Assumed subluxated bag lens complex-temporal anterior capsular contraction

A 72-year-old female presented with complaints of blurred vision and glare in the left eye for six months. She underwent left eye (LE) cataract surgery 2 years back. She had consulted outside for the same and was referred to as LE decentered IOL for further management. The vision in LE was 6/18, which improved to 6/9. On slit-lamp examination, the LE showed a mid-dilated pupil with posterior synechiae at two points temporally, with anterior capsular contraction and opacification only in the temporal aspect, half covering the visual area Fig. 1a. Nasally, no rhexis margin was seen, and the anterior chamber was quiet. Retro illumination showed anterior capsular opacification and no posterior capsular opacification with well-centered IOL Fig. 1b. Temporal capsular contraction mimicked like a subluxated bag IOL complex, where the treatment protocol differs. So careful examination is a must to differentiate between both like anterior rhexis margin, posterior capsule, zonular dehiscence, and pupillary abnormalities, taken into account to arrive at a conclusion. Anterior Nd- Yag capsulotomy was advised, visual area was cleared, preventing further capsular contraction syndrome, and vision improved to 6/6 Fig. 1c.Figure 1: (a) Temporal anterior capsular contraction with opacification along with posterior synechiae and pseudoexfoliation mimicking nasal bag IOL subluxation. (b) In retroillumination showing elschnig pearl like opacification in anterior capsule with clear posterior capsule and no decentration of lens. (c) Post Nd yag clearance of anterior capsule in pupillary area and centered IOLAnterior capsular contraction syndrome (ACCS), characterized by capsular wrinkling and fibrosis leading to reduced equatorial diameter of the capsular bag, intraocular lens (IOL) decentration, and tilt, was initially named by Davison.1 The ACCS will have a negative impact on the patient’s vision and visual quality. In severe cases, it may lead to IOL dislocation.2–4 The cellular pathogenesis involves various factors such as trauma during cataract surgery, inflammatory response following IOL implantation, disruption of the blood-aqueous barrier and blood-retinal barrier, and stimulation from IOLs. These factors can stimulate residual lens epithelial cells (LECs) present at the capsulorrhexis opening, leading to the production of excessive Extracellular matrix (ECM), mainly collagen fibers.5 We have found that the course of ACCS can develop in the weeks to years following surgery, and in high-risk patients such as those with pseudoexfoliation (PEX), high myopia, and Retinitis pigmentosa (RP), the incidence of ACCS may increase to 10% to 30% or more.6,7 Furthermore, a comprehensive population study with a 30-year follow-up indicates that late in-the-bag IOL dislocation can occur after cataract surgery, ranging from 6 months to 25 years or even longer, and it is associated with zonular dehiscence and capsular bag contraction.8,9 In our case, temporal capsular contraction and opacification of the anterior lens capsule mimicked, like a subluxated bag IOL complex, but on careful examination, revealed anterior capsular contraction with posterior synechiae, which would have triggered a more inflammatory reaction in the temporal aspect, leading to capsular contraction locally over that area. Differentiating it from a subluxated IOL is important in the management protocol. This case has a unique presentation never reported before, and we did Nd-Yag anterior capsulotomy, and vision improved to 6/6. Author contributions Dr Bala Saraswathy: Concept and definition of intellectual content, literature search, and manuscript editing, data collection; Dr Kalpana Narendran: Concept and design. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.