When Capsular Fibrosis Strikes Hard!

To present a case of complete anterior capsular fibrosis within 2months of uncomplicated cataract surgery and to review possible causes for the fibrosis.

Patient self-referred to Eye emergency in the NHS practice in UK and then was referred to Cornea Unit for management.

 A case report of a 91-year-old female, who underwent cataract surgery, on the left eye at an external cataract provider in May 2022. She presented to the NHS eye emergency in July 2022, with complaints of a sudden painless loss of vision with no other pathological features of redness, anterior chamber activity or pupillary reflex changes. There was no red reflex and no fundal view. Visual Acuity was 0.3 LogMAR on the right and HM on the left eye. Early cataract was seen on the right and suspected IOL opacification with thick posterior capsular opacification. An Ultrasound B scan was conducted which showed clear vitreous and normal retinal features. She was Hyperopic in both eyes. Systemically very healthy and only taking medications for Essential Hypertension. 

On referral to specialist unit a complete anterior capsular fibrosis was noted with no view of the implant and no fundal view or red reflex. Surgical capsulotomy was offered, but a YAG laser capsulotomy was attempted. First attempt at YAG capsulotomy opened fibrotic bands which stretached out and formed an opening in the central area of the anterior capsule. This imemdiately confirmed a clear lens implant and also showed signs of thick posterior capsular opacification. Red reflex was seen and fundal view was also hazily visible. The vision immediately improved to 0.7 LogMAR on the left eye which improved further to 0.5 logMAR with posterior YAG capsulotomy done after 6 weeks , with further arrangements for refraction.

Capsular opacification is a well-recognised complication of cataract surgery with intraocular IOL implant surgery. Improvements in surgical techniques, IOL materials and design related factors have helped in the reduction of incidence of posterior capsular opacification. In terms of anterior capsular opacification, it is a fibrotic entity which is confirmed histopathologically with presence of fibrous metaplasia of lens epithelial cells (LECs). Various known causes that must be kept in mind are old age (>90years), zonular weakness, small capsulorhexis and post operative uveitis. This is even more relevant with the advent of newer multifocal and accommodating IOLs and various strategies must be applied to mitigate this risk.