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 Table of Contents  
Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 333-334

Severe anterior capsular contraction with complete occlusion of capsulotomy after femtosecond laser-assisted cataract surgery

1 Cataract and Glaucoma Services, Centre for Sight, New Delhi, India
2 Fellowship in Cornea -Refractive Surgery, Director Cornea-Refractive and Cataract Department, Centre for Sight, New Delhi, India
3 Cataract and Refractive Surgery, Centre for Sight, New Delhi, India

Date of Submission13-Oct-2022
Date of Acceptance08-Dec-2022
Date of Web Publication28-Apr-2023

Correspondence Address:
Swati Singh
Cataract and Glaucoma Services, Centre for Sight, B-5/24, Safdarjung Enclave, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2682_22

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Anterior capsular contraction syndrome can cause a remarkable loss of sight in the postoperative period, requiring early laser or surgical treatment for visual rehabilitation. Despite several studies comparing the outcomes of femtolaser cataract surgery and conventional phacoemulsification, the incidence of anterior capsular contraction after laser cataract surgery is not known. We present a case of severe anterior capsular contraction with total occlusion of capsular opening in a patient after 7 weeks of uneventful femtolaser-assisted cataract surgery, who was treated with neodymium: yttrium aluminum garnet laser anterior capsulotomy. There is no other published report of complete occlusion of femtolaser capsulotomy by capsular contraction and fibrosis.

Keywords: Anterior capsular contraction syndrome, capsular phimosis, femtolaser cataract surgery, high myopia, Nd: YAG laser capsulotomy, phacoemulsification

How to cite this article:
Singh S, Sachdev MS, Gupta H. Severe anterior capsular contraction with complete occlusion of capsulotomy after femtosecond laser-assisted cataract surgery. Indian J Ophthalmol Case Rep 2023;3:333-4

How to cite this URL:
Singh S, Sachdev MS, Gupta H. Severe anterior capsular contraction with complete occlusion of capsulotomy after femtosecond laser-assisted cataract surgery. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 5];3:333-4. Available from: https://www.ijoreports.in/text.asp?2023/3/2/333/374969

A predictable and round capsulotomy of defined size under real-time anterior segment optical coherence tomography (OCT) guidance is the strength of femtosecond laser-assisted cataract surgery (FLACS) as it helps in keeping the intraocular lens (IOL) well centered in the bag, ensuring better capsular overlap and good refractive outcomes with premium IOLs.[1] Studies have compared the visual outcomes and complications of FLACS with routine phacoemulsification,[2] but there is limited literature on anterior capsular contraction syndrome (ACCS) in FLACS patients. ACCS is an exaggerated reduction of anterior capsular opening and equatorial capsular bag diameter after cataract surgery, caused by myofibroblastic metaplasia of residual anterior lens epithelial cells (LECs) in response to injury or a contact with the IOL optic.[3] It is commonly seen in the first 3–6 months of cataract surgery, and zonular weakness, postoperative inflammation, dysfunctional blood–aqueous barrier, and small size of capsulotomy are key factors implicated in disease pathogenesis.[3],[4] Patients with pseudoexfoliation, uveitis, high myopia, myotonic dystrophy, diabetes mellitus, and history of vitreoretinal (VR) surgery have a high risk of developing the disease.[4] Visual symptoms are caused by the presence of a thick fibrotic membrane in the visual axis, IOL decentration, and a hyperopic shift induced by haptic flexion. Marked vision loss in the postoperative period may require multiple sittings of laser anterior capsulotomy or surgical excision of the fibrosed capsule, nullifying the benefits of femtolaser precision. We present a case of severe anterior capsular contraction with complete occlusion of capsular opening in a patient after FLACS, which has not been published before.

Patient consent

A written informed consent has been obtained from the patient for publication of the report and de-identified pictures.

  Case Report Top

A 41-year-old woman with high myopia and diabetes mellitus presented with the complaint of diminished vision in her left eye (LE). She gave a history of retinal detachment in the same eye 6 years ago, for which a VR surgery was done elsewhere with no records available. Corrected distance visual acuity (CDVA) in LE was 20/200, and dilated examination revealed advanced immature cataract (nuclear sclerosis grade 3–4 with cortical and posterior subcapsular cataract grade 3). She underwent an uneventful FLACS with a 5-mm capsulotomy using a total of 0.6 J energy and lens fragmentation in quadrants with softening with a total energy consumption of 5.5 J. A single-piece hydrophobic acrylic IOL (ICB00) was implanted in the bag. Anterior capsular polishing was not performed. The early postoperative period was uneventful, and CDVA at 1 month was 20/30. She was on topical steroids in tapering dose for 6 weeks. After 7 weeks of surgery, she returned to the clinic complaining of blurred vision. Examination revealed a CDVA of 20/120 and a complete occlusion of capsulotomy opening with a fibrous plaque and slight superior decentration of the IOL [Figure 1]a. Neodymium: yttrium aluminum garnet (Nd: YAG) laser anterior capsulotomy was done using a total energy of 48 mJ [Figure 1]b. She was prescribed prednisolone acetate 1% drops at four-hourly intervals and tapered slowly in 4 weeks. After 3 months, her CDVA was 20/30 with a stable IOL and no evidence of refibrosis.
Figure 1: (a) Left eye of patient at 7 weeks of femtolaser-assisted cataract surgery, showing capsular contracture with completely occluded capsulotomy opening. (b) Left eye after Nd: YAG laser anterior capsulotomy. Nd: YAG = neodymium-doped yttrium aluminum garnet laser

