Capsular Block Syndrome after an Intravitreal Injection of Ranibizumab: A Case Report.

Introduction: We present a case of capsular block syndrome that occurred after intravitreal injection of ranibizumab in a patient with age-related macular degeneration, which has not been reported in the literature. Case Presentation: A 78-year-old male presented with decreased visual acuity in the right eye. Slit-lamp examination findings were unremarkable; however, AMD was diagnosed based on fundus examination, fluorescein angiography, and optical coherence tomography (OCT). Subsequently, the patient was administered an intravitreal injection of ranibizumab. A slit-lamp examination revealed residual cortical material, numerous inflammatory cells, and posterior capsular distension 1 week after the injection. OCT showed an adhesion of the intraocular lens to the continuous curvilinear capsulorhexis site. The patient's vision improved following Nd:YAG laser posterior capsulotomy. Conclusion: Meticulous cortical removal is crucial during phacoemulsification to prevent capsular block syndrome. In patients with a history of cataract surgery, verifying the absence of residual cortical material before administering an intravitreal injection of ranibizumab is important.

A potential role for inflammatory cytokines in a rare late-onset capsular block syndrome: a case report.

BACKGROUND: Late-onset capsule block syndrome (CBS) is a rare complication of cataract phacoemulsification and the implantation of a posterior chamber intraocular lens (PCIOL), which manifests six months to years after surgery. The hallmark of CBS is the formation of an opaque liquid substance between the implanted intraocular lens (IOL) and the posterior capsule. However, its pathogenesis remains unclear. CASE PRESENTATION: A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor. CONCLUSIONS: Anterior segment vitrectomy surgery proved to be a successful treatment for late-onset CBS, presenting a challenging case. In the human lens, inflammatory cytokines originating from the opaque substances may contribute to abnormal metabolism in the sealed area, a consequence of late-onset CBS.

Anterior Segment Optical Coherence Tomography Findings in Capsular Block Syndrome with Improvement in Myopia following Neodymium-Yttrium Aluminum Garnet Laser Treatment.

Introduction: Lacteocrumenasia is a relatively rare postoperative complication of cataract surgery. It is classified as a late-onset type of capsular block syndrome (CBS) and is often accompanied by myopia; however, its mechanism is not clearly understood. Case Presentation: We report a case of a 62-year-old male patient having CBS with myopia. The patient was treated with neodymium-yttrium aluminum garnet (Nd-YAG) laser posterior capsulotomy. We measured and compared the depth of the intraocular lens using anterior segment optical coherence tomography (AS-OCT) before and after laser treatment. Treatment resulted in refraction improvement of more than 1.0 diopters. The intraocular lens depth before and after Nd-YAG laser irradiation had very mild changes of less than 0.05 mm, which did not explain the refractive changes. Conclusion: Myopia in the early-onset type of CBS is caused by anterior deviation of the intraocular lens; however, the evaluation of this case using AS-OCT suggested that an abnormal intraocular lens position may not be involved in late-onset CBS.

Late-Onset Capsular Block Syndrome with Pupillary Block Angle Closure after Cataract Surgery with Posterior Chamber Intraocular Lens Implantation: A Case Report.

Introduction: Pseudophakic pupillary block angle-closure glaucoma is an uncommon complication following uneventful cataract surgery with posterior chamber intraocular lens (IOL) implantation. Interestingly, capsular block syndrome (CBS) has been reported as another plausible cause of pseudophakic pupillary block angle-closure glaucoma, especially in the early postoperative period. Unlike early postoperative CBS, late postoperative CBS is not associated with a shallow anterior chamber, myopic shift, or elevated intraocular pressure. We report a case of late postoperative CBS presenting with an acute-onset pupillary block angle-closure attack occurring 13 years after uneventful cataract surgery with posterior chamber IOL implantation, which has not been reported in the literature. Case Presentation: An 87-year-old male diagnosed with pseudoexfoliation syndrome developed pseudophakic pupillary block following uneventful cataract surgery with posterior chamber IOL implantation. Late-onset CBS has been identified as the underlying cause of the pupillary block. The combination of zonular laxity observed in pseudoexfoliation syndrome and the presence of a Soemmering ring are potential predisposing factors for this condition. After performing laser peripheral iridotomy (LPI) followed by Nd: YAG capsulotomy, the pupillary block was resolved and vision was improved. Conclusion: CBS should be considered as a potential cause of pseudophakic pupillary block, even in the late postoperative period. The management of late-onset CBS accompanied by pupillary block angle-closure glaucoma typically includes LPI to eliminate the pupillary block, followed by Nd: YAG capsulotomy.

