Síndrome do bloqueio capsular precoce relato de caso e especulação sobre o tamanho da parte óptica da lente como fator de risco

Abstract

INTRODUÇÃOA síndrome do bloqueio capsular é uma complicação da cirurgia de catarata que surgiu após a introdução da capsulorrexe (1) . Pode ocorrer no per-operatório, pós-operatório precoce ou tardio, com múltiplas etiologias propostas (2,3) . Na forma per-operatória o núcleo do cristalino bloqueia a capsulorrexe durante a manobra de hidrodissecção, podendo levar a ruptura da cápsula posterior (2) . Nas formas pós-operatórias, tanto na precoce como na tardia é possível o bloqueio se dá através do contato entre a parte óptica da lente intraocular (LIO) e a capsulorrexe, sendo possível identificar acúmulo de líquido entre estas, o que desloca a LIO anteriormente gerando desvio miópico, podendo ainda diminuir a profundidade da câmara anterior e levar a aumento da pressão intraocular (1)(2)(3)(4)(5) . Descrevemos aqui um caso de bloqueio caspular precoce tratado por nova intervenção cirúrgica no segundo dia de pós-operatório (DPO), questionando sobre sua possível relação com o diâmetro da parte óptica da LIO. Relato do casoPaciente masculino, 81 anos, submetido à facectomia por catarata senil em olho direito, sem intercorrências, pela técnica de facoemulsificação. Durante a cirurgia duas substâncias viscoelásticas diferentes foram utilizadas, para os estágios iniciais até a confecção da capsulorrexe, já para as etapas de irrigação/ aspiração e implante da LIO foi utilizada a metilcelulose a 2% (Coatel, Baush Lomb). A facoemulsificação foi feita pela técnica de múltipla divisão circunferencial (6) , utilizando a combinação de sulfato de condroitina a 4% e hialuronato de sódio a 1,65%(Discovisc, Alcon). Após o implante da LIO, realizamos irrigação/aspiração automatizada dos restos de viscoelástico da câmara anterior com mobilização lateral da LIO e tentativa de irrigação de solução salina balanceada atrás da parte óptica. O comprimento axial do olho à biometria óptica foi de 23,57 mm. A LIO implantada no saco capsular foi de peça única em acrílico hidrofílico (C Flex Apheric, Rayner) com refração esférica pós-operatória estimada em aproximadamente -0,50 dioptrias.No primeiro DPO o paciente se apresentou afirmando que, apesar da programação cirúrgica para resultar em boa visão não corrigida para longe, estava enxergando melhor de perto. A acuidade visual (AV) não corrigida era de 0,1. Com correção de -2,50 dioptrias esfé-ricas e -0,50 dioptrias cilíndricas a 120º a AV chegava a 0,5. Havia mínimo edema de córnea peri-incisional e traços de células inflamatórias em câmara anterior. No segundo DPO a AV e refração permaneciam inalteradas. Ao exame notava-se LIO centrada, porém com a presença de separação nítida e ampla entre a parte óptica da LIO e cápsula posterior, melhor identificada após midríase farmacológica (Figura 1). A câmara anterior parecia ter profundidade normal e a pressão intraocular era igual a 11mmHg. Diante do diagnóstico de síndrome do bloqueio capsular precoce, optamos por retornar o paciente à sala cirúrgica. Após preparo com anestesia tópica e colírio de idopovidona a 5% e campos cirúrgicos adesivo...

Capsular block syndrome - report of two cases

“…Kim et al (15) observed six cases in 206 cases (2.9%) with this IOL, while with other IOLs, according to various authors, the frequency ranges from 0.3 to 1.6% (1,10,15,21,22) . Marback et al (16) reported an even lower prevalence of 0.02%.…”

“…(8) For the early type, Kim et al (15) reported that increased axial length is a risk factor, mentioning a diameter greater than 25 mm. Although these cases have been reported with different lens types (1,2,6,15,16,20) , the early type is more common in lenses with flexible haptics, as they are more easily pushed forward. (5) In particular, the condition has been associated with a specific type of IOL, the Akreus Adapt by Bausch & Lomb.…”

“…(10) Therefore, any case of suspected myopic biometric error in the immediate PO period should be examined with pupil dilation to exclude CBS. (16) The same mechanism can also cause angle closure with increased IOP. (1,2,5,8,10,14) By contrast, in the late type this does not usually occur (2,5) , but there tends to backward distension of the PC, as suggested by Theng et al (14) and verified in the two cases reported here.…”

“…(6,10,11) Invasive treatments have been performed such as slit lamp needling (20) and aspiration of material retained behind the IOL by irrigation/aspiration. (16,20) For late CBS, there are only 3 reports of spontaneous resolution. (5) The generally indicated procedure is posterior capsulotomy (6,8,12,14) because it promotes greater IOL stability in the capsular bag and has a lower risk of complications.…”

“…However, there are few reports of the late type. (1,(5)(6)(7)(8)(10)(11)(12)(13)(14)(15)(16) Both types can impair visual acuity (VA) and lead to further complications that should be readily recognised and managed.…”

