp examination, a complete closure of the anterior capsular opening was noted, with a 3-mm superior paracentral area of dense fibrosis and folds of anterior capsule radiating outward. Thick sheets and filaments of exfoliative material were evident on the anterior capsule [Figure 2]. IOL was central and enclosed in the capsular bag. As the thick fibrotic area did not cover the visual axis entirely, we decided to proceed conservatively with a neodymium: YAG (Nd:YAG) laser anterior capsulotomy. Five laser incisions of maximum energy 4.5 mJ were placed in a cruciate manner in the central 4-mm zone to clear the visual axis [Figure 3]. The visual acuity was restored to 6/9.
Figure 2: Complete closure of the anterior capsular opening with thick sheets and filaments of exfoliative material on the anterior capsule

Click here to view
Figure 3: Nd: YAG laser anterior capsulotomy done to clear the visual axis. Nd: YAG (Neodymium: Yttrium Aluminium Garnet)

Click here to view

  Discussion Top

CCS has been defined as an exaggerated reduction in the anterior capsular opening and equatorial capsular bag diameter after extracapsular cataract surgery.[2]

The identified predisposing factors include pseudoexfoliation syndrome,[1],[2] uveitis,[2] myotonic dystrophy,[1] retinitis pigmentosa,[4] and diabetic retinopathy.[5] Surgical factors provoking CCS include zonular weakness[1] small capsulorrhexis,[6] and IOL design and biomaterial.[7]

Pathological changes causing capsular contracture are presumed to be subcapsular proliferation and fibrous metaplasia of the residual LECs.[8] The resultant progressive fibrosis exerts a centripetal force causing capsular bag shrinking, which is countered by the centrifugal forces exerted by strong zonular support. In cases of possible zonular laxity, the combined effort of weakened zonules may be unable to oppose the relatively increased centripetal force of the fibrosed capsular bag. This causes a progressive shortening of the anterior capsular opening, and rarely in its most severe form, leads to complete closure. The amount of residual LECs depends on the size of the capsulorrhexis opening, which should be between 5.5 and 6.0 mm and can be reduced by polishing the undersurface of the anterior capsule. Some studies suggest that the IOL biomaterial can influence capsular fibrosis. Acrylate copolymer IOL and PMMA IOL are probably better at preventing capsular contraction than silicone optics.[9]

A CTR or capsule-bending ring (CBR) may prevent anterior capsular fibrosis by providing stability and necessary centrifugal force to the capsular bag.[10] There are only a few reports of capsular contraction occurring despite insertion of CTR (Faschinger and Eckhardt, 1999[11]; Waheed et al., 2001[12]; Sudhir and Rao, 2001[13]). To the best of our knowledge, report of complete occlusion and fibrosis of anterior capsular opening despite the use of CTR is extremely rare.[7]

We are reporting a case of complete occlusion and fibrosis of the capsulorrhexis opening with the use of a hydrophilic acrylic IOL with a PMMA CTR in a patient with pseudoexfoliation. In this case, complete occlusion of the anterior capsular opening is presumed to be the result of imbalance between the centrifugal force applied by the CTR to the capsular bag, which could not combat the contractile forces of the fibrosing anterior capsular edge. The fibrosed anterior capsule can be cut open either surgically or with the use of ND:YAG laser. Davison[2] first described the use of Nd: YAG laser for anterior capsulotomy to treat capsular contraction, prevent IOL decentration, and restore visual acuity.

  Conclusion Top

In conclusion, our report indicates that the use of CTR for capsular bag support in patients with pseudoexfoliation does not guarantee prevention of anterior capsule contraction, and even complete occlusion has been noted. Therefore, careful observation of the postoperative progress in such patients is essential to identify early capsular contraction. If and when identified, a Nd:YAG laser anterior capsulotomy can be performed successfully in cases of capsular fibrosis with complete occlusion of the opening, providing a functionally satisfying result and preventing the need for repeat surgery.

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.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hayashi H, Hayashi K, Nakao F, Hayashi F, Anterior capsular contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. Br J Ophthalmol 1998;82:1429-32.  Back to cited text no. 1
Davison JA. Capsule contraction syndrome. J Cataract Refract Surg 1993;19:582-9.  Back to cited text no. 2
Nagamoto T, Bissen-Miyajima H. A ring to support the capsular bag after continuous curvilinear capsulorhexis. J Cataract Refract Surg 1994;20:417-20.  Back to cited text no. 3
Hayashi K, Hayashi H, Matsuo K, Nakao F, Hayashi F. Anterior capsular contraction and intraocular lens dislocation after implant surgery in eyes with retinitis pigmentosa. Ophthalmology 1998;105:1239-43.  Back to cited text no. 4
Hayashi K, Hayashi H, Nakao F, Hayashi F. Reduction in the area of the anterior capsule opening after poly-methylmethacrylate, silicone, and soft acrylic intraocular lens implantation. Am J Ophthalmol 1997;123:441-7.  Back to cited text no. 5
Sugimoto Y, Takayanagi K, Tsuzuki S, Takahashi Y, Akagi Y Postoperative changes over time in size of anterior capsulorrhexis in phacoemulsification/aspiration. Jpn J Ophthalmol 1998;42:495-8.  Back to cited text no. 6
Moreno-Montañés J, Sanchez-Tocino H, Rodriguez-Conde R. Complete anterior capsule contraction after phacoemulsification with acrylic intraocular lens and endocapsular ring implantation. J Cataract Refract Surg 2002;28:717-9.  Back to cited text no. 7
Spang KM, Rohrbach JM, Weidle EG. Complete occlusion of the anterior capsular opening after intact capsulorrhexis: Clinicopathologic correlation. Am J Ophthalmol 1999;127:343-5.  Back to cited text no. 8
Cochener B, Jacq P-L, Colin J. Capsule contractionafter continuous curvilinear capsulorhexis: Poly(methylmethacrylate) versus silicone intraocular lenses. J Cataract Refract Surg 1999;25:1362-9.  Back to cited text no. 9
Nishi O, Nishi K, Menapace R. Capsule-bending ring for the prevention of capsular opacification. Ophthalmic Surg Lasers 1998;29:749-53.  Back to cited text no. 10
Faschinger CW, Eckhardt M. Complete capsulorrhexis opening occlusion despite capsular tension ring implantation. J Cataract Refract Surg 1999;25:1013–5.  Back to cited text no. 11
Sudhir RR, Rao SK. Capsulorrhexis phimosis in retinitis pigmentosa despite capsular tension ring implantation. J Cataract Refract Surg 2001;27:1691–94.  Back to cited text no. 12
Waheed K, Eleftheriadis H, Liu C. Anterior capsular phimosis in eyes with a capsular tension ring. J. Cataract Refract Surg 2001;27:1688-90.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded37    
    Comments [Add]    

Recommend this journal