A 60-year-old man presented with a recent onset of decreased in vision in the right eye (OD). Both eyes (OU) had undergone uncomplicated cataract surgery 10 years back. Best corrected visual acuity (BCVA) OD was 20/60 and 20/400 in the left eye (OS). Slit-lamp examination revealed a normal anterior chamber and a well-centered in-the-bag intraocular lens (IOL) in OU. There was an accumulation of homogenous opaque turbid fluid in the retrolental space with posterior bowing of the posterior capsule (PC) in OD Fig. 1a and b, confirmed on anterior segment optical coherence tomography (AS-OCT) Fig. 1c. A diagnosis of delayed capsular bag distension syndrome (CBDS) was made in OD. Fundoscopy revealed early dry age-related macular degeneration (ARMD) in OD and a large macular scar in OS. A single, small nick with Nd-YAG laser was made just above the inferior edge of PC, resulting in immediate release of turbid fluid, clear central visual axis Fig. 1d-f and improvement in vision to 20/20 in OD. At 6 months follow-up, the visual axis remained clear, the inferior opening in the PC remained stable and patent without enlargement Fig. 1g-i. There was no vitreous prolapse, no recurrence of fluid accumulation, and BCVA remained stable at 20/20.Figure 1: (a) Diffuse light examination and (b) direct slit illumination of the right eye shows an in-the-bag IOL. There is backward bowing of posterior capsule with turbid fluid accumulated in the bag; (c) AS-OCT revealed homogenous hyper-reflective material in the bag between posterior surface of IOL and posterior capsule; (d and e) Immediate post-laser slit-lamp photographs showed an inferior small slit shaped opening in the posterior capsule (white arrow) with prompt release of the entrapped fluid and clear central visual axis; (f) AS-OCT shows a clear intraocular lens, intact posterior capsule in the center and minimal retrolental hyper-reflective material. (g-h) Follow-up slit-lamp images at 6 months showing a clear visual axis and a stable inferior opening (white arrow). (i) AS-OCT shows complete and persistent resolution without recurrent fluid. AS-OCT = Anterior segment optical coherence tomography, IOL = Intraocular lensVarious treatment options for CBDS described in the literature are Nd: YAG laser anterior or posterior capsulotomy, pars plana vitrectomy with posterior capsulotomy, or a peripheral iridotomy followed by anterior capsulotomy where cloudy fluid obscures the view of PC.1,2 In this case, an inferior laser capsulotomy was intentionally performed, deviating from the conventional central approach. The rationale for this technique was three-fold: First, to facilitate gravity-assisted drainage of the viscous retrolental fluid. Second, to reduce the risk of central floaters keeping the residual suspended particulate matter away from the visual axis. Third, to minimize post-procedure inflammation. This case highlights the utility of an inferior capsulotomy as a safe and effective alternative in managing cases of delayed milky capsular distension. Authors’ contributions PB – concept, design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, manuscript preparation, manuscript editing, and manuscript review. KK – concept, design, definition of intellectual content, and literature search 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 consent for 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.
Bansal et al. (Wed,) studied this question.