Femtosecond laser-assisted posterior capsulotomy for the treatment of capsular block syndrome.

We present a novel use of femtosecond laser to treat capsular block syndrome (CBS) in a patient with dense opaque capsular block, who presented 16 years postcataract surgery. The extensive posterior capsular distension and densely opaque, milky fluid trapped behind the intraocular lens (IOL) prevented the use of neodymium-doped yttrium aluminum garnet (Nd: YAG) laser posterior capsulotomy as primary treatment. Intra-operative optical coherence tomography enabled visualization of the posterior capsule and iris hooks were used to increase the pupillary diameter to enable femtosecond laser-assisted posterior capsulotomy to be performed in a minimally invasive technique. CBS was relieved successfully and Nd: YAG laser performed subsequently to remove residual posterior capsule opacification safely and with good visual outcomes. This method avoids risks associated with posterior vitrectomies and compromised IOL stability from inadvertent capsular bag damage, and adds to the expanding uses of femtosecond laser technology.

Findings in pseudophakic eye that developed liquefied aftercataract-like substance one day after vitrectomy.

Purpose: To report our findings in a case that had an accumulation of a translucent fluid between the intraocular lens (IOL) and posterior lens capsule one day after vitrectomy for a vitreous hemorrhage. Observations: A 67-year-old woman was diagnosed with diabetes 20 years before the vitrectomy and was treated with panretinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR) 14 years earlier. She underwent cataract surgery with an implantation of an IOL 4 years earlier. She was referred to our hospital because of a vitreous hemorrhage, and we performed uneventful vitrectomy. However, the day after the operation, a translucent liquid substance that resembled liquefied aftercataract was observed in the lens capsule bag. With time, the liquid substance became cloudy. The opacification progressed for two years after the vitrectomy, and her visual acuity decreased. We then performed neodymium: YAG (Nd: YAG) laser posterior capsulotomy, and the cloudy liquid dispersed into the vitreous and the visual acuity improved. Conclusions and importance: Our findings indicate that liquified aftercataract-like substance can form after vitrectomy in a pseudophakic eye. We suggest that the aqueous humor might flow into the space behind the IOL during or just after the vitrectomy and was trapped behind the IOL optics. Then, the proliferating lens epithelial cells might be dissolved forming the white liquid substance immediately after the surgery.

Retro-intraocular Lens Irrigation-aspiration to Prevent Capsular Block Syndrome at the Hands of Novice Surgeons.

Retro-intraocular lens (IOL) irrigation-aspiration is of paramount importance in order to remove the viscoelastic substance from the retro-IOL space and to prevent any early post-operative capsular block syndrome. However, manoeuvring the IOL to reach the retro-IOL space may be difficult at the hands of novice surgeons despite the use of coaxial or bimanual irrigation-aspiration probes. We describe a simpler and safer technique in order to facilitate the removal of this retro-IOL viscoelastic substance using a 26-Gauge bent-cannula mounted on a 2-ml syringe. The fluid is injected forcefully along with sideways movement of cannula in a single-plane to displace the viscoelastic substance.

[Late capsular block syndrome]. / Sindrom kapsul'nogo bloka posle fakoémul'sifikatsii katarakty.

The article describes 5 cases of capsular block syndrome (CBS). This late cataract surgery complication has not been sufficiently covered in Russian scientific literature. Diagnostics were based mainly on slit-lamp biomicroscopy and anterior segment optical coherence tomography. In all cases, examination revealed a retro-optical space filled with content of different transparency and homogeneity (transparent liquid, opaque liquid, regenerative lens material). The condition caused visual acuity to decrease in each case. Patient management included follow-ups (2 cases), yttrium-aluminum-garnet laser (YAG-laser) puncture of posterior lens capsule (1 case) or YAG-laser posterior capsulotomy (2 cases). YAG-laser treatment resulted in visual functions improvement.

Late postoperative capsular bag distension syndrome.

PURPOSE: Capsular bag distension syndrome is to be seen as a relatively rare complication after cataract surgery. MATERIALS AND METHODS: We describe our experience of late-onset capsular bag distension syndrome with one case onset 4 years after cataract surgery. Nowadays diagnostic imaging methods were used. The literature was reviewed to summarize the diagnosis, classification, use of diagnostic aids, and the current treatments for the capsular bag distension syndrome. Visual acuity was assessed using the ETDRS (Early Treatment Diabetic Retinopathy Study) chart. DISCUSSION: A 72-year-old woman presented with decreased visual acuity and blurred vision 4 years after phacoemulsification with continuous curvilinear capsulorhexis (CCC) and in-the-bag IOL implantation. After the slit lamp examination, patient was investigated with Scheimpflug camera (OCULUS Pentacam HR) and anterior segment spectral domain OCT (Optovue, Avanti RTVue XR), which confirmed the diagnosis of capsular block syndrome. Aspiration of the turbid fluid behind the lens and capsular bag lavage resulted in resolution of her symptoms. Aspirated fluid was examined. We have observed no CBS recurrence. CONCLUSION: CBS is the relatively rare complication of the standard cataract surgery, which can occur during surgery and in a postoperative period. CBS can be solved successfully after regular diagnosis using modern imaging methods.

Postoperative Capsular Bag Distension Syndrome - Risk Factors and Treatment.

Introduction:Postoperative capsular bag distension syndrome (CBDS) is a rare complication of cataract surgery which might occur in the early postoperative period, as well as several years after uncomplicated surgery. The aim of this study was to review the current evidence on postoperative capsular bag distension syndrome. Material and Methods: PubMed and Web of Science were used for literature search. Results: The typical presentation involves deterioration in visual acuity, unexpected myopic shift or less frequently hyperopia. In eyes with clear capsular fluid and no posterior capsule opacification, usually in the late postoperative period, CBDS can be asymptomatic. Risk factors for developing CBDS include retained ophthalmic viscoelastic device, inadequate subincisional cortex cleaning, apposition between the intraocular lens (IOL) and the capsular bag, postoperative inflammation and IOL sequestration with Propionibacterium acnes. Visualization of the CBDS can be aided with Scheimpflug imaging, ultrasound biomicroscopy, and particularly anterior-segment optical coherence tomography. Conclusion:Nd:YAG posterior capsulotomy, and in some cases anterior capsulotomy, is accepted as a standard and effective CBDS treatment. Surgical approach could be beneficial in cases suspected of Propionibacterium acnes presence or when it is impossible to perform Nd:YAG posterior capsulotomy.

A novel minimal fluid technique for effective and safe lens hydrodissection during cataract surgery.

Traditional hydrodissection may cause posterior capsule rupture (PCR) if excessive fluid accumulates. In this study, we describe the successful application of a novel minimal fluid hydrodissection technique in 100 consecutive cataract surgery cases. This technique separates the nucleus from the capsule utilizing low hydrostatic pressure and precise kinetic movement of a small volume (around 0.2 cc) of balanced salt solution. There were no instances of PCR. This technique is suitable for a range of cases, including femtosecond laser-assisted cataract surgery and posterior subcapsular cataract.

Influence of irrigation dynamic pressure-assisted hydrodissection on intraocular pressure and the posterior chamber-anterior hyaloid membrane barrier during cataract surgery.

