Ayu - Tugas - Capsular Opacification and Contraction

CAPSULAR OPACIFICATION AND
CONTRACTION
Andi ayu lestari
INTRODUCTION
The most common late occurrence after cataract surgery by means of

ECCE or phacoemulsification is posterior capsule opacification
(PCO).
In addition, contracture of a continuous curvilinear capsulorrhexis may

occlude the visual axis because of anterior capsule fibrosis and
phimosis.
American Academy of Ophthalmology. Lens and Cataract – Basic and Clinical Science Course, Section 11. 2020 - 2021. San Fransisco: American Academy of Ophthalmology. Pg. 199-204
POSTERIOR CAPSULE OPACIFICATION
Capsular opacification 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, fibroblastic 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 configuration, referred to as
a Soemmering ring.
Soemmering ring.
If the epithelial cells migrate out of the capsular bag, translucent globular masses
resembling fish eggs (Elschnig pearls) form on the edge of the capsular opening.
These pearls can fill the pupil or remain hidden behind the iris.
Histologic examination shows that these “fish 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 opacification.
These lens epithelial cells are capable of undergoing metaplasia with conversion to
myofibroblasts.
These cells can produce a matrix of fibrous and basement membrane collagen.
Contraction of this collagen matrix causes wrinkles in the posterior capsule, with
resultant distortion of vision and glare.
American Academy of Ophthalmology. Lens and Cataract – Basic and Clinical Science Course, Section (A) Vacuolated or pearl-type on retroillumination; (B) Elschnig pearl
11. 2020 - 2021. San Fransisco: American Academy of Ophthalmology. Pg. 199-204
formation (arrow) on edge of capsulotomy;
The reported incidence of PCO varies widely but has been diminishing as a result of modern IOL designs and placement.
Older studies reported that the frequency of Nd:YAG laser capsulotomy varied 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 up to 5%.
IOL design is now considered the dominant factor both in inhibiting posterior migration of lens epithelial cells and in
influencing the rate of PCO.
The IOL material also has a modest effect on opacification rates.
Hydrogel IOLs are associated with the highest rate, followed by PMMA, then silicone; IOLs made of hydrophobic acrylic
material are associated with the lowest rate.
Compared to round-edge optics, the truncated square-edge optic design is associated with lower rates of PCO in both
silicone and acrylic IOLs, although these lenses may increase the incidence of undesirable optical reflections and positive
dysphotopsias.
Other factors thought to increase PCO rate include:
• younger age of the patient
• history of intraocular inflammation
• pseudoexfoliation syndrome
• anterior capsulorrhexis that does not cover 360° of the IOL edge
• incomplete cortical cleanup
• round-edge design of the IOL optic
• time elapsed since surgery
• presence of silicone oil
There seems to be no difference in PCO rates with prolonged use of postoperative

topical corticosteroids or NSAIDs.
ANTERIOR CAPSULE FIBROSIS AND PHIMOSIS
Capsular fibrosis 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 experience symptoms such as:
• glare, especially at night because of physiologic mydriasis in darkness, or
• a perception that vision has become cloudy or hazy.
The term capsular phimosis describes the postoperative contraction of the

anterior capsule opening as a result of circumferential fibrosis.
Phimosis produces symptoms similar to and often more pronounced than those of fibrosis
alone.
Fibrosis and anterior capsule contraction occur more frequently with :

• smaller capsulorrhexis openings,
• underlying pseudoexfoliation syndrome, and
• abnormal or asymmetric zonular support (eg, penetrating or blunt trauma,
Marfan syndrome, or surgical trauma).
Anterior capsule contraction may contribute to late pseudophacodonesis

or in- the-bag IOL subluxation due to stress on the zonular apparatus.
Anterior capsule contraction, but not PCO, may be reduced with anterior
capsule polishing to remove residual lens epithelial cells.
American Academy of Ophthalmology. Lens and Cataract – Basic and Clinical Science Course, Section 11. 2020 -
2021. San Fransisco: American Academy of Ophthalmology. Pg. 199-204
Capsular phimosis can be treated with several radial

