Managing milky capsular bag distension with inferior laser capsulotomy not the usual cut

A 60-year-old man presented with recent onset decrease in vision in the right eye (OD). Both eyes (OU) had undergone uncomplicated cataract surgery ten years back. Best corrected visual acuity OD was 20/60 and 20/400 in the left eye (OS). Slit lamp examination revealed a normal anterior chamber, and a well centred in-the-bag intraocular lens (IOL) in OU. There was accumulation of homogenous opaque turbid fluid in the retrolental space with posterior bowing of the posterior capsule (PC) in OD [Fig.1 a,b], confirmed on anterior segment optical coherence tomography (AS-OCT) [Fig. 1c]. A diagnosis of delayed capsular bag distension syndrome (CBDS) was made in OD. Fundoscopy revealed early dry age-related macular degeneration (ARMD) in OD and a large macular scar in OS. A single, small nick with Nd-YAG laser was made just above the inferior edge of PC resulting in immediate release of turbid fluid, clear central visual axis [Fig.1d-f] and improvement in vision to 20/20 in OD. At 6 months follow up, the visual axis remained clear, the inferior opening in the PC remained stable and patent without enlargement [Fig.1g-i]. There was no vitreous prolapse, no recurrence of fluid accumulation, and BCVA remained stable at 20/20.

Various treatment options for CBDS described in literature are Nd:YAG laser anterior or posterior capsulotomy, pars plana vitrectomy with posterior capsulotomy or a peripheral iridotomy followed by anterior capsulotomy where cloudy fluid obscures view of PC.^[1,2] In this case, an inferior laser capsulotomy was intentionally performed, deviating from the conventional central approach. The rationale for this technique was threefold: first, to facilitate gravity- assisted drainage of the viscous retrolental fluid. Second, to reduce the risk of central floaters keeping the residual suspended particulate matter away from visual axis. Third, was to minimize post procedure inflammation. This case highlights the utility of an inferior capsulotomy as a safe and effective alternative in managing cases of delayed milky capsular distension.