Complications related to a well-performed capsulorhexis are rare, but they do exist. Capsule contraction syndrome (CCS) is one of them. The pathogenesis of this syndrome is related to anterior capsule fibrosis, which is caused by metaplastic lens epithelium cells.1 The shrinkage of the anterior capsule opening is directly related to the health of the lens zonular fibers.2 This progressive constriction of the anterior capsule opening is especially observed in some ocular conditions such as pseudoexfoliation (PXF).3
Several ways to prevent CCS have been proposed, but up to now, to our knowledge, none of them were able to completely avoid this complication, especially in eyes with pathological zonular fragility.4 The reason for this is that almost all of these methods are meant to avoid the effect of the capsular contraction, but they do not act on the cause, which is the metaplasia of the anterior lens epithelium cells. Some studies have already shown that the removal of anterior lens epithelium cells by aspiration helps to maintain the size of the capsulorhexis opening, and that can help prevent CCS.5
Between 2009 and 2016, we performed a study that involved 9 patients who had cataracts associated with PXF syndrome. There were 3 men and 6 women, ranging in age from 63 to 85 years. In the first 2 years, we followed a routine: in the first eye, we aspirated the most anterior lens epithelium cells possible with a bimanual technique; in the second eye, we did not perform any aspiration of the posterior face of the anterior capsule, leaving the layer of epithelial cells intact. That was done in 6 eyes of the first three patients. After following up these 6 eyes for 2 years, serial photographs showed an intense fibrosis, already with some degree of capsular contraction in the eyes in which we did not aspirate the anterior epithelial cells, whereas the contralateral eyes presented little or no fibrosis. Figures 1 and 2 show more prominent fibrosis in an eye that was not submitted to cell aspiration. In the course of our work, we felt that it would not be fair to leave one of the eyes of the subsequent patients with no aspiration of the anterior lens epithelium cells, precisely because of this large difference in fibrosis of the anterior capsules between the two eyes. Therefore in 2011, we started aspirating the cells in both eyes of the same patient, and we continued to do so until 2016. During this period, we operated on 12 eyes of 6 patients. All these eyes presented a very low degree of fibrosis in the anterior capsules, with no capsular contraction.
A common feature of PXF syndrome is zonular fragility, and because of that, CCS is more common in the eyes affected by this pathology.3 To prevent any complications that might occur after any eye surgery, we must act at its origin. The use of endocapsular rings is an attempt to counteract the centripetal force created by the anterior capsule fibrosis, which causes capsular contraction, without acting on the origin of the fibrotic process, which is the metaplasia of the anterior lens epithelium cells. Therefore, it seems obvious that the most efficient way to avoid CCS is to leave the anterior capsule as free as possible from these cells. This has already been suggested in a previous stuy.5 This work alone clearly shows that aspiration of epithelial cells from the anterior lens capsule helps to maintain the size of a capsulorhexis, and therefore can prevent CCS.
In our study, the photographic follow-up of the 6 eyes of the first three patients in whom we performed cellular aspiration in one of the eyes, and not in the contralateral one, clearly shows the great difference in the postoperative capsular fibrosis between the two eyes. In the eyes in which we did not perform the cells aspiration, there was an intense fibrosis already with a certain degree of capsular contraction. In the eyes in which we performed the cells aspiration, the fibrosis was minimal and it appeared to be insufficient to create the centripetal force necessary to cause anterior capsular contraction. The other eyes of the 12 surgeries performed between 2011 and 2016, in which we conducted cell aspiration bilaterally, showed the same trend: minimal fibrosis with no capsular contraction. We can also conclude in our study that the early indication of cataract surgery in PXF might be an issue to be considered. In an early cataract, we will certainly achieve a better mydriasis and therefore, a more complete aspiration of the lens epithelial cells. Another important factor to be considered is that the zonular fragility accompanies the development of cataract. The more mature the cataract gets, the more fragile the zonular fibers become, until the point where the lens begins to develop phacodonesis,6 a condition in which the aspiration of the anterior epithelial cells can become extremely difficult or even impossible.
In summary, this case series suggests that it is possible to prevent CCS using aspiration alone without an endocapsular ring. However, it is necessary to consider the risk for capsular rupture using the technique of aspiration of the anterior lens epithelium cells alone compared with the use of an endocapsular ring.
1. Caporossi A, Casprini F, Tosi GM, Balestrazzi A, Stumpo M, Toti P. Histology of anterior capsule fibrosis following phacoemulsification. J Cataract Refract Surg
2. Joo CK, Shin JA, Kim JH. Capsular opening contraction after continuous curvilinear capsulorhexis and intraocular lens implantation. J Cataract Refract Surg
3. Hayashi H, Hayashi K, Nakao F, Hayashi F. Anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. Br J Ophthalmol
4. Scherer M, Bertelmann E, Rieck P. Late spontaneous in-the-bag intraocular lens and capsular tension ring dislocation in pseudoexfoliation syndrome. J Cataract Refract Surg
5. Tadros A, Bhatt UK, Karim MNA, Zaheer A, Thomas PW. Removal of lens epithelial cells and the effect on capsulorhexis size. J Cataract Refract Surg
6. Bartholomew RS. Phakodonesis: a sign of incipient lens displacement. Br. J. Ophthalmol