Capsular Bag Distension due to Inflammatory Reaction after Cataract Surgery

1
Capsular Bag Distension due to Inflammatory
Reaction after Cataract Surgery

• Hong Kyun Kim, Ji Woong Lee, Kwang Hyun Kim
• Dept. of Ophthalmology, Kyungpook National
  University
• Daegu,Korea
• Dept. of Ophthalmology, Dongguk University
• Gyeongju,Korea

2
Introduction

• Capsular bag distension(CBD) after cataract
  surgery is a rare complication.
• CBD is characterized by distension of the
  capsular bag and accumulation of a transparent
  substance inside the capsular bag.
• In some case series about the CBD, several
  pathogenetic mechnisms was proposed.
• But, We experienced a case of CBD originated
  by undescribed cause.

3
Purpose

• To describe another cause of capsular bag
  distension after uneventful cataract surgery.
• And classify CBD into 2 categories according to
  the pathogenetic mechnism.

4
Case Report

• An 62 year-old-man who have suffered from uveitic
  glaucoma and complicated cataract in the left
  eye.
• BCVA od) 0.8 os) 0.3
• Ant. segment
• od) mild nuclear sclerosis
• os) mild nuclear sclerosis with
  marked PSC
• optic disc
• os) Cup/Disc ratio was
  .9/0.9(horizontal/vertical)
• with narrow neuroretianl rim
  area.

5
Case Report

• He had uneventful phacoemulsification after
  continuous curvilinear capsulorhexis.
• A single piece acrylic IOL(Acrysof) was
  implanted in the capsular bag using sodium
  hyaluronate 1.4(Healon GV).

6
Case Report

• On the first postoperative day, The best
  corrected visual acuity(BCVA) was 20/100 with
  1.00 -1.25 X 15.
• There was moderate anterior chamber reaction with
  cylitic membrane formation around anterior
  capsular margin.
• But, IOL was well positioned in the bag without
  any accumulated substance.
• The patient received fluorometholone 0.1 every
  two hours, ofloxacin eye drop 0.3 qid.

7
Case report

• On the third postoperative days, the patients
  BCVA was 20/50 with -2.50 -1.25 X 20.
• The posterior chamber was distended behind the
  IOL and a moderate inflammatory chamber reaction
  with posteior synechial formation inferotemporal
  anterior capsular margin were noted(Fig. 1)
• We changed the fluorometholone 0.1 into
  dexamethasone eye drop(Maxitrol) qid.

8
Case Report
Fig. 1. On the third postoperative day, there was
mopderate anterior chamber reaction with cyclitic
membrane formation. A transparent substance was
accumulated between IOL and posterior capsular
bag. Anterior capsular bag margin was attached to
the optic of IOL with fibrotic reaction.
9
Case Report

• One weeks postoperatively, the BCVA was 20/40
  with 0.25 1.25 X 25. Slitlamp examination
  showed clear and deep anterior chamber and the
  distension of capsular bag was disappeared.(Fig.
  2.)
• One month postoperatively, the BCVA was improved
  into 20/25. IOL was well positioned in the bag
  and no accumulated substance behind the IOL on
  slitlamp examination.

10
Case Report
Fig. 2. One week postoperative day, well
positioned IOL without capsular bag distention
was noted on slit lamp photograph(a) and an
photograph image after pupil dilation(b).
11
Discussion

• In our case of CBD, there were no retained
  substance such as viscoelastic material on the
  first postoperative day.
• But, we noted the cellular reaction around the
  anterior capsular margin and found attachment
  optic of the IOL with overlying anterior capsule.
  It suggest that inflammatory cellular reaction
  after surgery can cause CBD. Futhermore, The
  Distended capsular bag was deflated after
  resolving inflammatory reaction.

12
Discussion

• CBD was first described by Davison and Holtz.
  After that, there were many report anout CBD.
  But, to our knowledge, this is the first report
  in CBD that caused by inflammation.
• Including our case, we propose a new
  classification of the CBD into two groups
  according to the pathogenetic origin. The one is
  the inflammatory CBD, mainly formed by cellular
  reaction and the other is noninflammatory CBD.

13
Discussion

• Miyake et al was proposed a classification of
  capsular block syndrome. The classification was
  included two groups of capsular bag distesion
  after cataract surgery and a group of
  intraoperative capsular block.
• They described early postoperative capsular bag
  distension is caused by retained subtance in the
  bag. But, in our case, there was no accumulated
  substance in the bag.

J cataract Refract Surg 1998 24 1230-1234
14
Discussion

• In the Inflammatory Capsular Bag Distension,
  cellular reaction is the main role in the
  pathogenesis, on the contrary, non-inflammatory
  CBD is mainly caused by remnant viscoelastic
  material.(Table 1)
• inflammatory CBD can be matched to Miyakes
  late-postoperative CBS and noninflammatory CBD is
  a same category with Miyakes early postoperative
  CBS.

