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 Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 183-184  

A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector


Guru Nanak Eye Centre, New Delhi, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Dr. Gauri Bhushan
B-3/75B, Lawrence Road, New Delhi - 110 035
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-620X.169895

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   Abstract 

We report a case of delayed onset capsular block syndrome in a patient 6 years after undergoing cataract surgery. Ocular examination revealed marked diminution of vision accompanied with a collection of milky fluid between the intraocular lens and posterior capsule. To treat and to understand the pathology of the condition, aspiration of fluid using 25-gauge vitrector through pars plana was done, and contents sent for microbiological analysis which did not reveal any growth. Postoperative period was uneventful with the absence of intraocular inflammation and excellent visual recovery.

Keywords: Capsular block syndrome, delayed onset, propionibacterium acnes, 25-gauge vitrector


How to cite this article:
Raina UK, Bhushan G, Arora S, Rathie N. A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector. Oman J Ophthalmol 2015;8:183-4

How to cite this URL:
Raina UK, Bhushan G, Arora S, Rathie N. A rare case of delayed onset capsular block syndrome managed using 25-gauge vitrector. Oman J Ophthalmol [serial online] 2015 [cited 2020 Sep 24];8:183-4. Available from: http://www.ojoonline.org/text.asp?2015/8/3/183/169895


   Introduction Top


Capsular block syndrome (CBS) is one of the known rare complications of continuous curvilinear capsulorhexis.[1] Late onset CBS is characterized by a collection of milky white fluid in the space between the intraocular lens (IOL) and the posterior capsule. Clinically, patient reports diminution of vision which recovers rapidly once trapped fluid is released. The knowledge of the nature and origin of this fluid are limited with the possibility of an indolent Propionibacterium acnes invasion.


   Case Report Top


A 56-year-old lady presented with a progressive diminution of vision in right eye. She had a history of undergoing uneventful cataract surgery 6 years back. Slit lamp examination showed early cataractous changes in left eye and right eye revealed the collection of milky fluid in the retrolenticular space with distension of posterior capsule and the areas of white fluffy aggregates focally [Figure 1]. The anterior chamber was of normal depth with the absence of cells/flare. An adequately sized continuous curvilinear capsulorhexis was present, with no evidence of capsular phimosis and deposition of minimal iris pigment on the inferior part of anterior capsulorhexis. After obtaining consent, the patient was taken up for surgical removal of posterior capsule and fluid under local anesthesia. A 25-gauge anterior chamber maintainer was used to counter any intraoperative hypotony. Pars plana port using 25-gauge trocar cannula was created superotemporally 3.5 mm from the limbus. The posterior capsule was breached, and capsular bag contents aspirated initially with a 26-gauge needle inserted through the superotemporal port. The 25-gauge vitrectomy cutter was then inserted through the same port and used to create a posterior capsulotomy, and to perform limited anterior vitrectomy [Figure 2]. With the possibility of indolent P. acnes infection, at the end of procedure intravitreal vancomycin (1 mg/0.1 mL) was given. The aspirated material was immediately transferred to thioglycolate broth and sent to the lab within 30 min of collection. In the laboratory, the sample was incubated on brain heart infusion blood agar anaerobically at 37°C for colony formation. The part of the sample was also incubated on blood agar aerobically for aerobic contamination check. Although no growth was detected on aerobic or anaerobic agar cultures at the end of 72 h, the prolonged culture was done for 14 days to increase detection rate.[2] The patient was followed up for 3 months. Postoperative period was uneventful with good visual recovery BCVA 20/20.
Figure 1: Presence of milky fluid in capsular bag behind intraocular lens with a collection of dense white aggregates inferiorly

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Figure 2: (a) 26-gauge needle used to aspirate contents of capsular bag, (b) posterior capsulotomy made and anterior vitrectomy done using 25-gauge vitrectomy cutter, (c) postoperative appearance

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   Discussion Top


One of the rare complication of continuous curvilinear capsulorhexis and in-the-bag IOL placement is late onset CBS. There occurs a collection of milky fluid within capsular bag between the posterior capsule and posterior chamber IOL. Classically, the patient presents with diminution of vision associated with myopic shift due to forward movement of IOL and a shallow anterior chamber.

Miyake et al.[3] have classified CBS depending on the time of onset: Intraoperative, early postoperative, and late postoperative. As described in their study, in cases of late postoperative CBS collection of fluid could be attributed to metaplasia and proliferation of cortical cells within the capsular bag accompanied with circumferential adhesion of anterior capsule with the IOL. There is a release of turbid fluid by the metaplastic cells which gives the milky hue to the collected retrolenticular fluid. Studies in the past have argued on the nature of the fluid collected in a bag. Upon electrophoresis of the aspirated fluid contents noted was alpha-crystallin and collagen released from the residual lens epithelial cells. In three cases of late onset, CBS Eifrig performed electrophoresis and found mainly alpha-crystallins and a small amount of albumin contradicting role of any organism.[4] However, in isolated case reports, authors have also reported that upon the culture of the aspirated capsular bag fluid microbiological analysis has pointed to the possible role of P. acnes causing an indolent infection.[5],[6] Although literature does not document any definite case of P.acnes associated endophthalmitis after release of fluid post Nd: YAG capsulotomy, to err on the side of caution and in view of poor posterior capsule visualization, we decided to go through pars plana approach using 25-gauge cutter to expedite the surgical process and to avoid possible spilling of potentially infectious fluid into the vitreous cavity. An isolated case report demonstrated the use of 23-gauge vitrectomy cutter to aspirate contents of capsular bag; however, in our case, we used 25-gauge instruments to make the procedure less traumatic and to avoid risk of postoperative hypotony secondary to wound leak.[5] However, no organism was isolated from the aspirated fluid in our patient which led us to postulate that P. acnes may not be involved in all cases of late onset CBS.

In cases of late onset, CBS possible management options include posterior capsule disruption using Nd: YAG laser or a pars plana approach to lyse the capsule and aspirate fluid.[5],[7] Excellent postoperative recovery is noted in either of the methods, as seen in our patient. Using 25-gauge cutter enabled a least traumatic, sutureless, fast surgical removal of fluid collected within the capsular bag and can be considered as an option to manage a case of late onset CBS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Davison JA. Capsular bag distension after endophacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg 1990;16:99-108.  Back to cited text no. 1
    
2.
Butler-Wu SM, Burns EM, Pottinger PS, Magaret AS, Rakeman JL, Matsen FA 3rd, et al. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol 2011;49:2490-5.  Back to cited text no. 2
    
3.
Miyake K, Ota I, Ichihashi S, Miyake S, Tanaka Y, Terasaki H. New classification of capsular block syndrome. J Cataract Refract Surg 1998;24:1230-4.  Back to cited text no. 3
    
4.
Eifrig DE. Capsulorhexis-related lacteocrumenasia. J Cataract Refract Surg 1997;23:450-4.  Back to cited text no. 4
    
5.
Kollias AN, Vogel MA, de Kaspar HM, Lackerbauer CA, Grueterich M. Propionibacterium acnes in capsular bag distension syndrome. J Cataract Refract Surg 2010;36:167-9.  Back to cited text no. 5
    
6.
Dhaliwal DK, Farhi P, Eller AW, Kowalski RP. Late capsular block syndrome associated with Propionibacterium acnes. Arch Ophthalmol 2011;129:246-7.  Back to cited text no. 6
    
7.
Patil S, Azarbod P, Toufeeq A. Late-onset capsular block syndrome without lens displacement. Eye (Lond) 2007;21:113-4.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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