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Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 213-214

Unexpected mishap for a beginner surgeon

Consultant Ophthalmologist, Nims Hospital, Wandoor, Malappuram; Kims Alshifa Hospital, Perinthalmanna, Kerala, India

Date of Submission05-Jun-2020
Date of Acceptance06-Jun-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. R Rammia
Sameer Manzil, Kolarkunnu, P.O. Manjeri, Malappuram - 676 121, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_79_20

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How to cite this article:
Rammia R. Unexpected mishap for a beginner surgeon. Kerala J Ophthalmol 2020;32:213-4

How to cite this URL:
Rammia R. Unexpected mishap for a beginner surgeon. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Oct 24];32:213-4. Available from: http://www.kjophthal.com/text.asp?2020/32/2/213/293307

Dear Editor,

I would like to highlight the importance of using Pupil expanders and Rhexis marker while doing phacoemulsification in mid-dilated pupil especially by beginner surgeons.

Here, we present a case of Anterior Capsular Contraction Syndrome (ACCS) in an 85-year-old woman, after 3 weeks of cataract surgery.

Anterior segment examination in both eyes showed pupil of 5 mm and nuclear-sclerosis Gr 3.

A scan biometry LE:

During the intraoperative period, rhexis was difficult due to deep anterior chamber (high K readings) and mid-dilated pupil. But, I didn't use pupil expanders or a rhexis marker to carry out the capsulorhexis, and the pupil was of 5 mm. Capsulorrhexis was thus smaller than 5 mm. Phacoemulsification was also difficult due to deep anterior chamber and small rhexis. Postoperative day 1, visual acuity was 6/18 pinhole 6/12.

At 3 weeks, she complained of defective vision and was noted to have visual acuity of Counting finger 1 metre. Examination of her left eye revealed a thickened anterior capsule and occlusion of Capsulorrhexis opening. The patient was posted for Nd-YAG anterior capsulotomy [Figure 1].
Figure 1: Anterior capsular contraction and occlusion of caspular opening

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  Discussion Top

ACCS or capsule phimosis is an exaggerated fibrotic response reducing the size of the anterior capsulotomy and capsular bag diameter.[1] The onset of decreased visual acuity in ACCS patients can range from 2 weeks to >3 months.[2]

ACCS has been associated with multiple entities. Most common is a small-diameter Capsulorrhexis. Zonular weakness, chronic intraocular inflammation, uveitis, pseudo-exfoliation syndrome, zonular laxity, retinitis pigmentosa, advanced age, diabetes mellitus, Behcet's syndrome, myotonic muscular dystrophy, and high myopia are known risk factors.

ACCS may be prevented by utilizing a larger capsulorhexis size, meticulous lens epithelial cells cleanup at the time of phacoemulsification, or the use of anterior capsule Nd: YAG relaxing incisions in high-risk patients soon after phacoemulsification.[3]

In our case, we had small-diameter rhexis, deep anterior chamber, and patient's advanced age.

  Conclusion Top

Using Pupil expanders and Rhexis marker in mid-dilated pupil, especially by beginner surgeons, helps to prevent Anterior capsular contraction.

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


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
Jin-Poi T, Shatriah I, Khairy-Shamel ST, Zunaina E. Rapid anterior capsular contraction after phacoemulsification surgery in a patient with retinitis pigmentosa. Clin Ophthalmol 2013;7:839-42.  Back to cited text no. 2
Hayashi K, Yoshida M, Hirata A, Hayashi H. Anterior capsule relaxing incisions with neodymium: YAG laser for patients at high-risk for anterior capsule contraction. J Cataract Refract Surg 2011;37:97-103.  Back to cited text no. 3


  [Figure 1]


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