Capsular Block Syndrome

Capsular block syndrome (CBS) is caused by the intracapsular accumulation of liqueed material posterior
to the nucleus or IOL and subsequent occlusion of the anterior capsulotomy. CBS can occur
intraoperatively during hydrodissection of the nucleus and may lead to posterior capsule blowout,
especially in eyes with preexisting capsule defects or posterior polar cataract. Early postoperative CBS
may occur when residual OVD becomes trapped within the capsular bag, between the posterior capsule
and the posterior surface of the IOL. This may cause a myopic shift in the refractive error as a result of
anterior displacement of the lens optic. Anterior displacement of the iris diaphragm with shallowing of
the anterior chamber may also occur, which must be dierentiated from a ciliary block mechanism. If left
untreated, CBS may lead to posterior synechiae and secondary glaucoma. Nd:YAG laser anterior
capsulotomy peripheral to the optic or posterior capsulotomy results in release of the trapped uid, with
resultant posterior movement of the IOL optic to its intended position, deepening of the anterior
chamber, and resolution of the myopic shift. Late postoperative CBS may occur years after surgery with
the accumulation of a turbid or milky uid between the posterior capsule and the IOL that is consistent
with the by-products of trapped, residual lens epithelial cells. The patient may be asymptomatic, and
myopic shift is uncommon in these cases. Simple laser posterior capsulotomy usually resolves this
condition without complications. Miyake K, Ota I, Ichihashi S, Miyake S, Tanaka Y, Terasaki H. New
classication of capsular block syndrome. J Cataract Refract Surg 1998;24(9):1230–1234.

Uveitis-Glaucoma-Hyphema Syndrome Uveitis-glaucoma-hyphema (UGH) syndrome was rst described in

the context of rigid or closed-loop ACIOLs. It may also develop in patients with posterior chamber
lenses, owing to contact between lens haptics and uveal tissue in the posterior chamber. The classic
triad or individual components of the syndrome may occur as a result of inappropriate IOL sizing,
contact between the implant and vascular structures or the corneal endothelium, or defects in implant
manufacturing. Uveitis, glaucoma, and/or hyphema may respond to treatment with cycloplegics and
topical anti-inammatory or ocular hypotensive medications. If medical therapy does not suciently
address the ndings or if inammation threatens either retinal or corneal function, IOL removal must be
considered. This procedure may be complicated because of inammatory scars, particularly in the
anterior chamber angle or posterior to the iris. If such scarring is present, the surgeon may need to
amputate the haptics from the optic and remove the lens piecemeal, rotating the haptic material out of
the synechial tunnels to minimize trauma to the eye. In some cases, it is safer to leave portions of the
haptics in place. Early lens explantation may reduce the risk of corneal decompensation and CME.

Pseudophakic Bullous Keratopathy Certain IOL designs, particularly iris-clip lenses (iris-xated lenses with
the optic anterior to the iris) and closed-loop exible anterior chamber lenses, were associated with an
increased risk of corneal decompensation. Iris-clip lenses have been shown to contact the corneal
endothelium during eye movement. Endothelial cell loss associated with closed-loop ACIOLs is thought
to be due to chronic inammation and contact between the lens and peripheral corneal endothelial cells.
Thus, these two lens types are no longer in clinical use. Patients with underlying corneal endothelial
dysfunction such as Fuchs corneal dystrophy have an increased risk of postoperative corneal edema.

