Case series: “Double arch” changes caused by capsule contraction syndrome after cataract surgery in highly myopic eyes

A 41-year-old female patient with a history of high myopia and refractive surgery of anterior chamber IOL(AC-IOL) implantation in phakic eyes was diagnosed with a nuclear cataract in her right eye. The axial length of the right eye was 31.44 mm. Uneventful AC-IOL explantation and phacoemulsification cataract extraction was performed (W.X.), and a CT Asphina 509 M IOL with a power of + 2 D was implanted. One week after the surgery, the corrected distance visual acuity(CDVA) was 20/50, with a refraction of -2.00/-2.00*85. Neither visual discomfort nor structural abnormality of the operated eye were detected in the postoperative 1 week and 1 month. However, the patient complained of blurred vision at 4 months postoperatively. Her CDVA of the right eye decreased to 20/200, with a refraction of -1.50/-2.50*77. A slit-lamp examination revealed an arch-shape change of the pupil, along with a pupil capture of the IOL (Fig. 1A). After pupil dilation, fibrosis and opacity of the anterior capsule ring with obvious IOL tilt and deformation were noted (Fig. 1B). The IOL optic was squeezed into arch-shape and the inferior part of it curled out of the capsular bag. Ultrasound biomicroscopy(UBM)(SW-3200, Suoer, Tianjin, China) examination showed that the IOL optic bent into the anterior chamber, approaching the cornea endothelium (Fig. 1C). We then performed a neodymium:YAG(Nd:YAG) laser anterior capsulotomy with a radial relaxing incision to enlarge the anterior capsule opening, hoping that the IOL can be expanded and reset into the capsule bag. However, the force of the shrunk anterior capsule opening is so strong that the IOL extruded even further into the anterior chamber. Local cornea edema appeared 2 days after laser treatment (Fig. 1D), suggesting that the IOL may have contacted the corneal endothelium. Consequently, we decided to adjust the IOL position by surgery. After a 2.0 mm clear cornea incision, an ophthalmic viscosurgical device(OVD) was injected, then a venous scissor was used to cut the anterior capsule radially to loosen the capsule contraction. However, the bent structure of the IOL and the synechia between the plate haptic and capsule prevented us from separating and rotating the IOL. Finally, the haptics were pulled out from the capsular bag by the viscoelastic needle and placed in the sulcus. Then OVD was removed by irrigation/aspiration(I/A), and the incision was hydrated with a balanced salt solution. One week after the adjustment, however, her blurred vision persisted, with a CDVA of 20/100. A careful slit-lamp examination revealed posterior capsule folds and the opacity of this patient. (Fig. 1E) Successful Nd:YAG laser posterior capsulotomy was performed. One week later, her CDVA reached 20/50 with a refraction of -3.00/-2.75*98. The patient was satisfied with her improvement in vision. The IOL remained stable (Fig. 1F) on the follow-up visit of 3 months after the adjustment surgery.

A 61-year-old male patient with a history of high myopia had uneventful micro-incision cataract surgery(MICS) with phacoemulsification (W.X) in his left eye. His preoperative axial length was 32.8 mm. During surgery, a continuous curvilinear capsulorhexis of approximately 5.5 mm in diameter was performed, and a CT Asphina 509 M IOL with the power of + 3 D was implanted into the capsular bag. The immediate postoperative condition was uneventful, and the CDVA after 1 month was 20/25 with a refraction of -3.25/-0.75*27. However, his CDVA decreased to 20/50 with a refraction of -2.25/-1.50*155 at 3 months postoperatively. A slit-lamp examination revealed an arch-shape change of the pupil, similar to case 1 (Fig. 2A). After pupil dilation, an anterior capsule contraction and an arch-shape change of the IOL were noted (Fig. 2B). A UBM examination showed that IOL was bent outside the capsule (Fig. 2C,D). Based on our experience from the first patient, we performed adjustment surgery to place the IOL into the ciliary sulcus. One week after the surgery, the CDVA of this patient was 20/100, and the slit-lamp examination detected posterior capsule relaxation and opacity. A Nd:YAG laser posterior capsulotomy was performed (Fig. 2E). One week later, his CDVA reached 20/25 with a refraction of -3.75/-0.50*20. The patient was satisfied with his improvement in vision. We reviewed the patient’s mydriatic photograph at 1 week after cataract surgery and noticed that the inferior edge of the IOL optic was not overlapped by the anterior capsule opening (Fig. 2F).