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  Discussion Top

The application of femtosecond laser in cataract surgery has been researched and the outcomes compared with conventional phacoemulsification.[2] However, there is no study comparing the incidence of ACCS in conventional phacoemulsification and FLACS. Femtolaser treatment has been reported to induce release of prostaglandins and proinflammatory cytokines. Upregulation of prostaglandin E2 (PGE2) has been linked to post-laser miosis. Increased levels of some anti-inflammatory (Interleukin-1 receptor antagonist ) and antiangiogenic cytokines (interleukin [IL]-18) along with profibrotic intraocular cytokines, fibroblast growth factor (FGF)-2, tumor necrosis factor (TNF)-α, and leukemia inhibitor factor (LIF), have been found in femtolaser-treated eyes.[5] A literature review showed reports which also differentiate the femtolaser capsulotomy from manual continuous curvilinear capsulorhexis (CCC). An upregulation of LEC death with a wide demarcation zone was reported in the laser group by Mayer et al.,[6] which they proposed could be preventing posterior capsular opacification (PCO) by inhibiting LEC proliferation, migration, or metaplasia. Few studies have shown that femtolaser capsulotomy is weaker compared to manual CCC. Abell et al.[7] found microscopic postage stamp perforations in femtolaser capsulotomy, which increased the risk of anterior capsular tear. However, the impact of these unique features of femtolaser treatment on the capsular bag needs to be studied further in eyes without preexisting risk factors to derive a conclusion. Our patient had high myopia, diabetes, and history of VR surgery, making her a high-risk case for capsular contraction postsurgery.

The role of anterior capsular polishing to remove the residual LECs remains controversial. Wang et al.[8] reported that anterior capsule polishing can reduce the extent of the anterior capsule contraction and increase IOL stability. However, others have found no reduction in residual cell growth with this maneuver.[9] The authors, as a routine, do not polish the anterior capsule in every case. In this case also, capsular polishing was not done. We found only one published report of a patient with retinitis pigmentosa who developed ACCS after FLACS in one eye.[10] However, the patient did not develop capsular contraction in the fellow eye which had a conventional phacoemulsification 4 years ago.

  Conclusion Top

Patients with preexisting risk factors may exhibit rapid ACCS despite a well-centered and adequate-sized capsulotomy in FLACS. Inflammation related to the femtolaser procedure may trigger an exaggerated fibroblastic response in these cases. We propose that such patients should be followed more frequently after surgery and a dilated examination be conducted at 6 weeks and 3 months for an early diagnosis of ACCS when they can be treated with YAG laser, thereby preventing the need of a surgical procedure.

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

Grewal DS, Schultz T, Basti S, Dick HB. Femtosecond laser-assisted cataract surgery-current status and future directions. Surv Ophthalmol 2016;61:103-31.  Back to cited text no. 1
Day AC, Burr JM, Bennett K, Bunce C, Doré CJ, Rubin GS, et al. Femtosecond laser-assisted cataract surgery versus phacoemulsification cataract surgery (FACT): A randomized noninferiority trial. Ophthalmol 2020;127:1012-9.  Back to cited text no. 2
Davison JA. Capsule contraction syndrome. J Cataract Refract Surg 1993;19:582-9.  Back to cited text no. 3
Kato S, Suzuki T, Hayashi Y, Numaga J, Hattori T, Yuguchi T, et al. Risk factors for contraction of the anterior capsule opening after cataract surgery. J Cataract Refract Surg 2002;28:109-12.  Back to cited text no. 4
Chen H, Lin H, Zheng D, Liu Y, Chen W, Liu Y. Expression of cytokines, chemokines and growth factors in patients undergoing cataract surgery with femtosecond laser pretreatment. PloS One 2015;10:e0137227. doi: 10.1371/journal.pone. 0137227.  Back to cited text no. 5
Mayer WJ, Klaproth OK, Ostovic M, Terfort A, Vavaleskou T, Hengerer FH, Kohnen T. Cell death and ultrastructural morphology of femtosecond laser–assisted anterior capsulotomy. Invest Ophthalmol Vis Sci 2014;55:893-8.  Back to cited text no. 6
Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology 2014;121:17-24.  Back to cited text no. 7
Wang D, Yu X, Li Z, Ding X, Lian H, Mao J, et al. The effect of anterior capsule polishing on capsular contraction and lens stability in cataract patients with high myopia. J Ophthalmol 2018;2018:8676451. doi: 10.1155/2018/8676451.  Back to cited text no. 8
Liu X, Cheng B, Zheng D, Liu Y, Liu Y. Role of anterior capsule polishing in residual lens epithelial cell proliferation J Cataract Refract Surg 2010;36:208-14.  Back to cited text no. 9
Johnson W, Magrath G, Perry L. Rapid anterior capsule contraction after femtosecond laser–assisted cataract surgery in a patient with retinitis pigmentosa. JCRS Online Case Rep 2018;7. doi: 10.1016/j.jcro. 2018.11.001.  Back to cited text no. 10


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