• Users Online: 281
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 186-188

Femtosecond laser-assisted anterior capsulotomy for capsule phimosis

Department of Cataract and Glaucoma, Giridhar Eye Institute, Kochi, Kerala, India

Date of Submission08-Mar-2020
Date of Decision23-Mar-2020
Date of Acceptance05-Apr-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Jibi Suresh
Keecheril House, S. N. Junction, Palarivattom, Kochi - 682 025, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_29_20

Rights and Permissions

The centripetal constriction and fibrosis of the capsulorhexis following cataract surgery are known as anterior capsule phimosis. A 44-year-old myopic female who underwent uneventful phacoemulsification with in-the-bag intraocular lens implantation in the right eye presented 2 months later with cloudy vision due to significant capsular phimosis. Her best-corrected visual acuity was 20/32 in the right eye. She underwent femtosecond laser-assisted capsulotomy using a power of 10 μJ. Femtosecond laser is a more precise and predictable method of treating anterior capsule phimosis as compared to the existing treatment modalities, such as neodymium: YAG capsular opening.

Keywords: Capsule phimosis, femtosecond laser, high myope

How to cite this article:
Suresh J, Saikumar S J, Lakshmi J. Femtosecond laser-assisted anterior capsulotomy for capsule phimosis. Kerala J Ophthalmol 2020;32:186-8

How to cite this URL:
Suresh J, Saikumar S J, Lakshmi J. Femtosecond laser-assisted anterior capsulotomy for capsule phimosis. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Oct 25];32:186-8. Available from: http://www.kjophthal.com/text.asp?2020/32/2/186/293292

  Introduction Top

An exaggerated fibrotic response which reduces the size of anterior capsulotomy and capsular bag diameter is known as anterior capsule phimosis.[1] It usually develops 3–6 months after phacoemulsification surgery as a reparation reaction of anterior capsule opening.

  Case Report Top

A 44-year-old female underwent uneventful right eye phacoemulsification with intraocular lens (IOL) implantation in the bag. She was a high myope who has undergone barrage laser in both eyes. The axial length in her right eye was 26.68 mm and the intraocular lens power of 10 D was implanted. Preoperatively, the refraction was −8.75 D for distant vision improving to 20/80 and +1.00 add for near vision improving to N18. After 2 months of cataract surgery, she presented to us with cloudy vision in the right eye [Figure 1]. On examination, her best-corrected visual acuity was 20/32 and slit lamp revealed anterior capsular phimosis and quiet anterior chamber. Fundus examination showed multiple well-lasered lattices and no new treatable lesions in the periphery.
Figure 1: Anterior capsule phimosis

Click here to view

Anterior-segment optical coherence tomography (Zeiss) was done to assess the distance between anterior capsule and surface of IOL [Figure 2]. This case was treated with the help of femtosecond laser.
Figure 2: ASOCT image showing the distance between the intraocular lens and the fibrosed capsule

Click here to view

Under topical anesthesia, eye was fixed under the Lensx Laser (Alcon, Geneva) and was docked using the laser interface. The laser system is integrated with three-dimensional spectral-domain optical coherence tomography, which creates an image of the anterior segment of the eye. Using this, both anterior capsule and surface of the IOL can be clearly differentiated.

The femtosecond laser pattern was aligned at pupil center, and capsulotomy enlargement of 3.5 mm diameter with 80% depth was performed using 10 μJ power. At the end of the laser treatment, some adhesions were found between the fibrosed capsule and the IOL. After this, the patient was shifted to the operation theater, and under the operating microscope, adhesions were released and additional capsule ring was removed with microforceps by opening the previous incision.

The patient was seen the next day under slit lamp, and there was no remnant of anterior capsule in the pupillary area. After 5 days postoperatively, she was stable. After 2 weeks, her refraction for distant vision with −0.50/−0.50 × 110 was 20/20 and near vision was N6 with +2.50 add in the right eye. Informed consent was taken from the patient [Figure 3].
Figure 3: Postoperative image after femtosecond laser capsulotomy

