**4. A case of early capsular shrinkage syndrome after cataract surgery for retinitis pigmentosa and high myopia eyes**

On March 5, 2018, a patient with binocular retinitis pigmentosa and high myopia complicated with cataract was admitted to hospital. The visual acuity was hand motion in both eyes; intraocular pressure was 15 mmHg in the right eye and 20 mmHg in the left eye; there was alternating exotropia and nystagmus in both eyes. The lens cortex of the right eye had localized opacity, and the nucleus was opaque and dark brown; the left lens nucleus was opaque and brown-yellow, and there was obvious posterior subcapsular opacity (**Figure 9**).

The patient underwent small incision cataract extraction in the right eye and phacoemulsification cataract surgery in the left eye on March 8, 2018, and April 3, 2018, respectively. The author knew that both retinitis pigmentosa and high myopia are risk factors for capsular contraction syndrome (CCS), small incision cataract extraction in the right eye was performed gently and the continuous curvilinear capsulorhexis (CCC) diameter was larger than 6 mm; the patient's lens suspensory

ligament was found to loosen during capsulorhexis. When the residual cortex was aspirated, starfish-like cortical debris was found attached to the posterior capsule, which was polished using a viscoelastic needle. As the pupil could not be fully dilated, the IOL positioning hook assisted in the dilation of the pupil, the equatorial cortex was aspirated as far as possible, the posterior capsule was carefully polished, and finally, a one-piece hydrophilic acrylic IOL was implanted. Postoperative vision in the right eye was 0.2, intraocular pressure was 17 mmHg, the cornea was clear, pupils were round, light reflection was good, aqueous flare was ++, the IOL position was good, and retinitis pigmentosa and high myopic changes were observed in the fundus. The patient received prednisolone acetate eye drops 8 times a day and levofloxacin, pranoprofen, and 3% sodium hyaluronate eye drops four times a day. At the re-examination 1 week after the operation, the anterior chamber inflammation was significantly relieved, the IOL position was stable, the rest were similar to that at 1 day after surgery. The patient came to the hospital for scheduled cataract surgery for the left eye, 20 days after the operation. Re-examination showed right eye visual acuity as 0.25 and the intraocular pressure as 18 mmHg; the cornea was clear as revealed by the slit lamp examination, the aqueous flare was -, the pupils were round, and light reflection was good. Mydriatic examination showed that the anterior capsular opening was shrunk to less than 4 mm with obvious CCS (**Figure 10**).

CCS was quite obvious soon after cataract surgery, and timely detection and treatment were necessary to prevent serious complications. Therefore, after communicating with the patient, YAG laser anterior capsular opening lysis was performed for the right eye of the patient. First, the site of the anterior capsule with less tension was selected; then the anterior capsule was opened using laser, and the laser was used continuously at the contralateral site to loosen the shrunk anterior capsule, and the rest was performed in a manner similar to that followed to loosen the anterior capsule around the entire circumstance. It was forbidden to directly select the edge of the capsular opening for laser lysis, as asymmetrical dehiscence of the capsular membrane might occur due to excessive tension (**Figure 11**).

After YAG laser surgery, slit-lamp examination showed that the patient had more floating white crystalline cortical debris in the anterior chamber of the right eye. The intraocular pressure was 30 mmHg. He received prednisolone acetate eye drops four times a day; timolol eye drops two times/day; levofloxacin, pranoprofen,