Unexpected Refractive Results Cataract surgery and IOL implantation aord an important opportunity to
provide patients with desirable refractive outcomes. See Chapter 7 in this volume and BCSC Section 13,
Refractive Surgery, for a discussion of cataract surgery as a refractive procedure. Unintended
postoperative refractive errors may be the result of a preoperative error in measurement of axial length
or in keratometry readings. Choosing the correct IOL power is more dicult in patients undergoing
simultaneous penetrating keratoplasty, in patients with silicone oil in the vitreous cavity, and in patients
who have had prior refractive surgery (see Chapter 6). The surgeon’s failure to conrm the proper IOL at
the time of surgery may result in implantation of the incorrect lens. Unexpected postoperative refractive
results may occur because of the inversion of an angulated IOL or placement of the lens in the sulcus
when it was calculated for placement in the capsular bag, either of which results in anterior
displacement and changes the eective power of the IOL. The clinician should rule out or treat other
causes of an anterior or posterior shift in the IOL position, such as posterior capsule rupture, capsular
block, or ciliary block. Mislabeling or manufacturing defects are rarely the cause of these problems.
Incorrect lens power should be suspected early in the postoperative course when the visual acuity is less
than expected and is conrmed by refraction. Medical-record documentation of the source of the error
and full disclosure to the patient are necessary. If the magnitude of the postoperative refractive error
produces symptomatic ametropia, anisometropia, or dissatisfaction on the part of the patient, the
surgeon can consider several options: overrefraction for glasses or contact-lens wear IOL exchange
insertion of a piggyback IOL a secondary keratorefractive procedure

IOL Glare, Dysphotopsia, and Opacification In addition to lens decentration and capsular opacication,
glare can result when the diameter of the IOL optic is smaller than the diameter of the scotopic pupil.
Optics with a square-edge design and multifocal IOLs are more likely to produce glare and halos, even
when well centered. Spherical aberration may cause some degree of distortion or glare under scotopic
conditions when the pupil is dilated, even if the iris covers the edge of the lens optic. Aspheric IOLs may
reduce some of these phenomena and improve contrast sensitivity. Spherical aberration of the cornea
changes with age and corneal refractive surgery, and various aspheric IOLs can be matched to the
degree of corneal asphericity. Positive dysphotopsia is described as glare, streaks, ashes, arcs, or halos
of light in the midperiphery. It is more common with truncated square-edge IOLs and those
manufactured from higher-index materials. Negative dysphotopsia is described as an arcuate dark or
dim crescent-shaped region, usually in the temporal visual eld. It occurs in the setting of a PCIOL
centered in the capsular bag with the anterior capsule edge overlapping the lens optic. Though reported
with most styles of PCIOLs, negative dysphotopsia is more common with smaller, square-edge optic
designs. Temporal light rays may interact with the nasal lens edge and anterior capsule, causing a
shadow (penumbra) on the nasal retina in susceptible eyes. This eect is more common with a miotic or
nasally located pupil and is relieved with dilation or by blocking light from the temporal side. Although
symptoms are common in the early postoperative period, they improve over time in most patients,
presumably as the capsule contracts or opacies in the periphery. Initially, observation is advised. For
patients with prolonged symptoms and compromised vision, surgery may be necessary. Repositioning of
the optic anterior to the capsulorrhexis by reverse optic capture through the capsulorrhexis (with the
haptics in the capsular bag) or sulcus xation of an appropriate PCIOL with a larger optic with rounded