Nd:YAG laser anterior capsulotomies to release the
annular contraction, reduce the traction on the zonule,
and enlarge the anterior capsule opening.
This procedure is performed 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 fibrotic ring is

Figure 11-14 Illustration of Nd:YAG laser anterior
tougher and thus requires more laser power than does
the posterior capsule. capsulotomy. Multiple radial anterior
capsulotomies (arrows) can relieve anterior
capsule phimosis and traction on the zonular
fibers. (Illustration by Christine Gralapp.)
ND: YAG LASER CAPSULOTOMY
The Nd:YAG laser is used to treat secondary opacification of the posterior capsule
and/ or contraction of the anterior capsule.
Alternatively, intraocular surgical cleaning of the capsule may be performed during

concurrent anterior segment surgery to maintain an intact posterior capsule if desired.
To reduce the possibility of vitreous prolapse around the IOL and into the anterior chamber,
posterior capsulotomy would ideally be delayed if possible until there is adequate
apposition and fusion of the anterior and posterior capsules peripheral to the lens optic.
Otherwise, the ideal time to treat symptomatic posterior capsule opacity with posterior
capsulotomy has not been established.
ND: YAG LASER CAPSULOTOMY
In addition to capsulotomy, the Nd:YAG laser can be used for :
• vitreolysis,
• synechiolysis,
• iris cystotomy,
• iridotomy,
• anterior hyaloidotomy for malignant glaucoma,
• removal of precipitates and membranes from an IOL surface, and
• removal of fragmentation of retained cortical material.
ND: YAG LASER CAPSULOTOMY- INDICATIONS
The success rate of Nd:YAG laser posterior capsulotomy exceeds 95%.
Indications for Nd:YAG capsulotomy include the following:

• visual acuity symptomatically decreased as a result of PCO
• a hazy posterior capsule preventing a clear view of the ocular fundus required for
diagnostic and therapeutic purposes
• monocular diplopia, a Maddox rod–like effect, or glare caused by wrinkling of the
posterior capsule or by encroachment of a partially opened posterior capsule into the
visual axis
• contraction of anterior capsulotomy (capsular phimosis) causing encroachment on the
visual axis, excessive traction on the zonular fibers, or alteration of the lens optic position
• capsular block syndrome
ND: YAG LASER CAPSULOTOMY- CONTRAINDICATIONS
Contraindications for Nd:YAG laser capsulotomy include the following:
• inadequate visualization of the posterior capsule
• a patient who is unable to remain still or hold fixation during the
procedure (use of a contact lens or retrobulbar anesthesia may
enhance the feasibility of a capsulotomy in such patients)
Relative Contraindications:
• active intraocular inflammation,
• uncontrolled glaucoma,
• high risk of retinal detachment, and
• suspected CME
ND: YAG LASER CAPSULOTOMY- PROCEDURE
• The center of the visual axis, usually 3–4 mm in diameter, is the desired site for posterior
capsulotomy.
• Dilation is not always necessary for the procedure, but it may be helpful when a larger opening is
desired.
• The opening should equate approximately to the size of the physiologically dilated pupil
under scotopic conditions (scotopic vision is the vision of the eye under low-light levels) – this
should average around 4–5 mm in the pseudophakic eye.
• A high plus-powered anterior segment laser lens may improve ocular stability and enlarge the cone
angle of the beam, reducing the depth of focus.
• The smaller focus diameter facilitates the laser pulse puncture of the capsule, and structures in
front of and behind the point of focus are less likely to be damaged.
Capsulotomy can be performed in :
• a spiral (Fig 11-15A),
• cruciate (Fig 11-15B), or
• inverted D–shaped pattern, beginning in the periphery to
reduce the likelihood of central optic pitting until ideal energy
levels and focus have been established.
Occasional IOL dislocation into the vitreous has been reported after
capsulotomy, particularly with silicone plate–haptic lenses.
Constructing the capsulotomy in a spiraling circular pattern,

