Introduction

After continuous curvilinear capsulorrhexis in uneventful phacoemulsification cataract surgery, the anterior capsule opening often contracts to some degree.1, 2 In rare cases the contraction can be severe, leading to anterior capsule contraction syndrome (ACCS). ACCS consists of opacification, fibrosis, and contraction of the anterior capsule. When the constriction affects the visual axis, visual acuity decreases. In advanced cases, intraocular lens decentration and flexion of the haptics onto the anterior surface of the optic can occur.3 Once formed, removal of fibrosis often needs surgical removal.4 Nd:YAG opening frequently requires excessive laser energy with complications such as IOL pitting, cystoid macular oedema, or residual fibrotic material in the anterior chamber that may lead to inflammation and secondary glaucoma. Surgical treatment options for ACCS include the use of a capsulorrhexis forceps to peel the fibrotic capsule,5 microscissors4 or vitrector-cut capsulotomy.6 The latter carries the risk IOL damage or severe iris damage, as the tip of the vitrector needs to be pushed towards the IOL to engage the opening of the vitrector with the anterior capsule. We report here a novel, minimally invasive and safe technique of bimanual anterior capsulotomy and haptic reposition or amputation in a small case series to restore a clear visual axis.

Materials and methods

This retrospective clinical study included patients who received phacoemulsification and IOL implantation between November 2010 and December 2011. Informed consent was obtained from all patients prior to surgical procedures. In all cases a hydrophilic one-piece acrylic IOL (Quatrix IOL, Corneal Laboratories, La Rochelle, France) was used. Inclusion criteria included successful creation of a complete and appropriately sized CCC and IOL fixation in the capsular bag. Patients with pseudoexfoliation syndrome or a history of uveitis and intra-operative complications were excluded. A standard technique (2.75 mm clear corneal incision, Duovisc, phaco-chop, bimannual irrigation-aspiration(I/A), 1 mg intracameral Cefuroxime) and platform (Infinity, Alcon, Fort Worth, TX, USA) was used in all cases. Out of this cohort the rate of ACCS was determined and a novel technique for revision of ACCS is described.

Results and report of technique

The retrospective study included 268 eyes (109 left and 159 right). Four (1.5%) eyes of this cohort developed a ACCS grade 2 according to Toto et al,7 requiring surgical intervention (Figure 1). Subtenons anaesthesia (Lidocaine 2%/Mepivacaine 0.5% 50:50 (4–6 ml)) was used in all four cases. After surgical disinfection with 2.5% povidone iodine and draping the anterior chamber was entered obliquely at 6 o’clock with a 20-gauge MVR blade and an anterior chamber maintainer was inserted. Two additional 20-gauge paracenteses were made in the 10 and 2 o’clock positions. The anterior capsule was opened with the MVR blade and a small amount of viscoleastic material was placed underneath the anterior capsule. Grieshaber 23-gauge endgrasping forceps and standard curved scissors were used for bimanual surgical anterior capsulectomy. Briefly, the edge of the anterior capsulotomy was lifted with the forceps for stablization and the anterior capsule opening was enlarged by tangential cuts with the scissors (Supplementary Video 1).

Figure 1
figure 1

(a) Anterior capsule contraction syndrome with complete obliteration of the visual axis. Arrows define the dislocated haptics. Asterisks show anterior capsule opening. (b) Anterior capsule contraction syndrome with IOL decentration and haptic dislocation. Arrows point to haptics. Asterisks show anterior capsule opening.

In two cases, amputation of the IOL haptics to achieve a free optical axis (clip 1) was necessary. The cut capsule and haptics were removed from the anterior chamber using the endgrasping forceps. At the end of surgery, viscoelastic was removed with a Simcoe cannula and 1 mg intracameral Cefuroxime was given prior to hydration of the paracentesis. Postoperative G dexamethasone 0.1% and G Ofloxacin 0.3% q.i.d. were prescribed for 7 days. One day after capsulectomy, the visual acuity improved objectively and subjectively in all patients (Table 1).

Table 1 Patient data

Discussion

The incidence of ACCS with the Quatrix IOL (Croma-Pharma GmbH, Leobendorf, Austria), a single-piece hydrophilic acrylic aspheric IOL, has been reported previously to be about 5%.8 We report here a lower incidence of ACCS with the Quatrix IOL of 1.5% in a large cohort undergoing standard phacoemulsification cataract extraction, although only cases with visually significant ACCS were included. All of our cases with ACCS were treated surgically using a novel minimally invasive technique. Several factors promote capsular contraction syndrome. Apart from capsulorhexis technique, risk factors for the development of ACCS include pseudoexfoliation syndrome,9 diabetes mellitus,10, 11 and retinitis pigmentosa.12 IOL design and IOL composition are significant factors in the development of ACCS as well.1314 Treatment of ACCS depends on the degree of visual disability due to whitening of the capsule over the IOL optic. We report here a minimally invasive technique using standard 23-gauge vitreoretinal forceps and horizontal scissors to bimanually remove the fibrotic anterior capsule, and in some cases to perform haptic amputation. Although we describe this technique exclusively in ACCS associated with the Quatrix IOL, it is likely to be useful in ACCS associated with other types of acrylic one-piece IOLs. Potential sequelae of haptic amputation may be iris chafing with development of microhyphema or bag IOL complex dislocation because of further contracture of the bag. This technique has the advantage over other forms of surgical removal that only small paracenteses are required to gain access and maintain stability of the anterior chamber. This results in minimal induction of astigmatism and rapid postoperative visual rehabilitation. The use of an anterior chamber maintainer makes this procedure very safe and cost efficient. Using the bimanual technique also offers more control and minimal risk of damaging the IOL than with laser capsulotomy while being able to remove even tenacious membranes.