Click here to view

  Discussion Top

Anterior capsule phimosis develops due to myofibroblastic metaplasia of the anterior cuboidal lens epithelial cells (LECs) and transformation to actin positive smooth muscle. Progressive contraction of the anterior myofibroblastic cells can cause imbalance between centrifugal and centripetal forces on the zonules, which may result in malposition of the capsulotomy opening, angulation of the haptics, or optic edges of IOL even the entire IOL. It may cause the capsular complex displacement or total IOL luxation into the vitreous cavity due to zonular dehiscence.[2]


Prostaglandins, interleukin (IL)-1 and 6, and basic fibroblast growth factor, produced by residual LECs, increased in aqueous humor after cataract surgery that stimulates proliferation of the cuboidal lens epithelial cells by the alterations in cell-to-cell contact interactions. Increased concentration of TGF in high myopia is responsible for greater chances in these patients for the development of anterior capsule phimosis.[3]

Risk factors

Contraction of capsular opening due to myofibroblastic metaplasia was strongly correlated with several ocular and systemic factors, such as diabetes mellitus, uveitis, and retinitis pigmentosa. Zonular weakness due to advanced age, trauma, high myopia, certain connective tissue disorders, and previous vitreoretinal surgery are the predispositing factors for IOL displacement in capsular contraction syndrome. Pseudoexfoliation syndrome has dual predisposition factor as increased anterior-chamber inflammation by increased vascular permeability and has fragile zonules with weak stretching capability that causes zonular dehiscence.[4]


To prevent the occurrence of capsular phimosis, Davison first proposed YAG laser relaxing anterior capsulotomies at 2–3 weeks after cataract surgery.[1]

Neodymium (Nd):YAG laser can create radial opening in the edge of capsular phimosis and perform significant circular enlargement; it can be effective in resolving the capsular synechiae of the haptics. However, it has several complications such as IOL pitting, anterior-chamber inflammation, and secondary glaucoma, due to residual fibrotic material in the anterior chamber. The femtosecond laser typically emits pulses of less than 600 fs duration with pulse energies in the range of several micro-Joules. This enables the femtosecond laser to cut with much greater precision than the Nd: YAG laser (mJ level) or manual techniques.

Gerten et al. reported femtolaser-assisted capsulotomy in three of his cases where viscoelastic was injected between the IOL and fibrotic capsule before laser application.[5]

Schweitzer et al. performed similar technique of capsulotomy assisted by femtosecond laser but without injection of viscoelastics.[6]

Toto et al. have reported that the use of femtosecond laser for capsulotomy extension offers advantages over the Nd: YAG laser in anterior capsule phimosis.[7]

  Conclusion Top

Femtosecond lasers are capable of cutting even dense fibrotic tissues in the eye. However, the disadvantage of higher treatment cost of the femtosecond laser pseudophakic capsulotomy, as compared to Nd:YAG capsulotomy, limits its widespread use.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Davison JA. Capsule contraction syndrome. J Cataract Refract Surg 1993;19:582-9.  Back to cited text no. 1
Aose M, Matsushima H, Mukai K, Katsuki Y, Gotoh N, Senoo T. Influence of intraocular lens implantation on anterior capsule contraction and posterior capsule opacification. J Cataract Refract Surg 2014;40:2128-33.  Back to cited text no. 2
Hayashi Y, Kato S, Maeda T, Kaiya T, Kitano S. Immunohistologic study of interleukin-1, transforming growth factor-beta, and alpha-smooth muscle actin in lens epithelial cells in diabetic eyes. J Cataract Refract Surg 2005;31:2187-92.  Back to cited text no. 3
Kim SY, Yang JW, Lee YC, Kim SY. Effect of haptic material and number of intraocular lens on anterior capsule contraction after cataract surgery. Korean J Ophthalmol 2013;27:7-11.  Back to cited text no. 4
Gerten G, Schultz M, Oberheide U. Treating capsule contraction syndrome with a femtosecond laser. J Cataract Refract Surg 2016;42:1255-61.  Back to cited text no. 5
Schweitzer C, Tellouck L, Gaboriau T, Leger F. Anterior capsule contraction treated by femtosecond laser capsulotomy. J Refract Surg 2015;31:202-4.  Back to cited text no. 6
Toto L, Viggiano P, Vecchiarino L, Evangelista F, Borrelli E, Mastropasqua L. Anterior capsule contraction syndrome: A successful multimodal therapeutic approach. Int J Ophthalmol 2019;12:1356-8.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded19    
    Comments [Add]    

Recommend this journal