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Sudden-Onset Painless Blurry Vision

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his late 30s with a history of proliferative diabetic retinopathy presented for evaluation of sudden-onset painless blurry vision of the right eye. His ocular history included nonclearing vitreous hemorrhage in the right eye requiring pars plana vitrectomy, panretinal photocoagulation, multiple treatments with intravitreous bevacizumab, and cataract extraction with placement of an intraocular lens (IOL) into the capsular bag approximately 4 years ago. At his routine follow-up visit 2 weeks prior, the proliferative diabetic retinopathy was quiescent, and his Snellen visual acuity was 20/20 OD with manifest refraction of −1.50 + 0.25 × 180. Examination of the anterior segment at that time was unremarkable.

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Capsular bag distention syndrome

B. Perform posterior capsulotomy with Nd:YAG laser

The key to diagnosis is recognizing hyperdistention of the capsular bag with a turbid milieu posterior to the IOL (Figure 1) along with a myopic shift. Anterior segment OCT confirmed the diagnosis. Performing a posterior capsulotomy would allow egress of the turbid material into the vitreous cavity and provide immediate resolution of the refractive change with minimal risk. If this was not successful, we would then perform a posterior capsulotomy during pars plana vitrectomy (choice A). Exchanging the IOL (choice C) is not preferred because decreasing the new lens power to compensate for the myopic shift would result in a hyperopic surprise, as the procedure itself would resolve the capsular bag distention syndrome (CBDS). Observation (choice D) is preferable when the patient does not want intervention; however, the myopic shift needs to be corrected with an updated manifest refraction.

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Article Information

Corresponding Author: Peter H. Tang, MD, PhD, Department of Ophthalmology, Byers Eye Institute, Stanford University, 2452 Watson Ct, Palo Alto, CA 94303 (ptang@stanford.edu).

Published Online: June 6, 2019. doi:10.1001/jamaophthalmol.2019.1431

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Mastropasqua  L, Toto  L, De Nicola  G, Nubile  M, Carpineto  P.  OCT imaging of capsular block syndrome with crystalline cortical remnants in the capsular bag.  Ophthalmic Surg Lasers Imaging. 2009;40(4):399-402. doi:10.3928/15428877-20096030-08PubMedGoogle ScholarCrossref
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Zafeiropoulos  P, Katsanos  A, Gorgoli  K, Asproudis  I, Aspiotis  M.  Late-onset capsular bag distension syndrome: a report of two cases.  Acta Medica (Hradec Kralove). 2014;57(4):165-167. doi:10.14712/18059694.2015.83PubMedGoogle ScholarCrossref
8.
Galvin  JC, Berdoukas  P, Fung  AT.  Two cases of very late-onset capsular bag distension syndrome.  Am J Ophthalmol Case Rep. 2018;10:268-270. doi:10.1016/j.ajoc.2018.03.019PubMedGoogle ScholarCrossref
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Kollias  AN, Vogel  MA, de Kaspar  HM, Lackerbauer  CA, Grueterich  M.  Propionibacterium acnes in capsular bag distension syndrome.  J Cataract Refract Surg. 2010;36(1):167-169. doi:10.1016/j.jcrs.2009.06.047PubMedGoogle ScholarCrossref
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