15
Discussion
16
Conclusion

• We report another cause of CBD and classified
  according to the etiology. But, the
  classification needs more clinical approval and
  experimental proof.

17
Capsular Bag Distension due to Inflammatory
Reaction after Cataract Surgery
Hong Kyun Kim, Ji Woong Lee, Kwang Hyun Kim
Dept. of Ophthalmology, Kyungpook National
University. Daegu, Korea Dept. of Ophthalmology,
Dongguk University Gyeongju, Korea
Introduction
One month postoperatively, the BCVA was improved
into 20/25. IOL was well positioned in the bag
and no accumulated substance behind the IOL on
slitlamp examination.
Capsular bag distension(CBD) after cataract
surgery is a rare complication. CBD is
characterized by distension of the capsular bag
and accumulation of a transparent substance
inside the capsular bag. In some case series
about the CBD, several pathogenetic mechnisms was
proposed. But, We experienced a case of CBD
originated by undescribed cause.
Discussion

In our cases of CBD, there were no retained
substance such as viscoelastic material on the
first postoperative day. But, we noted the
cellular reaction around the anterior capsular
margin and found attachment optic of the IOL with
overlying anterior capsule. It suggest that
inflammatory cellular reaction after surgery can
cause CBD. Futhermore, The Distended capsular bag
was deflated after resolving inflammatory
reaction. CBD was first described by Davison and
Holtz. After that, there were many report anout
CBD. But, to our knowledge, this is the first
report in CBD that caused by inflammation.
Including our case, we propose a new
classification of the CBD into two groups
according to the pathogenetic origin. The one is
the inflammatory CBD, mainly formed by cellular
reaction and the other is noninflammatory CBD.
Miyake et al was proposed a classification of
capsular block syndrome. The classification was
included two groups of capsular bag distension
after cataract surgery and a group of
intraoperative capsular block. They described
early postoperative capsular bag distension is
caused by retained subtance in the bag. But, in
our case, there was no accumulated substance in
the bag. In early postoperative period, as we
described, inflammatory cell is the main role in
the pathogenesis of inflammatory CBD. And in late
postoperative period, there are another cellular
mechanism such as fibrotic change was enrolled
the pathgenesis in late inflammatory CBD. This
late inflammatory CBD can be matched to Miyakes
late postoperative CBS. In many cases of early
postoperative CBD, we can find the retained
viscoelastic material(VEM). In our experience,
there were few cellular reaction and fibrotic
adhesion between IOL and anterior capsule in such
cases. The physical property of retained VEM
maybe is the main role in pathogenesis and
maintenance of the distension. We classified the
cases into noninflammatory CBD and this group is
the same category in Miyakes early postoperative
CBS. We report another cause of CBD and
classified according to the etiology. But, the
classification needs more clinical approval and
experimental proof.
Purpose

Fig. 1. On the third postoperative day, there was
mopderate anterior chamber reaction with cyclitic
membrane formation. A transparent substance was
accumulated between IOL and posterior capsular
bag. Anterior capsular bag margin was attached to
the optic of IOL with fibrotic reaction
To describe another cause of capsular bag
distension after uneventful cataract surgery. And
classify CBD into 2 categories according to the
pathogenetic mechnism.
Methods
An 62 year-old-man who have suffered from
uveitic glaucoma and complicated cataract in the
left eye had uneventful phacoemulsification after
continuous curvilinear capsulorhexis. A single
piece acrylic IOL(Acrysof) was implanted in the
capsular bag using sodium hyaluronate 1.4(Healon
GV). On the first postoperative day, The best
corrected visual acuity(BCVA) was 20/100 with
1.00 -1.25 X 15. And there was moderate anterior
chamber reaction with cylitic membrane formation
around anterior capsular margin on. But, IOL was
well positioned in the bag without any
accumulated substance. The patient received
fluorometholone 0.1 every two hours, ofloxacin
eye drop 0.3 qid. On the third postoperative
days, the patients BCVA was 20/50 with -2.50
-1.25 X 20. On slitlamp examination, the
posterior chamber was distended behind the IOL
and a moderate inflammatory chamber reaction with
posteior synechial formation inferotemporal
anterior capsular margin were noted(fig. 1) We
changed the fluorometholone 0.1 into
dexamethasone eye drop(Maxitrol) qid. for his
anterior chamber reaction. One week
postoperatively, the BCVA was 20/40 with 0.25
1.25 X 25. Slitlamp examination showed clear and
deep anterior chamber and the distension of
capsular bag was disappeared.
a
b
Fig. 2. One week postoperative day, well
positioned IOL without capsular bag distention
was noted on slit lamp photograph(a) and an
photograph image after pupil dilation(b).
Table 1. Classification of Capsular Bag Distension