edges may be successful in most cases. Implantation of a piggyback IOL or an anterior capsulectomy has
been successful in some cases. Several types of IOLs have developed opacities or discoloration, either
immediately after implantation or progressively over years. There are many dierent causes, which vary
with the IOL manufacturer, material, and storage, as well as surgical adjuvants and associated patient
conditions. Five general processes of IOL opacication have been identied: deposits or precipitates on the
surface of or in the IOL optic (such as calcium deposits on silicone IOLs in asteroid hyalosis) influx of
water in hydrophobic optic material (glistenings) staining of the IOL by capsular dyes or medications IOL
coating by substances such as ophthalmic ointment or silicone oil progressive degradation of the IOL
material (such as snowflake degeneration in polymethyl methacrylate [PMMA] IOLs) Calcium deposition
within or on the surface of hydrophilic acrylic lenses can produce signicant visual symptoms, and IOL
explantation may be required. Calcium deposits on silicone lenses have been reported in eyes with
asteroid hyalosis, usually after posterior capsulotomy. Glistenings are uid-lled microvacuoles that form
within an IOL optic when it is in an aqueous environment. They are observed within all types of IOL
material but are associated primarily with certain hydrophobic acrylic IOLs. Glistening formation and
intensity increase with time. Although their appearance may be striking on slit-lamp examination,
glistenings have not been shown to aect best-corrected visual acuity. Although studies have
documented a negative eect on contrast sensitivity at high spatial frequency, IOL explantation for
glistenings is rarely reported. Interlenticular opacications have been noted between piggybacked
PCIOLs, especially in cases when both are made of hydrophobic acrylic material and placed in the
capsular bag. Using IOLs made of 2 dierent materials, enlarging the capsulorrhexis, and placing 1 lens in
the capsular bag and 1 in the sulcus may reduce the incidence. Patients with diractive or refractive
multifocal IOLs are more likely to experience glare, decreased contrast sensitivity, or loss of desired
multifocality with minor IOL decentration, altered pupil diameter or position, or posterior capsule
opacity. A pseudoaccommodating lens may vault anteriorly (a condition known as Z syndrome) due to
misplaced haptics or asymmetric capsular contraction. This syndrome can often be managed by
posterior capsulotomy, but the lens may need to be surgically repositioned or explanted. Toric IOLs must
be located on a precise axis for maximal astigmatic correction. These lenses may need to be
repositioned if they are placed improperly or rotate postoperatively. Toric IOL rotation is more common
in highly myopic eyes when the lens is oriented in the vertical meridian. Colin J, Praud D, Touboul D,
Schweitzer C. Incidence of glistenings with the latest generation of yellow-tinted hydrophobic acrylic
intraocular lenses. J Cataract Refract Surg. 2012;38(7): 1140– 1146. Espandar L, Mukherjee N, Werner L,
Mamalis N, Kim T. Diagnosis and management of opacied silicone intraocular lenses in patients with
asteroid hyalosis. J Cataract Refract Surg. 2015;41(1):222–225. Holladay JT, Zhao H, Reisin CR. Negative
dysphotopsia: the enigmatic penumbra. J Cataract Refract Surg. 2012;38(7):1251–1265. Jin H, Limberger
IJ, Ehmer A, Guo H, Auarth GU. Impact of axis misalignment of toric intraocular lenses on refractive
outcomes after cataract surgery. J Cataract Refract Surg. 2010;36(12):2061–2072. Masket S, Fram NR.
Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract
Refract Surg. 2011;37(7):1199–1207. Werner L. Causes of intraocular lens opacication or discoloration. J
Cataract Refract Surg. 2007;33(4):713–726. Werner L. Glistenings and surface light scattering in
intraocular lenses. J Cataract Refract Surg. 2010;36(8):1398–1420.

