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Anterior capsular phimosis following cataract surgery: AS-OCT features and Nd:YAG laser management
*Corresponding author: Balamurugan Ramatchandirane, Department of Ophthalmology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India. bala16690@yahoo.co.in
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Received: ,
Accepted: ,
How to cite this article: Shagila R, Ramatchandirane B. Anterior capsular phimosis following cataract surgery: AS-OCT features and Nd:YAG laser management. Global J Cataract Surg Res Ophthalmol. 2025;4:149-51. doi: 10.25259/GJCSRO_17_2025
Abstract
Anterior capsular phimosis is a well-known postoperative complication of cataract surgery, characterised by progressive constriction of the capsulorhexis opening due to fibrotic changes in the anterior capsule. We report a case of a 62-year-old male who presented with decreased vision in the left eye 6 weeks after undergoing cataract surgery with intraocular lens (IOL) implantation and capsular tension ring insertion. There was an oval-shaped anterior capsular phimosis with temporal haptic flexion of the IOL, along with posterior capsular opacification and wrinkling of the anterior capsule. Anterior segment optical coherence tomography (AS-OCT) showed a thick subcapsular fibrosis extending to the anterior surface after crossing the anterior capsular margin. Neodymium: yttrium-aluminum-garnet laser anterior capsular lysis was performed at four clock positions. One week after the procedure, exaggerated fibrosis was observed at the laser sites, which subsequently stabilised without any IOL decentration over a 4-month follow-up period. The final best-corrected visual acuity improved to 6/9. This case highlights anterior capsular phimosis, with AS-OCT imaging demonstrating subcapsular fibrosis that causes anterior capsule undulations and extends across the capsular edge onto the anterior capsule surface, along with the treatment response.
Keywords
Anterior capsular phimosis
Anterior capsular contraction syndrome
Capsular contraction syndrome
Subcapsular fibrosis
Nd: YAG laser capsulotomy
INTRODUCTION
Anterior capsular phimosis is a well-known postoperative complication of cataract surgery, characterised by progressive constriction of the capsulorhexis opening due to fibrotic changes in the anterior capsule.[1-3] It can lead to visual disturbances because of lens tilt, lens subluxation, and obstruction of the visual axis. Capsular lysis using a neodymium: yttrium aluminium garnet (Nd:YAG) laser is the procedure of choice in the early stages.[1-3] In this case report, we highlight anterior capsular phimosis, [Figure 1a-d], with anterior segment optical coherence tomography (AS-OCT) imaging demonstrating subcapsular fibrosis causing anterior capsule undulations and extending across the capsular edge onto the anterior capsule surface [Figure 2a and b], along with the treatment response.
- (a) Oval-shaped anterior capsular phimosis with wrinkling surface. (b) Capsular lysis performed using an Nd: YAG laser with radial incisions at the 1, 4, 5 and 7 o’clock positions (black arrows). (c) One-week post-laser capsulotomy, demonstrating an exaggerated fibrotic response at the relaxing incision sites (black arrows). (d) 4 months after treatment, showing a stable capsular opening without any further contraction (black arrows) or intraocular lens tilting or decentration.
- (a) Anterior segment optical coherence tomography (AS-OCT) image (vertical raster) showing a thick subcapsular fibrosis migrating to the anterior surface after crossing the anterior capsule margin (arrows). (b) AS-OCT image (horizontal raster) showing undulating capsular surface caused by the contracting subcapsular fibrosis.
CASE REPORT
A 62-year-old male presented to us with complaints of decreased vision in his left eye for the past 6 weeks. His best-corrected visual acuity was 6/6 (+1.50 diopter sphere [DS]) in the right eye and 6/12 (+0.75 DS) in the left eye. His intraocular pressure in both eyes was normal. Eight weeks ago, he had undergone phacoemulsification cataract surgery with posterior chamber intraocular lens (IOL) implantation and capsular tension ring (CTR) insertion at an outside hospital. The reason for CTR placement was not mentioned in the discharge summary, and the patient was unaware of it. On slit-lamp examination, an oval-shaped anterior capsular phimosis was observed, along with temporal flexion of one haptic, which was classified as grade I anterior capsular phimosis (as per the classification given by Gerten et al.[4]). Posterior capsular opacification was noted in the left eye. The optic portion of the IOL remained centred in the visual axis, with no signs of tilt or subluxation [Figure 1a]. A wrinkling of the anterior capsule was also observed. AS-OCT with a vertical raster line across the anterior capsule showed a thick subcapsular fibrosis, which seems to be migrating on the anterior surface after crossing the anterior capsular edge (arrow). Figure 2b demonstrates that the thick subcapsular fibrosis caused contraction and an undulating capsular surface. Fundus examination revealed that a stage I epiretinal membrane (ERM) was observed in the macular region of the left eye. Due to the haptic flexion and significant anterior capsular contraction, we performed anterior capsular lysis using an Nd: YAG laser. Capsular lysis was performed radially at the 1 o’clock, 4 o’clock, 5 o’clock and 7 o’clock positions ([Figure 1b], black arrows). At the 1-week follow-up, exaggerated healing was noted at the relaxing sites, with moulding of the edges [Figure 1c], which stabilised over 4 months [Figure 1d]. At the final 4-month follow-up, there was no further flexion of the IOL or progression of anterior capsular contraction. Best-corrected visual acuity improved to 6/9, with a clear visual axis.
DISCUSSION
Anterior capsular phimosis, also known as capsular contraction syndrome (CCS), is a well-documented complication of cataract surgery.[1-3] It is characterised by the contraction of the capsulorhexis opening caused by exaggerated fibrosis of the lens capsule. Lens epithelial cells undergo metaplastic transformation into fibrotic spindle cells, which contribute to the development of fibrosis.[1,2] Predisposing factors[1-3] include small capsulorhexis, uveitis, zonular weakness, IOL design and material, pseudoexfoliation, retinitis pigmentosa and diabetes. This condition can lead to visual disturbances due to IOL tilt, decentration or subluxation, and in some cases, may even cause retinal detachment. Radial capsulotomy using Nd: YAG laser is the procedure of choice for anterior capsular phimosis.[1-3] In severe cases, surgical excision of the membrane may be required.[1,2] In our case, we present anterior capsular phimosis that developed 2-month post-cataract surgery, likely associated with underlying zonular weakness. Zonular weakness is already a known risk factor for the CCS.[1-3,5] The subcapsular fibrosis contributed to contraction and undulation of the anterior capsule [Figure 2a and b] and was seen migrating across the capsular margin to the anterior surface. In our case, it is noteworthy that anterior CCS occurred concurrently with an ERM (stage 1).[6] We also observed exaggerated healing with fibrosis at the laser sites within 1 week.
CONCLUSION
Anterior capsular phimosis is a well-known complication of cataract surgery, especially in the presence of risk factors such as zonular weakness and small capsulorhexis. This case illustrates anterior capsular phimosis, with AS-OCT imaging demonstrating subcapsular fibrosis that causes undulation of the anterior capsule, extending across the capsular edge onto the anterior capsule surface, along with the treatment response.
Ethical approval:
Institutional review board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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