Rare Complication Of A Selective Laser Device For Anterior Capsulotomy In Cataract Surgery – A Case Series

To report a series of three cases where an endothelial impression was noted after the use of the CAPSULaser selective laser device for anterior capsulotomy in cataract surgery.

Nethradhama Super Speciality Eye Hospital, Jayanagar, Bangalore.

Following anterior chamber paracentesis, CAPSULBlue dye (EXCEL-LENS, Inc.) which is 0.4% trypan blue, was injected. In two cases, the dye was injected with the cannula directed towards the endothelium. It was diluted with balanced salt solution (BSS) after 30s and washed out after 60s. In the third case, although the dye was injected with the cannula directed downwards, into the anterior chamber, it was not diluted at 30s and was directly washed with BSS after 60s. The CAPSULaser (EXCEL-LENS, Inc.) beam was focused and centered on the anterior capsule. During the firing of the diode laser on the anterior capsule, a laser impression in the form of a circle was noted on the endothelium. In all 3 cases, the laser capsulotomy has tissue tags and a micro rhexis forceps was used to complete the capsulotomy. This was followed by routine phacoemulsification with PCIOL implantation. All patients were examined on postoperative days 1, 15, and 30. On each visit, UCVA and BCVA, slit lamp findings, IOP, slit lamp photography, AS-OCT, and specular microscopy were done. All the patients were treated with routine postoperative medication while 2 patients required the use of topical hyperosmotic agents due to striate keratopathy and moderate corneal edema. One month postoperatively, all three patients had clear corneas with best-corrected vision of 20/20. The endothelial impression disappeared in 2 patients while a partial impression remained in the third patient at one month postoperatively.

We hypothesize that a higher concentration of CAPSULBlue dye compared to the standard 0.06% trypan blue, coupled with the surgical technique caused endothelial staining and endothelial laser impression leading to delayed recovery. However, the patients had clear corneas and no loss of BCVA at one month. This can be avoided by injecting the dye slowly with the cannula directed into the anterior chamber, diluting it with BSS at 30s, and washing it at 60s to avoid endothelial staining. The patients require long-term follow-up to assess possible long-term complications. To the best of our knowledge, this is the first case series reporting endothelial impressions with the use of CAPSULBlue dye and the CAPSULaser system for anterior capsulotomy.