rather than in a cruciate pattern, creates an opening that is less
likely to extend radially, reducing the risk of dislocation.
Also, the diameter of the capsulotomy should not exceed that of the
IOL optic.
Figure 11-15 Illustrations of Nd:YAG laser posterior capsulotomy. A, A spiral pattern (arrow) may reduce
American Academy of Ophthalmology. Lens and Cataract – Basic and Clinical the risk of radial tears. B, A cruciate pattern (arrows) or inverted D–shaped pattern (not shown) with
Science Course, Section 11. 2020 - 2021. San Fransisco: American Academy of an inferior flap hinge allows for initial punctures in the periphery and may help reduce the risk of central
Ophthalmology. Pg. 199-204 IOL laser damage. (Illustration by Christine Gralapp.)
Cruciate Pattern
• this involves using the YAG laser to create a cross
pattern which then allows the resultant capsule
flaps to retract out of the visual axis.
• Because they are still attached, this method tends to
avoid the creation of free-floating capsular
fragments in the vitreous.
• If needed, additional laser spots can be placed
along the mid-position of these flaps to further
expand the size of the central opening.
• Care must be taken to properly aim the laser to
Circular Pattern avoid pitting the optic in the central visual axis.
• this involves using the YAG laser to create a circular pattern which then allows for a round
posterior capsular opening
• the circular capsular cut-out can end up free-floating in the vitreous and can create a disturbing,
large floater in the patient’s vision
• if the circular opening is left intact at the bottom then the capsular flap will still be attached
and will be less likely to cause a floater
• lasers shots do not need to be placed in the central optical zone using this method so the chance of
central optic pitting is low
Devgan U. YAG Laser Capsulotomy Techniques Los Angeles. August 11, 2018 [cited 2022 March 14]. Available from:
https://cataractcoach.com/2018/08/11/yag-laser-capsulotomy-techniques/
Two different opening patterns of Nd:YAG laser posterior capsulotomy.
Kim Y, Park J. The Effect of Two Different Opening Patterns of Neodymium:YAG Laser Posterior Capsulotomy on Visual Function. Journal
of the Korean Ophthalmological Society. 2012;53:390.
The laser settings depend on the density of the fibrous growth and vary from about 2 to 6 mJ per spot.
The total number of spots also varies and it typically between 10 and 30.
Acrylic IOLs tend to be a bit more resistant to pitting from the YAG shots compared to silicone IOLs.
The laser off-set can be dialed in to minimize the risk of pitting.
Laser power is initially set at 1 mJ/pulse and may be increased if necessary.
Some research suggests that the total energy applied should be less than 80 mJ in order to reduce the risk of
a significant IOP spike.
Devgan U. YAG Laser Capsulotomy Techniques Los Angeles. August 11, 2018 [cited 2022 March 14]. Available from:
https://cataractcoach.com/2018/08/11/yag-laser-capsulotomy-techniques/
Hosam Elfallal. Nd-YAG Posterior Capsulotomy (#015 ). August 6,2021 [cited 2022 March 14]. Available from: https://www.youtube.com/watch?v=pgcLFmp66pA
When minimal laser energy is applied, the anterior vitreous face may remain intact.
A ruptured anterior vitreous face will usually not result in anterior chamber prolapse by the barrier
effect of a PCIOL, although in rare instances vitreous strands can migrate around the lens and
through the pupil.
Any PCIOL can be damaged by laser energy, but the threshold for lens damage appears to be
lower for silicone than for other materials.
The surgeon focuses the laser just behind the posterior capsule; pulses too far behind the IOL
will be ineffective.
The safest approach is to focus the laser beam slightly behind the posterior surface of the
capsule for the initial application and then move anteriorly for subsequent applications until
the desired puncture is achieved.
In cases of anterior capsule contraction, multiple

relaxing incisions of the fibrotic ring relieve the
contracting force and create a larger optical opening
(see Fig 11-14).
Occasionally, the Nd:YAG laser is insufficient to