Capsular block syndrome - report of two cases

“…Kim et al (15) observed six cases in 206 cases (2.9%) with this IOL, while with other IOLs, according to various authors, the frequency ranges from 0.3 to 1.6% (1,10,15,21,22) . Marback et al (16) reported an even lower prevalence of 0.02%.…”

“…(8) For the early type, Kim et al (15) reported that increased axial length is a risk factor, mentioning a diameter greater than 25 mm. Although these cases have been reported with different lens types (1,2,6,15,16,20) , the early type is more common in lenses with flexible haptics, as they are more easily pushed forward. (5) In particular, the condition has been associated with a specific type of IOL, the Akreus Adapt by Bausch & Lomb.…”

“…(10) Therefore, any case of suspected myopic biometric error in the immediate PO period should be examined with pupil dilation to exclude CBS. (16) The same mechanism can also cause angle closure with increased IOP. (1,2,5,8,10,14) By contrast, in the late type this does not usually occur (2,5) , but there tends to backward distension of the PC, as suggested by Theng et al (14) and verified in the two cases reported here.…”

“…(6,10,11) Invasive treatments have been performed such as slit lamp needling (20) and aspiration of material retained behind the IOL by irrigation/aspiration. (16,20) For late CBS, there are only 3 reports of spontaneous resolution. (5) The generally indicated procedure is posterior capsulotomy (6,8,12,14) because it promotes greater IOL stability in the capsular bag and has a lower risk of complications.…”

“…However, there are few reports of the late type. (1,(5)(6)(7)(8)(10)(11)(12)(13)(14)(15)(16) Both types can impair visual acuity (VA) and lead to further complications that should be readily recognised and managed.…”

Capsular block syndrome - report of two cases

“…Kim et al (15) observed six cases in 206 cases (2.9%) with this IOL, while with other IOLs, according to various authors, the frequency ranges from 0.3 to 1.6% (1,10,15,21,22) . Marback et al (16) reported an even lower prevalence of 0.02%.…”

“…(8) For the early type, Kim et al (15) reported that increased axial length is a risk factor, mentioning a diameter greater than 25 mm. Although these cases have been reported with different lens types (1,2,6,15,16,20) , the early type is more common in lenses with flexible haptics, as they are more easily pushed forward. (5) In particular, the condition has been associated with a specific type of IOL, the Akreus Adapt by Bausch & Lomb.…”

“…(10) Therefore, any case of suspected myopic biometric error in the immediate PO period should be examined with pupil dilation to exclude CBS. (16) The same mechanism can also cause angle closure with increased IOP. (1,2,5,8,10,14) By contrast, in the late type this does not usually occur (2,5) , but there tends to backward distension of the PC, as suggested by Theng et al (14) and verified in the two cases reported here.…”

“…(6,10,11) Invasive treatments have been performed such as slit lamp needling (20) and aspiration of material retained behind the IOL by irrigation/aspiration. (16,20) For late CBS, there are only 3 reports of spontaneous resolution. (5) The generally indicated procedure is posterior capsulotomy (6,8,12,14) because it promotes greater IOL stability in the capsular bag and has a lower risk of complications.…”

“…However, there are few reports of the late type. (1,(5)(6)(7)(8)(10)(11)(12)(13)(14)(15)(16) Both types can impair visual acuity (VA) and lead to further complications that should be readily recognised and managed.…”

Capsular block syndrome - report of two cases

“…Kim et al (15) observed six cases in 206 cases (2.9%) with this IOL, while with other IOLs, according to various authors, the frequency ranges from 0.3 to 1.6% (1,10,15,21,22) . Marback et al (16) reported an even lower prevalence of 0.02%.…”

“…(8) For the early type, Kim et al (15) reported that increased axial length is a risk factor, mentioning a diameter greater than 25 mm. Although these cases have been reported with different lens types (1,2,6,15,16,20) , the early type is more common in lenses with flexible haptics, as they are more easily pushed forward. (5) In particular, the condition has been associated with a specific type of IOL, the Akreus Adapt by Bausch & Lomb.…”

“…(10) Therefore, any case of suspected myopic biometric error in the immediate PO period should be examined with pupil dilation to exclude CBS. (16) The same mechanism can also cause angle closure with increased IOP. (1,2,5,8,10,14) By contrast, in the late type this does not usually occur (2,5) , but there tends to backward distension of the PC, as suggested by Theng et al (14) and verified in the two cases reported here.…”

“…(6,10,11) Invasive treatments have been performed such as slit lamp needling (20) and aspiration of material retained behind the IOL by irrigation/aspiration. (16,20) For late CBS, there are only 3 reports of spontaneous resolution. (5) The generally indicated procedure is posterior capsulotomy (6,8,12,14) because it promotes greater IOL stability in the capsular bag and has a lower risk of complications.…”

“…However, there are few reports of the late type. (1,(5)(6)(7)(8)(10)(11)(12)(13)(14)(15)(16) Both types can impair visual acuity (VA) and lead to further complications that should be readily recognised and managed.…”