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Letters to the Editor

"Reverse" optic capture complicating retained viscoelastic in capsular bag following phacoemulsification

Bandyopadhyay, Supratik MS; Brar, Gagandeep Singh MS; Sukhija, Jaspreet MS; Ram, Jagat MS; Gupta, Amod MS

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Indian Journal of Ophthalmology: May–Jun 2007 - Volume 55 - Issue 3 - p 238-239
doi: 10.4103/0301-4738.31955
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Dear Editor,

Retained viscoelastic in the capsular bag may lead to capsular bag distension syndrome (CBDS).1 We present a case of anterior capture of the optic of an intraocular lens (IOL) in the capsulorrhexis margin following retention of Viscoat ® (Alcon Surgical, Fort Worth, Texas) in the capsular bag.

A 35-year-old male was taken up for phacoemulsification under local anesthesia for right eye traumatic cataract. The size of capsulorrhexis was approximately 5.5 mm. Uneventful phacoemulsification of nucleus was performed. After filling the capsular bag with Viscoat ® a 22-dioptre acrylic foldable IOL (Alcon Acrysof MA 60BM, Fort Worth Texas) was implanted in the capsular bag. After implantation, viscoelastic was aspirated from the anterior chamber as well as from the capsular bag.

On the first postoperative day the patient had an uncorrected visual acuity of 20/60, which was improving to 20/20 with pinhole. The optic of the IOL was found to be outside the capsular bag whereas both the haptics were well placed within the capsular bag [Fig. 1a and b]. There was posterior bowing of the posterior capsule with retained viscoelastic in the capsular bag [Fig. 1a]. The IOP was 18 mm of Hg and fundus examination was normal. Retinoscopy revealed myopia of -1.75 diopters.

Figure 1
Figure 1:
a) Clinical photograph of the right eye on first postoperative day following phacoemulsification. Note the space between the IOL optic and the posterior capsule due to retained viscoelastic (bold arrow). Also note that the IOL optic is anterior to the capsulorrhexis margin (fine arrow). (b) Photograph of the same eye in retro-illumination. Note the disappearance of the capsulorrhexis margin near the haptic-optic junction (arrow)

The patient was observed for one week postoperatively for spontaneous clearing of the retained viscoelastic but there was no change in the status. Subsequently, the retained viscoelastic was aspirated and IOL repositioned completely within the capsular bag. After the second intervention, the IOL optic remained well covered by the capsulorrhexis margin [Fig. 2a and b] and the patient achieved an unaided distance visual acuity of 20/17.

Figure 2
Figure 2:
(a) Clinical photograph of the same eye following aspiration of the viscoelastic. Note the capsular bag placement of the IOL and close apposition of the IOL optic to the posterior capsule. (b) Clinical photograph of same eye in retro-illumination. Note the complete capsulorrhexis margin and capsular bag fixation of the IOL

Entrapment of viscoelastic within the capsular bag can cause anterior vaulting of the IOL optic. The forward movement of the IOL can cause occlusion of the circular anterior capsule opening by the IOL optic.2 Due to addition of chondroitin sulfate, Viscoat ® is more difficult to remove as a bolus at the end of the surgery. Siguira et al. showed that the distension was caused by aqueous humor being drawn into the capsular bag by an osmotic gradient created by retained sodium hyaluronate.3 In the present case, significant amount of Viscoat ® was retained within the capsular bag, which resulted in expulsion of the IOL optic from the capsular bag. Postoperatively if the capsulorrhexis rim is partially adhered to the IOL optic then saccadic eye movements can increase intracapsular pressure by a unidirectional inertial displacement of fluid into the capsular bag.4 Nd:YAG laser disruption of the posterior capsule would have cleared the viscoelastic and rectified the myopic shift, but was unlikely to release the optic capture, so a surgical intervention was carried out.

This condition simulated the optic capture usually performed in the pediatric age group but of reverse nature i.e., the IOL was in the bag and captured in the anterior capsulorrhexis margin, so we termed this as 'reverse' optic capture. It is recommended that every effort should be made to aspirate the viscoelastic at the end of the procedure to avoid such an unwanted complication.

1. Theng JT, Jap A, Chec SP. Capsular block syndrome: A case series J Cataract Refractive Surg. 2000;26:462–7
2. Davison JA. Capsular bag distention after endo-phacoemulsification and posterior chamber intraocular lens implantation J Cataract Refract Surg. 1990;16:99–108
3. Sugiura T, Miyauchi S, Eguchi S, Obata H, Namba H, Fujino Y, et al Analysis of liquid substance accumulated in the distended capsular bag in the early post-operative capsular block J Cataract Refract Surg. 2000;26:420–5
4. Zacharias J. Early postoperative capsular block syndrome related to saccadic-eye-movement-induced fluid flow into the capsular bag J Cataract Refractive Surg. 2000;26:415–9
© 2007 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow