A 67-year-old man has a history of uncomplicated cataract surgery with insertion of Crystalens implants OU two years ago. Four months after the surgeries he developed visually significant posterior capsular opacities that were treated with Nd:YAG laser posterior capsulotomy. After the laser treatments his uncorrected visual acuity was 20/25 and J3 OD and 20/20 and J1 OS. He now returns for an annual eye exam and denies any change in vision. His uncorrected vision is unchanged. Anterior segment exam reveals a clear cornea, quiet anterior chamber, well-positioned IOL and a central opening of the posterior capsule in each eye. Posterior segment exam is normal OU. Slit lamp photos show the following:
What unusual finding is present?
There is a recurrence of posterior capsular opacification from progressive fibrosis and proliferation of lens epithelial cells at the margin of the posterior capsulotomy OU. The size of the posterior openings has shrunk to less than 1/3 their original size, and significant Elschnig pearl formation is visible OS.
How would you manage the patient?
Management options include observation with consideration of repeat Nd:YAG laser capsulotomy in the future if the uncorrected visual acuity changes (due to either PCO affecting the visual axis or change in IOL position from capsular contraction), or performing the laser capsulotomy now to prevent a change in vision/lens position. Another possible choice would be to prescribe a topical steroid and/or NSAID in an attempt to halt progression of the capsular changes; however, there is no evident intraocular inflammation on exam and side effects of prolonged topical drops (i.e., elevated IOP) are a concern.
How did I treat the patient?
I have seen changes in Crystalens vaulting as a result of capsular fibrosis and contraction. While this typically occurs within the first 6 months after lens implantation, I have witnessed it as late as 2 years after surgery. Therefore, I scheduled the patient for repeat Nd:YAG laser posterior capsulotomies, and I enlarged the central posterior opening and cut the traction bands that had developed.
Discussion:
Recurrent PCO is known to occur in children but is extremely rare in adults. Risk factors include young age and ocular inflammation, but IOL material and edge design probably contribute as well.
In my experience, almost every patient who receives a Crystalens develops posterior capsular opacification within several months of surgery despite polishing the posterior capsule and underside of the anterior capsule. As mentioned above, I have seen shifts in lens position as a consequence, so I like to perform Nd:YAG capsulotomies as soon as I note a PCO. If I do so within 3 months of the cataract/lens replacement surgery, then I prophylactically treat for CME by prescribing a topical steroid and NSAID.