**67**

**Figure 11.**

*Special Cases in Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

and 3% sodium hyaluronate eye drops four times/day, and the patient was asked to visit for re-examination the next day. The re-examination showed that the visual acuity of the right eye was 0.25 and the intraocular pressure was 22 mmHg. The slitlamp examination showed that the cortical debris floating in the anterior chamber of the right eye was significantly reduced, and the IOL position was stable. The patient was instructed to continue the medication and to visit for re-examination after 3 days. The re-examination showed the visual acuity of the right eye was 0.25, and the intraocular pressure was 17 mmHg. The slit-lamp examination showed only a small amount of floating cortical debris in the anterior chamber of the right eye, and the IOL position was stable; the patient was instructed to continue the previous medication. Because the degree of cataract in the left eye of the patient was lighter than that of the right eye and the nuclear hardness grade was lower than that of the right eye, phacoemulsification cataract aspiration in the left eye was scheduled on April 3, 2018. Owing to the experience in the right eye, special attention was paid to the prevention of CCS during the perioperative period of the left eye. First, preoperatively, non-steroidal anti-inflammatory drug pranoprofen eye drops were administered four times a day to reduce the intraoperative inflammation and maintain the dilated state of the pupil during the operation. Second, operations were performed as gently as possible during the surgery to reduce mechanical irritation to the iris to reduce the release of inflammatory mediators. During capsulorhexis, the suspensory ligament of the lens was loosened, and the diameter of the capsulorhexis opening was larger than 6 mm. Sufficient hydrodissection was performed to reduce the pulling effect of the intraoperative operation on the ligament, during the phacoemulsification process, the nucleus was split into smaller nuclei as far as possible before performing emulsification to reduce the release of ultrasound energy. When the emulsification was completed and the residual cortex was aspirated, the central part of the posterior capsule showed starfish-like attached cortical debris, which was tightly attached to the posterior capsule. It was mechanically polished using a viscoelastic needle, and the anterior subcapsular region was polished using a polisher around the whole circumference to reduce postoperative

*The shrinkage of the anterior capsular opening is significantly reduced after laser lysis in the right eye.*

**Figure 10.** *Anterior capsular opening of the right eye is shrunk.*

*Current Cataract Surgical Techniques*

ligament was found to loosen during capsulorhexis. When the residual cortex was aspirated, starfish-like cortical debris was found attached to the posterior capsule, which was polished using a viscoelastic needle. As the pupil could not be fully dilated, the IOL positioning hook assisted in the dilation of the pupil, the equatorial cortex was aspirated as far as possible, the posterior capsule was carefully polished, and finally, a one-piece hydrophilic acrylic IOL was implanted. Postoperative vision in the right eye was 0.2, intraocular pressure was 17 mmHg, the cornea was clear, pupils were round, light reflection was good, aqueous flare was ++, the IOL position was good, and retinitis pigmentosa and high myopic changes were observed in the fundus. The patient received prednisolone acetate eye drops 8 times a day and levofloxacin, pranoprofen, and 3% sodium hyaluronate eye drops four times a day. At the re-examination 1 week after the operation, the anterior chamber inflammation was significantly relieved, the IOL position was stable, the rest were similar to that at 1 day after surgery. The patient came to the hospital for scheduled cataract surgery for the left eye, 20 days after the operation. Re-examination showed right eye visual acuity as 0.25 and the intraocular pressure as 18 mmHg; the cornea was clear as revealed by the slit lamp examination, the aqueous flare was -, the pupils were round, and light reflection was good. Mydriatic examination showed that the anterior capsular opening was shrunk to less than 4 mm with obvious CCS (**Figure 10**). CCS was quite obvious soon after cataract surgery, and timely detection and treatment were necessary to prevent serious complications. Therefore, after communicating with the patient, YAG laser anterior capsular opening lysis was performed for the right eye of the patient. First, the site of the anterior capsule with less tension was selected; then the anterior capsule was opened using laser, and the laser was used continuously at the contralateral site to loosen the shrunk anterior capsule, and the rest was performed in a manner similar to that followed to loosen the anterior capsule around the entire circumstance. It was forbidden to directly select the edge of the capsular opening for laser lysis, as asymmetrical dehiscence of

the capsular membrane might occur due to excessive tension (**Figure 11**).

