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Capsular Opacification and Contraction

Posterior Capsule Opacification

The most common late complication of 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. Posterior or anterior capsule opacification is amenable to treatment by
intraocular peeling or polishing of the capsule or by means of Nd:YAG laser capsulotomy.

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. 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. Significantly, the 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.

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 influence this rate include the age of the
patient, history of intraocular inflammation, presence of pseudoexfoliation syndrome, size of the
anterior capsulorrhexis, quality of the cortical cleanup, capsular fixation of the implant, design of
the lens implant (specifically, a reduction in incidence with posterior convex or a truncated
square-edge optic design), modification of the lens surface, and time elapsed since surgery.
There seems to be no difference 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 effect on opacification 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 influencing 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 reflections and positive dysphotopsias.

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 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 fibrosis. Phimosis produces symptoms similar to
and often more pronounced than those of fibrosis it self and may cause stress on the zonular
fibers or decentration of an IOL optic.

Anterior capsule contraction and fibrosis 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 fibers, 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 fibrotic ring is tougher and thus
requires more laser power than does the posterior capsule.

Figure 8-7 Nd:YAG laser anterior capsulotomy. Multiple radial anterior capsulotomies can
relieve anterior capsule phimosis and traction on the zonular fibers

Nd:YAG Laser Capsulotomy

Use of the Nd:YAG laser is now a standard procedure for the treatment of secondary
opacification of the posterior capsule or contraction of the anterior capsule. Alternatively,
intraocular surgical cleaning of the capsule may be performed during the course of concurrent
anterior segment surgery if it is desirable to maintain an intact posterior capsule. If possible,
posterior capsulotomy should be delayed until there is adequate apposition and fusion of the
anterior and posterior capsule peripheral to the lens optic to reduce the possibility of vitreous
prolapse around the IOL and into the anterior chamber. Otherwise, an ideal time to perform
posterior capsulotomy for treatment of symptomatic posterior capsule opacity has not been


The following are indications for Nd:YAG capsulotomy:

 visual acuity symptomatically decreased as a result of PCO

 a hazy posterior capsule preventing the clear view of the ocular fundus required for
diagnostic or 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
 capsular block syndrome


The following are contraindications for Nd:YAG laser capsulotomy:

 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)
 active intraocular inflammation, uncontrolled glaucoma, high risk of retinal detachment,
and suspected CME are all relative contraindications


Observation of the posterior capsule through an undilated pupil can help the surgeon pinpoint the
location of the visual axis. The center of the visual axis is the desired site for the opening, which
is usually adequate at 3–4 mm in diameter. In some circumstances, larger-diameter openings
may be required for more complete visualization of the fundus. Dilation is not always necessary
for the procedure but may be helpful if a larger opening in the posterior capsule is desired. When
viewing the posterior capsule, the surgeon should note before dilation any specific landmarks
near the visual axis, because the location of the visual axis may not be obvious through the
dilated pupil.

A high-plus-powered anterior segment laser lens, used with topical anesthesia, improves ocular
stability and enlarges 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.

Figure 8-8 Nd:YAG laser posterior capsulotomy. A, A spiral pattern (arrow) may reduce the risk
of radial tears. B, A cruciate pattern (arrows) or an inverted-D-shaped pattern (not shown) with
an inferior flap hinge allows for initial punctures in the periphery and may help reduce the risk of
central IOL laser damage.

Capsulotomy can be performed in a spiral (Fig 8-8A), cruciate (Fig 8-8B), 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
following capsulotomy has been reported, 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.

If 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 vitreous strands occasionally 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 laser pulse should be focused 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 8-7).

The success rate of Nd:YAG laser posterior capsulotomy exceeds 95%. 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.

In addition to capsulotomy, the Nd:YAG laser can be used for vitreolysis, synechialysis, iris
cystotomy, iridotomy, anterior hyaloidotomy for ciliary block, removal of precipitates and
membranes from an IOL surface, and fragmentation of retained cortical material.


Complications of Nd:YAG laser capsulotomy include transient or long-term elevated IOP, retinal
detachment, CME, hyphema, damage to or dislocation of the IOL, corneal edema, and corneal
abrasions (from the focusing contact lens for the laser surgery). Transient elevation of IOP
occurs in a significant 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 following the procedure. For
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 to reduce the risk of postprocedure IOP spikes,
inflammation, and CME.

Nd:YAG laser capsulotomy may increase the risk of retinal detachment; the reported incidence is
0%–3.6%. Approximately 50%–75% of the retinal detachments following cataract extraction
occur within 1 year of surgery or within 6 months of capsulotomy, often in association with a
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. Axial myopia, male sex, young age, trauma, vitreous
prolapse, a family history of retinal detachment, and preexisting vitreoretinal pathology are
factors that increase the risk of retinal detachment following Nd:YAG capsulotomy. All patients
at increased risk of retinal detachment should be instructed to promptly report any new
symptoms suggesting a PVD or retinal tear.

CME can occur following Nd:YAG capsulotomy. 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.