Kendra Bates* moved to California in the 1950s as a newlywed. On the whole, she has enjoyed a life of good health, but it recently became increasingly obvious that her vision was in decline. Her children urged her to get her vision checked, but she was reluctant to do so. Finally, after a rare visit back to the East Coast—and much prodding from the cousins who still lived there—she let one of her sons set up an eye appointment.
We Get a Look
Ms. Bates was referred to us for bilateral gradual vision loss. We noted that she was 89 years old and Caucasian and that her past ocular and systemic histories were unremarkable.
On examination, her visual acuity was 20/80 in the right eye and 20/60 in the left. The slit-lamp examination revealed bilateral moderately advanced nuclear sclerotic cataracts. We noted a scrolled leaf of anterior capsule floating in the anterior chamber of the right eye (Fig. 1).
The capsule in the left eye appeared normal. The intraocular pressure was normal in both eyes. The rest of the anterior and posterior segment examination was unremarkable.
At this point, there were several potential diagnoses for the scrolled leaf, including anterior remnant of the tunica vasculosa lentis, inflammatory membrane, pseudoexfoliation membrane and true exfoliation.
Surgery Goes Smoothly
We performed phacoemulsification in the right eye, with implantation of a foldable toric intraocular lens. During surgery, the leaf of the split anterior capsule was seen well through the operating microscope (Fig. 2). We used trypan blue 0.06 percent ophthalmic solution (Vision Blue) to delineate the split layers of the capsule during capsulorhexis (Fig. 3). At the conclusion of the surgery, the toric IOL was well-centered within the capsular bag (Fig. 4).
The capsulorhexis specimen was sent for histopathologic examination. The postoperative recovery was uneventful; the uncorrected Snellen visual acuity was 20/20 at last follow-up.
Histopathological analysis of the capsular remnants revealed diffuse thickening of the capsule, a more basophilic anterior two-thirds separated linearly from the posterior layer and unremarkable changes in lens epithelial cells (Fig. 5 and Fig. 6).
Final diagnosis was most consistent with “true exfoliation.”
What’s Your Diagnosis?
We successfully implant an IOL. (Fig. 1) At the slit lamp, we could clearly see a scrolled leaf of anterior capsule. (Fig. 2) Through the operating microscope, we could see the leaf of anterior capsule split. (Fig. 3) Using trypan blue made it easier for us to delineate the split layers of the capsule during capsulorhexis. (Fig. 4) The IOL was well-centered in the capsular bag at the conclusion of surgery.
We review photomicrographs of the capsulorhexis specimen. At 20x magnification (Fig. 5) and 40x magnification (Fig. 6), hematoxylin-eosin staining showed laminar separation of the more basophilic anterior two-thirds of the lens capsule (double-head arrows). Notice the normal lens epithelial cells (arrow heads).
True exfoliation (TE) of the lens capsule is rare and characterized by delamination and curling of the superficial layers into the anterior chamber.1,2
Elschnig first described TE in three glassblowers in 1922. Although exposure to excessive heat, intense infrared radiation, inflammation, metallic intraocular foreign bodies and trauma are considered as predisposing factors, there also have been reports of idiopathic true exfoliation without any of those risk factors being present, especially in older patients.3-7
There are only four reports of phacoemulsification with IOL implantation on TE patients in the literature.7-10
Trypan blue staining of the capsule is suggested in all reports to avoid creating a partial thickness capsulorhexis.
Several mechanisms for the development of TE have been described. Infrared radiation and excessive heat may be absorbed by the iris and transmitted to the lens, causing the degenerative epithelial changes,10 or thermal injury may directly activate proteolysis in the lens capsule, leading to splitting of the lens capsule fibers.11
In cases of idiopathic TE, age-related changes in the lens may play a role since idiopathic cases are more common in older patients.6
Ms. Bates’ Case
Our patient had no history of uveitis or excessive exposure to heat or infrared radiation. At microscopic examination, her lens epithelial cells were unremarkable.
We hypothesize that the split formation in the lens capsule layer was due to an aging process.
Ms. Bates’ case emphasizes the importance of precise examination of cataract cases. This is especially true for older patients, even without any predisposing factors. The case also illustrates the safety of phacoemulsification as a routine procedure in TE patients. * Patient name is fictitious.
1 Meades, K. and P. Versace. Aust NZ J Ophthalmol
2 Yamamoto, N. and A. Miyagawa. Graefes Arch Clin Exp Ophthalmol
3 Cashwell, L. F. et al. Ophthalmology
4 Fiore, P. M. and B. J. Shingleton. JAMA
5 Asakage, H. et al. J Jpn Ophthalmol Soc
6 Oharazawa, H. et al. J Nippon Med Sch
7 Rossiter, J. and A. Morris. Eye
8 Majima, K. et al. Ophthalmologica
9 Kulkarni, A. R. et al. Eye
10 Cooke, C. A. et al. J Cataract Refract Surg
11 Callahan, A. and B. A. Klien Arch Ophthalmol
___________________________ Dr. Espandar recently completed an ophthalmic pathology fellowship at the University of Utah in Salt Lake City. Dr. Mamalis is professor of ophthalmology and director of the ophthalmic pathology laboratory there.
Dr. Masket is clinical professor of ophthalmology at UCLA.
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