Sir,

Case report

A 3-week-old female infant presented with an absent red reflex in the left eye. Her past medical and ocular histories were unremarkable.

Examination revealed a persistent pupillary membrane (PPM) and what appeared to be an anterior polar cataract in the left eye (Figure 1). Dilated fundus examination and B-scan ultrasonography were unremarkable. Examination of the right eye was within normal limits.

Figure 1
figure 1

Intraoperative view of an opaque plaque on the external surface of the anterior capsule associated with PPM.

Full size image

The patient was scheduled for a left lensectomy and membranectomy. Two stab, clear corneal incisions were fashioned, and cohesive viscoelastic material was used to fill the anterior chamber. A Sinskey hook was used to lyse the PPM 360º. There was no evidence of an anterior polar cataract, and thus lensectomy was not performed. A whitish-grey plaque adherent to the external surface of the anterior capsule was noted. This was peeled off using a 25G cystotome, and Utrata forceps were then used to excise the remnant plaque (Supplementary Media). The anterior capsule was not violated and there were no intraoperative or postoperative complications. At 6 months of age, the patient had equal vision in both eyes as determined by Teller acuity cards in the right and left eyes, respectively, with part-time occlusion.

Comment

Most PPMs are fine strands that regress within the first weeks of life.1 Some may be amblyogenic;2 the decision to excise them depends on an assessment of their likely effect on visual development. They can be associated with cataracts and other ocular pathologies.3 Although anterior capsular plaques have been previously studied in the paediatric population, they are commonly on the internal aspect of the anterior capsule. They are thought to occur secondary to the differentiation of epithelial mesenchymal cells into myofibroblasts that secrete extracellular matrix.4 The plaque seen here was supracapsular, adherent to its external surface. Although careful removal of the plaque avoids unnecessary lensectomy, an iatrogenic secondary cataract may occur. Similar opacities have been anecdotally observed in other eyes with PPM. The mechanisms of anterior capsular synthesis and development are unclear.5

We illustrate a case of firmly adherent plaque on the external surface of the anterior capsule in a young patient with PPM. These can often be confused with anterior polar cataracts pre-operatively. Intraoperative differentiation of the two is critical to avoid unnecessary cataract extraction. We highlight a safe and simple technique using a cystotome and Utrata forceps to remove external capsular plaques while leaving the capsule intact.