After YAG laser surgery, slit-lamp examination showed that the patient had more floating white crystalline cortical debris in the anterior chamber of the right eye. The intraocular pressure was 30 mmHg. He received prednisolone acetate eye drops four times a day; timolol eye drops two times/day; levofloxacin, pranoprofen,

**66**

**Figure 10.**

*Anterior capsular opening of the right eye is shrunk.*

**Figure 11.** *The shrinkage of the anterior capsular opening is significantly reduced after laser lysis in the right eye.*

and 3% sodium hyaluronate eye drops four times/day, and the patient was asked to visit for re-examination the next day. The re-examination showed that the visual acuity of the right eye was 0.25 and the intraocular pressure was 22 mmHg. The slitlamp examination showed that the cortical debris floating in the anterior chamber of the right eye was significantly reduced, and the IOL position was stable. The patient was instructed to continue the medication and to visit for re-examination after 3 days. The re-examination showed the visual acuity of the right eye was 0.25, and the intraocular pressure was 17 mmHg. The slit-lamp examination showed only a small amount of floating cortical debris in the anterior chamber of the right eye, and the IOL position was stable; the patient was instructed to continue the previous medication. Because the degree of cataract in the left eye of the patient was lighter than that of the right eye and the nuclear hardness grade was lower than that of the right eye, phacoemulsification cataract aspiration in the left eye was scheduled on April 3, 2018. Owing to the experience in the right eye, special attention was paid to the prevention of CCS during the perioperative period of the left eye. First, preoperatively, non-steroidal anti-inflammatory drug pranoprofen eye drops were administered four times a day to reduce the intraoperative inflammation and maintain the dilated state of the pupil during the operation. Second, operations were performed as gently as possible during the surgery to reduce mechanical irritation to the iris to reduce the release of inflammatory mediators. During capsulorhexis, the suspensory ligament of the lens was loosened, and the diameter of the capsulorhexis opening was larger than 6 mm. Sufficient hydrodissection was performed to reduce the pulling effect of the intraoperative operation on the ligament, during the phacoemulsification process, the nucleus was split into smaller nuclei as far as possible before performing emulsification to reduce the release of ultrasound energy. When the emulsification was completed and the residual cortex was aspirated, the central part of the posterior capsule showed starfish-like attached cortical debris, which was tightly attached to the posterior capsule. It was mechanically polished using a viscoelastic needle, and the anterior subcapsular region was polished using a polisher around the whole circumference to reduce postoperative

proliferation. A one-piece hydrophilic acrylate IOL of the same model was implanted. On the second day after surgery, re-examination showed that the left eye visual acuity was 0.3, and the intraocular pressure was 16 mmHg; the slit-lamp examination showed clear cornea, round pupils, good light reflection, aqueous flare was ++, and normal IOL position. The patient received prednisolone acetate eye drops eight times a day and levofloxacin, pranoprofen, and 3% sodium hyaluronate eye drops four times a day. The left eye was re-examined 20 days after surgery, the visual acuity was 0.3, the intraocular pressure was 18 mmHg, the cornea was clear, the aqueous flare was -, the pupil was round, and the light reflection was good. Mydriatic examination showed that the anterior capsular opening was shrunk, less than 4 mm, and CCS was evident. A YAG laser anterior capsule lysis was performed for the patient's left eye, and good postoperative results were achieved (**Figure 12**).

#### **4.1 Discussion**

This case study analyzed a case of a complicated cataract patient with binocular retinitis pigmentosa and high myopia who developed severe CCS short-term postoperatively, and both eyes were treated using YAG laser lysis.

Most of the capsular bag shrinkage caused by non-specific stimulation after cataract surgery occurs in the anterior lens capsule [20]. Residual lens epithelial cells (LEC) under the margin of the anterior capsule produce a variety of cytokines under the surgical stimulation and stimulation by different material IOLs. These factors may react against LEC and make it produce collagen and fibers through autocrine or paracrine, leading to shrinkage of the anterior capsular opening [21].