Capsular Opacification and Contraction

Posterior Capsule Opacification The most common late complication of cataract surgery by means of
ECCE or phacoemulsication is posterior capsule opacication (PCO). In addition, contracture of a
continuous curvilinear capsulorrhexis may occlude the visual axis because of anterior capsule brosis and
phimosis. Posterior or anterior capsule opacication is amenable to treatment by intraocular peeling or
polishing of the capsule or by means of Nd:YAG laser capsulotomy. Capsular opacication stems from the
continued viability of lens epithelial cells that remain after removal of the nucleus and cortex. Opaque
secondary membranes are formed by proliferating lens epithelial cells, broblastic metaplasia, and
collagen deposition. Lens epithelial cells proliferate in several patterns. Sequestration of nucleated
bladder cells (Wedl cells) in a closed space between the adherent edges of the anterior and posterior
capsule results in a doughnut-shaped conguration, referred to as a Soemmering ring. If the epithelial
cells migrate out of the capsular bag, translucent globular masses resembling sh eggs (Elschnig pearls)
form on the edge of the capsular opening. These pearls can ll the pupil or remain hidden behind the iris.
Histologic examination shows that these “sh eggs” are nucleated bladder cells, identical to those
proliferating within the capsule of a Soemmering ring but usually lacking a basement membrane. If the
epithelial cells migrate across the anterior or posterior capsule, they may cause capsular wrinkling and
opacication. Signicantly, the lens epithelial cells are capable of undergoing metaplasia with conversion
to myobroblasts. These cells can produce a matrix of brous and basement membrane collagen.
Contraction of this collagen matrix causes wrinkles in the posterior capsule, with resultant distortion of
vision and glare. The reported incidence of PCO varies widely but has been diminishing with current IOL
design and placement. Older studies report that the frequency of Nd:YAG laser capsulotomy varies
between 3% and 53% within 3 years of cataract surgery. More recent clinical series with a 3- to 5-year
follow-up of cases with either hydrophobic acrylic or silicone square-edge design show PCO rates
between 0% and 4.7%. Factors thought to inuence this rate include the age of the patient, history of
intraocular inammation, presence of pseudoexfoliation syndrome, size of the anterior capsulorrhexis,
quality of the cortical cleanup, capsular xation of the implant, design of the lens implant (specically, a
reduction in incidence with posterior convex or a truncated square-edge optic design), modication of
the lens surface, and time elapsed since surgery. There seems to be no dierence in PCO rates with
prolonged use of postoperative topical corticosteroids or NSAIDs. The presence of intraocular silicone oil
may dramatically speed up the progression of PCO. The IOL material has a modest eect on opacication
rates. Hydrogel IOLs lead to the highest rate, followed by PMMA, then silicone; hydrophobic acrylic
material IOLs lead to the lowest rate. However, the IOL design is now considered the dominant factor
both in inhibiting posterior migration of lens epithelial cells and in inuencing the rate of PCO. The
truncated-edge design is associated with lower rates of PCO in both silicone and acrylic IOLs, although
these lenses may increase the incidence of undesirable optical reections and positive dysphotopsias.
Cheng JW, Wei RL, Cai JP, et al. Ecacy of dierent intraocular lens materials and optic edge designs in
preventing posterior capsular opacication: a meta-analysis. Am J Ophthalmol. 2007;143(3):428–436.
Dewey S. Posterior capsule opacication. Curr Opin Ophthalmol. 2006;17(1):45–53. Rönbeck M,
Zetterström C, Wejde G, Kugelberg M. Comparison of posterior capsule opacication development with 3
intraocular lens types: ve-year prospective study. J Cataract Refract Surg. 2009;35(11):1935–1940. Sacu
S, Menapace R, Findl L, Kiss B, Buehl W, Georgopoulos M. Long-term ecacy of adding a sharp posterior
edge to a three-piece silicone intraocular lens on capsule opacication: ve-year results of a randomized
study. Am J Ophthalmol. 2005;139(4):696–703.

Anterior Capsule Fibrosis and Phimosis Capsular brosis is associated with clouding of the anterior
capsule. If a substantial portion of the IOL optic is covered by the opaque anterior capsule, including
portions exposed through the undilated pupil, the patient may become symptomatic. Symptoms may
include glare, especially at night due to physiologic mydriasis in darkness, or a perception that vision has
become cloudy or hazy. The term capsular phimosis is used to describe the postoperative contraction of
the anterior capsule opening as a result of circumferential brosis. Phimosis produces symptoms similar
to and often more pronounced than those of brosis itself and may cause stress on the zonular bers or
decentration of an IOL optic. Anterior capsule contraction and brosis occur more frequently with smaller
capsulorrhexis openings, in patients with underlying pseudoexfoliation syndrome, and in other
situations with abnormal or asymmetric zonular support (eg, penetrating or blunt trauma, Marfan
syndrome, or surgical trauma). Anterior capsule contraction may contribute to late pseudophakodonesis
or in-the-bag IOL subluxation due to stress on the zonular apparatus. Anterior capsule polishing to
remove residual lens epithelial cells may help reduce anterior capsule contraction but not PCO. Capsular
phimosis can be treated with several radial Nd:YAG anterior capsulotomies to release the annular
contraction, reduce the traction on the zonular bers, and enlarge the anterior capsule opening (Fig 8-7).
This procedure is performed in a fashion similar to Nd:YAG laser posterior capsulotomy, with care taken
to not defocus too far posteriorly and damage the underlying IOL with laser pitting. In general, the
anterior capsule tissue or a brotic ring is tougher and thus requires more laser power than does the
posterior capsule.