address exceptionally dense fibrosis, which may
require surgical manipulation with a discission
knife, vitrectomy handpiece, or scissors. Figure 11-14 Illustration of Nd:YAG laser anterior
capsulotomy. Multiple radial anterior
capsulotomies (arrows) can relieve anterior
capsule phimosis and traction on the zonular
fibers. (Illustration by Christine Gralapp.)
ND: YAG LASER CAPSULOTOMY- COMPLICATIONS
Complications of Nd:YAG laser capsulotomy include:
• transient or long-term elevated IOP
• CME
• retinal detachment
• hyphema
• damage to or dislocation of the IOL
• corneal edema
• corneal abrasions (from the focusing contact lens for the laser surgery)
Transient elevation of IOP occurs in a substantial number of patients, with pressure levels
peaking 2–3 hours after surgery.
This elevation is likely due to obstruction of the outflow pathways by debris scattered
by the laser treatment.
It is more common in eyes with :

• vitreous prolapse,
• those without in-the-bag fixation of the IOL, or
• those with preexisting glaucoma.
Such elevation responds quickly to topical glaucoma medications, which can be

continued for 3–5 days after the procedure.
To reduce the risks of postprocedure IOP spikes, inflammation, and CME following
any type of laser capsular surgery, many surgeons prescribe :
• prophylactic preoperative and postoperative ocular hypotensive medications
(α-adrenergic agonist or β-blocker drops),
• as well as either topical corticosteroids or NSAIDs, although there is
insufficient evidence to uniformly recommend these prophylactically in patients
without additional risk factors.
• In patients with a history of CME or in high-risk patients such as those with
diabetic retinopathy, the prophylactic use of topical corticosteroids or
NSAIDs may be beneficial.
Nd:YAG laser capsulotomy may increase the risk of retinal detachment; the reported incidence is 0%–3.6%.
Approximately 50%–75% of retinal detachments after cataract extraction occur within 1 year of surgery or within 6
months of capsulotomy, often in association with posterior vitreous detachment (PVD).
In many cases, it is difficult to ascertain whether the retinal detachment is related to the capsulotomy or to the cataract
surgery itself or whether it is simply a consequence of a naturally occurring PVD.
Factors that increase the risk of retinal detachment after Nd:YAG capsulotomy include :
• axial myopia,
• male sex,
• young age,
• trauma,
• vitreous prolapse,
• a family history of retinal detachment, and
• preexisting vitreoretinal pathology.
It is important to instruct all patients to promptly report any new symptoms suggesting a PVD or retinal tear.
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CAPSULAR OPACIFICATION AND

The most common late occurrence after cataract surgery by means of

In addition, contracture of a continuous curvilinear capsulorrhexis may

Opaque secondary membranes are formed by proliferating lens

Lens epithelial cells proliferate in several patterns.

Sequestration of nucleated bladder cells (Wedl cells) in a closed

The IOL material also has a modest effect on opacification rates.

There seems to be no difference in PCO rates with prolonged use of postoperative

The term capsular phimosis describes the postoperative contraction of the

Fibrosis and anterior capsule contraction occur more frequently with :

Anterior capsule contraction may contribute to late pseudophacodonesis

Capsular phimosis can be treated with several radial

This procedure is performed similar to Nd:YAG laser

In general, the anterior capsule tissue or a fibrotic ring is

Alternatively, intraocular surgical cleaning of the capsule may be performed during

Indications for Nd:YAG capsulotomy include the following:

Constructing the capsulotomy in a spiraling circular pattern,

Two different opening patterns of Nd:YAG laser posterior capsulotomy.

The laser off-set can be dialed in to minimize the risk of pitting.

Laser power is initially set at 1 mJ/pulse and may be increased if necessary.

In cases of anterior capsule contraction, multiple

Occasionally, the Nd:YAG laser is insufficient to

It is more common in eyes with :

Such elevation responds quickly to topical glaucoma medications, which can be

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