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Elevated Intraocular Pressure With Visual Deterioration in a Pseudophakic Eye

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

A 78-year-old White man was referred to our clinic for evaluation of an unexplained subjective decrease in vision for more than 6 months, more pronounced in the right eye, and insufficiently controlled intraocular pressure (IOP). Local antiglaucoma therapy with a fixed-combination prostaglandin and β-blocker was used regularly in both eyes owing to long-standing primary open-angle glaucoma. Uneventful cataract surgery with phacoemulsification and in-the-bag insertion of an intraocular lens was performed 10 years earlier in both eyes. Best corrected visual acuity (BCVA) was 1.0 and 0.5 (Snellen equivalent, 20/20 and 20/40) OD and OS, respectively. His manifest refraction revealed a difference of −0.75 D sphere compared with his own preexisting glasses in the right eye. IOP was 24 mm Hg in the right eye and 18 mm Hg in the left eye.

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Late-onset postoperative capsular bag distension syndrome

C. Perform YAG capsulotomy

Postoperative capsular bag distension syndrome (CBDS) describes a rare complication of cataract surgery with an incidence of 0.73%, in which opaque fluid accumulates in the retrolental space between the artificial lens and the capsular bag after cataract surgery with intraocular lens placement and intact posterior capsule.1,2 Different variants of CBDS have been classified, according to time of onset (intraoperative, early postoperative, and late postoperative)2 or underlying pathomechanisms (noncellular, inflammatory, fibrotic).1

The early-onset variant occurs between 1 day and 2 weeks postoperatively by unknown cause, whereas the late-onset or fibrotic variant has been described on average 3.8 years after uneventful cataract surgery3 and is expected to be caused by lens epithelial cell proliferation and pseudometaplasia.1,2 Large amounts of α and β crystalline have been isolated from the retrolental milky substance.4

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Article Information

Corresponding Author: Thomas Falb, MD, Department of Ophthalmology, Medical University of Graz, Auenbruggerplatz 4, 8036 Graz, Austria (thomas.falb@medunigraz.at).

Published Online: May 26, 2022. doi:10.1001/jamaophthalmol.2022.0641

Conflict of Interest Disclosures: None reported.

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

References
1.
Kim  HK , Shin  JP .  Capsular block syndrome after cataract surgery: clinical analysis and classification.   J Cataract Refract Surg. 2008;34(3):357-363. doi:10.1016/j.jcrs.2007.11.026PubMedGoogle ScholarCrossref
2.
Miyake  K , Ota  I , Ichihashi  S , Miyake  S , Tanaka  Y , Terasaki  H .  New classification of capsular block syndrome.   J Cataract Refract Surg. 1998;24(9):1230-1234. doi:10.1016/S0886-3350(98)80017-5PubMedGoogle ScholarCrossref
3.
Miyake  K , Ota  I , Miyake  S , Horiguchi  M .  Liquefied after-cataract: a complication of continuous curvilinear capsulorhexis and intraocular lens implantation in the lens capsule.   Am J Ophthalmol. 1998;125(4):429-435. doi:10.1016/S0002-9394(99)80182-2PubMedGoogle ScholarCrossref
4.
Bao  Y-Z , Pei  X-T , Li  M-W , Li  X-X .  Late postoperative capsular block syndrome vs liquefied after-cataract.   J Cataract Refract Surg. 2008;34(10):1799-1802. doi:10.1016/j.jcrs.2008.04.057PubMedGoogle ScholarCrossref
5.
Liu  TY , Chou  PI .  Capsular block syndrome associated with secondary angle-closure glaucoma.   J Cataract Refract Surg. 2001;27(9):1503-1505. doi:10.1016/S0886-3350(01)00878-1PubMedGoogle ScholarCrossref
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Shah  NA , Goulstine  DB .  Capsular block syndrome presenting with a hyperopic shift.   J Cataract Refract Surg. 2006;32(11):1974-1976. doi:10.1016/j.jcrs.2006.06.026PubMedGoogle ScholarCrossref
7.
Lin  Y , Lin  J , Su  Z , Chen  Z , Yao  K .  Characterization and management of late postoperative capsular block syndrome following phacoemulsification or phacovitrectomy.   Am J Ophthalmol. 2019;204:19-25. doi:10.1016/j.ajo.2019.02.035PubMedGoogle ScholarCrossref
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Ramli  N , Chai  SM , Tan  GS ,  et al.  Efficacy of medical therapy in the initial management of acute primary angle closure in Asians.   Eye (Lond). 2010;24(10):1599-1602. doi:10.1038/eye.2010.92PubMedGoogle ScholarCrossref
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Lemley  CA , Han  DP .  Endophthalmitis: a review of current evaluation and management.   Retina. 2007;27(6):662-680. doi:10.1097/IAE.0b013e3180323f96PubMedGoogle ScholarCrossref
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Webers  CAB , van der Valk  R , Schouten  JSAG , Zeegers  MP , Prins  MH , Hendrikse  F .  Intraocular pressure-lowering effect of adding dorzolamide or latanoprost to timolol: a meta-analysis of randomized clinical trials.   Ophthalmology. 2007;114(1):40-46. doi:10.1016/j.ophtha.2006.07.018PubMedGoogle ScholarCrossref
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