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Consultation section

June consultation # 3

Agarwal, Amar MS, FRCS, FRCOphth

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Journal of Cataract & Refractive Surgery: June 2008 - Volume 34 - Issue 6 - p 884-885
doi: 10.1016/j.jcrs.2008.04.006
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This is an interesting case of an elderly woman who presents with bilateral, progressive, painless diminution in vision. There is no history suggestive of previous ocular disease, trauma, or systemic disorders. The patient's occupation is not mentioned in the case history and would be of particular interest.

The clinical signs described, as well as the surgical signs seen intraoperatively, are suggestive of capsular delamination or true exfoliation of the anterior lens capsule. True exfoliation or capsular delamination of the lens capsule is a rare condition in which there is a split in the layers of the lens capsule. This is seen typically as a thin, diaphanous, transparent membrane with attachment to the anterior lens capsule. Although the exact pathogenesis is not clear, an association with intense infrared radiation exposure1,2 has been established. There are reports3,4 of true exfoliation in elderly patients.

The main problems that can occur during cataract surgery are secondary to the condition not being recognized preoperatively. The surgeon might accidentally create only a partial-thickness capsulorhexis or a capsulorhexis that involves both layers along part of its extent and only 1 layer along the rest. The delaminated membrane can also become caught in the phaco or I/A tip if it is not removed completely along with the lens capsule created by the capsulorhexis, and this might lead to extension of the capsulorhexis margin.

Trypan blue or indocyanine green staining of the capsule is imperative to accurately identify both layers of the capsulorhexis or, alternatively, both leaflets of the capsulorhexis. Both layers generally stain, making visualization easier. The scrolled anterior leaf can be carefully peeled from the underlying remaining capsule with minimum resistance and no apparent damage to the lens capsule.

A CCC should be created on the remaining capsule with a combination of a cystotome or Utrata forceps, whichever technique the surgeon feels comfortable using. Care must be taken to ensure that a clear capsulorhexis margin is seen on completion of capsulorhexis and that no residual delaminated capsular layer is left before hydrodissection is started. After the capsulorhexis is made, a double-ring shape of the remaining capsular margins is sometimes visible.5 Phacoemulsification would then be performed. Care must be taken to avoid exerting excess traction on the inner layer of the capsulorhexis during cortical removal. The removed layers of the anterior capsule should be sent for histopathology to confirm the diagnosis. The postoperative follow-up would be as in any other case. Although no significant recurrence of exfoliative material on the IOL has been noted in true exfoliation, long-term follow-up is still advised. With appropriate techniques, capsular delamination or true exfoliation can be tackled safely with phacoemulsification.6–9

While considering cataract surgery in the other eye, it would be advisable to perform ultrasound biomicroscopy or anterior segment optical coherence tomography (OCT) to evaluate the anterior lens capsule before surgery to detect subclinical capsular delamination.

REFERENCES

1. Karp CL, Fazio JR, Culbertson WW, Green WR. True exfoliation of the lens capsule. Arch Ophthalmol. 1999;117:1078-1080.
2. Elschnig A., 1922. Abhlösung der Zonulalamelle bei Glasblasern [Detachment of the zonular lamellae in glassblowers.], Klin Monatsbl Augenheilkd, 69, 732-734.
3. Cashwell LF Jr, Holleman IL, Weaver RG, van Rens GH. Idiopathic true exfoliation of the lens capsule. Ophthalmology. 1989;96:348-351.
4. Yamamoto N, Miyagawa A. True exfoliation of the lens capsule following uveitis. Graefes Arch Clin Exp Ophthalmol. 2000;238:1009-1010.
5. Wollensak G, Wollensak J. Double contour of the lens capsule edges after continuous curvilinear capsulorhexis. Graefes Arch Clin Exp Ophthalmol. 1997;235:204-207.
6. Kulkarni AR, Al-Ibrahim J, Haider S, Elsherbiny S, Scott R. Phacoemulsification in true exfoliation of the lens capsule: a case series. Eye. 2007;21:835-837.
7. Cooke CA, Lum DJ, Wheeldon CE, Teoh H, McGhee CN. Surgical approach, histopathology, and pathogenesis in cataract associated with true lens exfoliation. J Cataract Refract Surg. 2007;33:735-738.
8. Oharazawa H, Suzuki H, Matsui H, Shiwa T, Takahashi H, Ohara K. Two cases of true exfoliation of the lens capsule after cataract surgery. J Nippon Med Sch. 2007;74:55-60.
9. Kelley JS, Tsai T, Kansora MB, Green WR. Capsulorrhexis in capsular delamination. Arch Ophthalmol. 2002;120:1581-1582.
© 2008 by Lippincott Williams & Wilkins, Inc.