PURPOSE: To evaluate the effects of irrigation dynamic pressure-assisted hydrodissection (irrigation-hydro: iH) on intraocular pressure (IOP) and the posterior chamber-anterior hyaloid membrane (PC-AHM) barrier in porcine eyes. STUDY DESIGN: Experimental. METHODS: In Experiment 1, IOP was recorded while irrigating the anterior chamber (AC), during iH, and during phacoemulsification and aspiration in 20 porcine eyes using bottle heights of 50, 70, and 90 cm. Under the same conditions, IOP was recorded during conventional manual cortical cleaving hydrodissection (manual hydro: mH) in 20 porcine eyes. In Experiment 2, after iH, ACs were perfused for 5 seconds with balanced salt solution containing 1.0-µm fluorescein beads in 20 porcine eyes using bottle heights of 70, 118, and 169 cm. PC-AHM barrier staining grade was evaluated by the Miyake-Apple view. RESULTS: iH proved successful in all cases. In Experiment 1, IOP during iH was relatively stable and peak IOP was below the baseline bottle height-dependent pressure. No eyes showed a peak IOP > 75 mmHg during iH, but 8 eyes showed a peak IOP > 75 mmHg during mH. In Experiment 2, neither AHT nor ruptured capsules were observed at any bottle height. CONCLUSION: Unlike mH, IOP during iH was relatively stable without any high peak IOP. Thus, iH offers a simple technique for reducing peak IOP and avoiding disturbance of the PC-AHM barrier.

The safety and efficacy of phaco-sleeve irrigation-assisted hydrodissection during femtosecond laser-assisted cataract surgery.

Femtosecond laser-assisted cataract surgery (FLACS) changes the intraoperative environment due to the generation of intracapsular gas that induces a high intracapsular volume. Manual hydrodissection (mH) may induce high intracapsular pressure (ICP) and additional intracapsular volume, thereby leading to capsular block syndrome (CBS). Since the phaco-sleeve irrigation-assisted hydrodissection (iH) technique is used to initially groove and split the lens and remove the intracapsular gas, this can reduce the intracapsular volume while bypassing the intracapsular lens prior to the hydrodissection. As iH uses the phaco tip to intentionally vacuum the intraocular fluid for use in inducing the irrigation jet from the sleeve side holes, the ICP cannot surpass the set irrigation pressure, thereby avoiding CBS. Using this technique, we performed FLACS without CBS in 310 cataract eyes. Our findings suggest that the iH technique may be beneficial for patients by preventing CBS during FLACS.

Bilateral early capsular block syndrome following implantation of the new trifocal toric lens.

A young patient underwent phacoemulsification with endocapsular implantation of trifocal toric lens in both eyes (AT LISA tri toric 939 MP, Carl-Zeiss, Germany). One-week postsurgery, he developed capsular block syndrome (CBS) in both eyes. There was deterioration of uncorrected visual acuity at 1-week postsurgery, with a myopic shift of 2.5 diopters (D) in the right eye and 2.0 D in the left eye. The intraocular pressure was only elevated in the left eye. Neodymium: yttrium-aluminum-garnet laser posterior capsulotomy resolved the block successfully in both eyes. A thick lens with a plate haptic design may have contributed to the early CBS.

Analysis of proteomic differences between liquefied after-cataracts and normal lenses using two-dimensional gel electrophoresis and mass spectrometry.

AIM: To analyze and identify the proteomic differences between liquefied after-cataracts and normal lenses by means of liquefied chromatography-tandem mass spectrometry (LC-MS/MS). METHODS: Three normal lenses and three liquefied after-cataracts were exposed to depolymerizing reagents to extract the total proteins. Protein concentrations were separated using two-dimensional gel electrophoresis (2-DE). The digitized images obtained with a GS-800 scanner were then analyzed with PDQuest7.0 software to detect the differentially-expressed protein spots. These protein spots were cut from the gel using a proteome work spot cutter and subjected to in-gel digestion with trypsin. The digested peptide separation was conducted by LC-MS/MS. RESULTS: The 2-DE maps showed that lens proteins were in a pH range of 3-10 with a relative molecular weight of 21-70 kD. The relative molecular weight of the more abundant proteins was localized at 25-50 kD, and the isoelectric points were found to lie between PI 4-9. The maps also showed that the protein level within the liquefied after-cataracts was at 29 points and significantly lower than in normal lenses. The 29 points were identified by LC-MS/MS, and ten of these proteins were identified by mass spectrometry and database queries: beta-crystallin B1, glyceraldehyde-3-phosphate dehydrogenase, carbonyl reductase (NADPH) 1, cDNA FLJ55253, gamma-crystallin D, GAS2-like protein 3, sorbitol dehydrogenase, DNA FLJ60282, phosphoglycerate kinase, and filensin. CONCLUSION: The level of the ten proteins may play an important role in the development of liquefied after-cataracts.

Irrigation dynamic pressure-assisted hydrodissection during cataract surgery.

The irrigation dynamic pressure-assisted hydrodissection technique (irrigation-hydro [iH]) does not require performing manual hydrodissection using a syringe and cannula to achieve cortical-capsular cleavage during cataract surgery. Since the iH technique uses the phaco tip to intentionally vacuum the intraocular fluid in order to induce the irrigation dynamic pressure for cortical-capsular cleavage, there is a reduction in the intraocular pressure (IOP) from the bottle-height-dependent hydrostatic pressure. Thus, since the peak irrigation pressure derived from the phaco tip sleeve will be limited by the height of the irrigation fluid bottle, this is advantageous in helping to avoid excessively high IOP during cortical-capsular hydrodissection. Using this technique, we were able to effectively perform phacoemulsification without complications in 607 of 609 cataract eyes. Our findings show that utilization of the iH technique would be of benefit to patients, as it prevents high-pressure hydrodissection-related complications, such as capsular block syndrome and tears in the anterior hyaloid membrane during cataract surgery.

Use of the phaco tip technique for lens cleavage and removal during cataract surgery.

Use of the phaco tip technique for lens cleavage and removal does not require manual hydrodissection using a syringe and cannula, or cortical removal using an irrigation/aspiration tip. The phaco tip is the only surgical instrument required for this technique. Its advantages include maintaining a stable intraocular pressure during cortical cleaving hydrodissection and lens removal, which includes the cortex.

A Case Report of Preoperative, Intraoperative, and Postoperative Anterior Chamber Shallowing Resulting from Different Mechanisms.

A 54-year-old woman with an epiretinal membrane in her left eye accompanied by a shallow anterior chamber due to primary angle closure glaucoma underwent vitrectomy and cataract surgery. During the cataract surgery, immediately after the ultrasonic tip had been removed from the anterior chamber, anterior chamber flattening occurred. An intraoperative fundus examination showed the development of acute intraoperative choroidal effusion. Postoperatively, the anterior chamber remained shallow even after the choroidal detachment had subsided; capsular bag distension seen by ultrasound biomicroscopy suggested the development of early postoperative capsular block syndrome. After neodymium:yttrium-aluminium-garnet laser capsulotomy, the anterior chamber deepened. Depending on the perioperative period, the mechanism of a flat anterior chamber can change, and understanding the underlying mechanisms is required for appropriate treatment.

Recurrent late-onset fibrotic capsular block syndrome after neodymium-yttrium-aluminum-garnet laser anterior capsulotomy: a case report.

BACKGROUND: Capsular block syndrome is an uncommon complication that occurs after cataract surgery. It is characterized by capsular distension, anterior intraocular lens displacement, anterior chamber shallowing, and unexpected myopic shifts. We report a case of recurrent fibrotic capsular block syndrome with Elschnig's pearl-type posterior capsule opacification 10 months after neodymium-yttrium-aluminum-garnet (Nd:YAG) laser anterior capsulotomy. CASE PRESENTATION: A 72-year-old Asian man complained of decreased visual acuity 5 years after undergoing phacoemulsification with posterior chamber lens implantation. Under slit-lamp examination, late postoperative capsular block syndrome was diagnosed and Nd:YAG laser anterior capsulotomy was performed. Ten months after anterior capsulotomy, the patient returned with decreased visual acuity and was diagnosed with recurrent fibrotic capsular block syndrome. Nd:YAG laser posterior capsulotomy was performed. CONCLUSIONS: We found that fibrotic capsular block syndrome could recur with Elschnig's pearl-type posterior capsule opacification after Nd:YAG laser anterior capsulotomy for late postoperative capsular block syndrome without posterior capsule opacification.

A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector.

We report a case of delayed onset capsular block syndrome in a patient 6 years after undergoing cataract surgery. Ocular examination revealed marked diminution of vision accompanied with a collection of milky fluid between the intraocular lens and posterior capsule. To treat and to understand the pathology of the condition, aspiration of fluid using 25-gauge vitrector through pars plana was done, and contents sent for microbiological analysis which did not reveal any growth. Postoperative period was uneventful with the absence of intraocular inflammation and excellent visual recovery.