Several studies have shown that silicone gel IOLs have a higher incidence of CCS than other types of IOLs [22, 23]. The study of Tsinopoulos et al. [24] showed that hydrophilic acrylate IOL has a higher incidence of CCS than hydrophobic acrylate IOL. Although hydrophilic acrylic material has better uveal biocompatibility, lower adhesion of bacteria and silicone oil, and less incidence of glare, its weak adhesion to type IV collagen leads to an increased incidence of fibrosis, which is more likely to lead to the occurrence of CCS [25–27]. The hydrophobic acrylate IOL can inhibit the migration of LEC to the optical zone and loops, thereby reducing the occurrence of CCS [22, 28, 29]. In this case, both eyes of the patient used hydrophilic acrylic IOL, which may also be one of the risk factors for the rapid occurrence of CCS. Studies have shown that one-piece acrylate and three-piece acrylate IOL have similar incidences of CCS [30]. Another study showed that four-loop IOL is more effective in preventing postoperative IOL eccentricity and CCS [31].

#### **Figure 12.**

*Image of the capsular opening that was shrunk after the operation of the left eye. Image of the capsular opening that is in good condition after YAG laser anterior capsule lysis.*

**69**

*Special Cases in Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

risk factors that are prone to CCS in the patient.

patients was all less than 10 mm2

suspensory ligament function.

than those without fundus disease [35].

Studies have shown that the size of the diameter of capsulorhexis is closely related to CCS. CCC larger than 5.5 mm showed an increasing trend in the change of the size of the capsulorhexis after surgery; conversely, the capsulorhexis opening of CCC smaller than 5 mm showed a gradually shrinking trend after the surgery [32]. Anterior capsule opacity after cataract surgery occurs only in the part where the anterior capsule is in contact with the IOL. Therefore, the smaller the capsulorhexis diameter, the more obvious the anterior capsule opacity and organization will be, thereby aggravating the occurrence of capsular bag shrinkage. To prevent postoperative CCS, the diameter of the capsulorhexis, in this case, was greater than 6 mm; however, it did not have an obvious preventive effect. This may be related to other

All diseases that easily affect the normal function of the suspensory ligament and lead to the fragility of the suspensory ligament are risk factors for the occurrence of CCS, including retinitis pigmentosa, high myopia, and advanced age [33]. The shrinkage area of the capsular bag of patients with retinitis pigmentosa was significantly larger than that of the normal control group, which was close to 25%. In total, 9.4% of the retinitis pigmentosa group underwent YAG laser anterior capsulotomy within 12 months after surgery. The anterior capsular opening area of these

barrier function, including exfoliation syndrome, uveitis, diabetes, and myotonic dystrophy, were all risk factors for CCS [35, 36]. The stimulation of cataract surgery is more likely to lead to the destruction of the barrier, thus causing the occurrence of CCS. Moreover, patients with diabetic retinopathy are more likely to develop CCS

The treatment of CCS includes YAG laser anterior capsulotomy and surgical treatment. YAG laser is a safe and effective method for the treatment of early CCS, which can effectively enlarge the anterior capsule opening and restore visual function [37]. The study by Deokule et al. [37] showed that the success rate of YAG laser treatment of CCS was 78%, while the failure rate of preoperative IOL eccentric cases was high. Some researchers have reported [38, 39] that the early preventive application of YAG laser after cataract surgery for anterior capsulotomy at meridian 0°, 120°, and 240° can effectively prevent the occurrence of CCS in high-risk patients without adverse reactions. In more severe cases of CCS, YAG laser lysis cannot achieve effective treatment, and the proliferating fibrous membrane must be surgically seaparted under the anterior capsule and the adhesion of IOL edges and loops, to remove the fibrous membrane as far as possible by cutting or tearing it off. Radial cutting or direct continuous circular capsulorhexis was performed on the narrowed anterior capsular opening to remove the fibrous membrane, and there was no recurrence during postoperative follow-up [40]. Yeh et al. [41] proposed to use an anterior vitrectomy to cut the shrunk anterior capsular opening to remove the subcapsular fibrous membrane and residual lens epithelial cells, which can reduce the chance of radial tear of the suspensory ligament and secondary IOL eccentricity. The disadvantage of the surgical method is that it may cause further damage to the suspensory ligament and IOL eccentricity for patients with poor

The prevention of CCS mainly includes the following aspects: (1) The application of preoperative non-steroidal anti-inflammatory drugs can effectively reduce the release of intraoperative inflammatory factors, thereby preventing the progression of anterior capsule shrinkage [42]. (2) Avoid excessive stimulation of the iris tissue and further aggravation of the destruction of the blood-aqueous barrier during whole operation. The diameter of the CCC should be 5.5–6.0 mm. The complete removal of the residual LEC under the anterior capsule helps to prevent the excessive proliferation of the anterior capsular opening, preventing CCS [43].

[34]. Diseases involving abnormal blood–aqueous

#### *Special Cases in Cataract Surgery DOI: http://dx.doi.org/10.5772/intechopen.98260*

*Current Cataract Surgical Techniques*

**4.1 Discussion**

proliferation. A one-piece hydrophilic acrylate IOL of the same model was implanted. On the second day after surgery, re-examination showed that the left eye visual acuity was 0.3, and the intraocular pressure was 16 mmHg; the slit-lamp examination showed clear cornea, round pupils, good light reflection, aqueous flare was ++, and normal IOL position. The patient received prednisolone acetate eye drops eight times a day and levofloxacin, pranoprofen, and 3% sodium hyaluronate eye drops four times a day. The left eye was re-examined 20 days after surgery, the visual acuity was 0.3, the intraocular pressure was 18 mmHg, the cornea was clear, the aqueous flare was -, the pupil was round, and the light reflection was good. Mydriatic examination showed that the anterior capsular opening was shrunk, less than 4 mm, and CCS was evident. A YAG laser anterior capsule lysis was performed for the patient's left eye, and good postoperative results were achieved (**Figure 12**).

This case study analyzed a case of a complicated cataract patient with binocular retinitis pigmentosa and high myopia who developed severe CCS short-term

Most of the capsular bag shrinkage caused by non-specific stimulation after cataract surgery occurs in the anterior lens capsule [20]. Residual lens epithelial cells (LEC) under the margin of the anterior capsule produce a variety of cytokines under the surgical stimulation and stimulation by different material IOLs. These factors may react against LEC and make it produce collagen and fibers through autocrine or paracrine, leading to shrinkage of the anterior capsular opening [21]. Several studies have shown that silicone gel IOLs have a higher incidence of CCS than other types of IOLs [22, 23]. The study of Tsinopoulos et al. [24] showed that hydrophilic acrylate IOL has a higher incidence of CCS than hydrophobic acrylate IOL. Although hydrophilic acrylic material has better uveal biocompatibility, lower adhesion of bacteria and silicone oil, and less incidence of glare, its weak adhesion to type IV collagen leads to an increased incidence of fibrosis, which is more likely to lead to the occurrence of CCS [25–27]. The hydrophobic acrylate IOL can inhibit the migration of LEC to the optical zone and loops, thereby reducing the occurrence of CCS [22, 28, 29]. In this case, both eyes of the patient used hydrophilic acrylic IOL, which may also be one of the risk factors for the rapid occurrence of CCS. Studies have shown that one-piece acrylate and three-piece acrylate IOL have similar incidences of CCS [30]. Another study showed that four-loop IOL is more

postoperatively, and both eyes were treated using YAG laser lysis.

effective in preventing postoperative IOL eccentricity and CCS [31].

*Image of the capsular opening that was shrunk after the operation of the left eye. Image of the capsular opening* 

*that is in good condition after YAG laser anterior capsule lysis.*

**68**

**Figure 12.**

Studies have shown that the size of the diameter of capsulorhexis is closely related to CCS. CCC larger than 5.5 mm showed an increasing trend in the change of the size of the capsulorhexis after surgery; conversely, the capsulorhexis opening of CCC smaller than 5 mm showed a gradually shrinking trend after the surgery [32]. Anterior capsule opacity after cataract surgery occurs only in the part where the anterior capsule is in contact with the IOL. Therefore, the smaller the capsulorhexis diameter, the more obvious the anterior capsule opacity and organization will be, thereby aggravating the occurrence of capsular bag shrinkage. To prevent postoperative CCS, the diameter of the capsulorhexis, in this case, was greater than 6 mm; however, it did not have an obvious preventive effect. This may be related to other risk factors that are prone to CCS in the patient.

All diseases that easily affect the normal function of the suspensory ligament and lead to the fragility of the suspensory ligament are risk factors for the occurrence of CCS, including retinitis pigmentosa, high myopia, and advanced age [33]. The shrinkage area of the capsular bag of patients with retinitis pigmentosa was significantly larger than that of the normal control group, which was close to 25%. In total, 9.4% of the retinitis pigmentosa group underwent YAG laser anterior capsulotomy within 12 months after surgery. The anterior capsular opening area of these patients was all less than 10 mm2 [34]. Diseases involving abnormal blood–aqueous barrier function, including exfoliation syndrome, uveitis, diabetes, and myotonic dystrophy, were all risk factors for CCS [35, 36]. The stimulation of cataract surgery is more likely to lead to the destruction of the barrier, thus causing the occurrence of CCS. Moreover, patients with diabetic retinopathy are more likely to develop CCS than those without fundus disease [35].

The treatment of CCS includes YAG laser anterior capsulotomy and surgical treatment. YAG laser is a safe and effective method for the treatment of early CCS, which can effectively enlarge the anterior capsule opening and restore visual function [37]. The study by Deokule et al. [37] showed that the success rate of YAG laser treatment of CCS was 78%, while the failure rate of preoperative IOL eccentric cases was high. Some researchers have reported [38, 39] that the early preventive application of YAG laser after cataract surgery for anterior capsulotomy at meridian 0°, 120°, and 240° can effectively prevent the occurrence of CCS in high-risk patients without adverse reactions. In more severe cases of CCS, YAG laser lysis cannot achieve effective treatment, and the proliferating fibrous membrane must be surgically seaparted under the anterior capsule and the adhesion of IOL edges and loops, to remove the fibrous membrane as far as possible by cutting or tearing it off. Radial cutting or direct continuous circular capsulorhexis was performed on the narrowed anterior capsular opening to remove the fibrous membrane, and there was no recurrence during postoperative follow-up [40]. Yeh et al. [41] proposed to use an anterior vitrectomy to cut the shrunk anterior capsular opening to remove the subcapsular fibrous membrane and residual lens epithelial cells, which can reduce the chance of radial tear of the suspensory ligament and secondary IOL eccentricity. The disadvantage of the surgical method is that it may cause further damage to the suspensory ligament and IOL eccentricity for patients with poor suspensory ligament function.

The prevention of CCS mainly includes the following aspects: (1) The application of preoperative non-steroidal anti-inflammatory drugs can effectively reduce the release of intraoperative inflammatory factors, thereby preventing the progression of anterior capsule shrinkage [42]. (2) Avoid excessive stimulation of the iris tissue and further aggravation of the destruction of the blood-aqueous barrier during whole operation. The diameter of the CCC should be 5.5–6.0 mm. The complete removal of the residual LEC under the anterior capsule helps to prevent the excessive proliferation of the anterior capsular opening, preventing CCS [43].

(3) Adequate anti-inflammatory treatment should be provided after the operation, which should be combined with glucocorticoid and non-steroidal anti-inflammatory eye drops, and the use time of non-steroidal anti-inflammatory drugs should be appropriately extended, which can effectively control the postoperative inflammatory response of operation and plays a role in preventing CCS. (4) In terms of IOL selection, hydrophobic acrylate materials are the first choice. (5) The use of intraoperative capsular tension ring. Studies have shown that the implantation of the capsular bag tension ring can effectively prevent IOL eccentricity, tilt, and significantly prevent capsular bag shrinkage [44, 45].
