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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 393-394

Commentary: Bilateral pediatric spontaneous anterior capsular rupture

Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication13-Apr-2022

Correspondence Address:
Savleen Kaur
Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2429_21

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How to cite this article:
Kaur S, Sukhija J. Commentary: Bilateral pediatric spontaneous anterior capsular rupture. Indian J Ophthalmol Case Rep 2022;2:393-4

How to cite this URL:
Kaur S, Sukhija J. Commentary: Bilateral pediatric spontaneous anterior capsular rupture. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 17];2:393-4. Available from: https://www.ijoreports.in/text.asp?2022/2/2/393/342956

Nontraumatic emergencies involving pediatric lens are not that common. Anterior capsular rupture is one such entity that can be detrimental for intraocular lens (IOL) implantation. The signs of a capsular rupture must be recognized and treated quickly and adequately. Whereas intraoperative rupture of the anterior capsule can be expected in intumescent cataracts, spontaneous ruptures that too bilateral are relatively less known.[1],[2],[3],[4],[5],[6],[7],[8],[9] One such case of bilateral symmetrical anterior capsular rupture is reported by authors[10] in a 7-year child in the present issue.

The identification of anterior capsular rupture is not that difficult. Lens matter can be seen in the anterior chamber in most cases, along with fibrosis of the edge of torn capsule, and calcification on remaining capsule depending on the chronicity of the rupture. Conjunctival congestion with corneal clouding and uveitis might be the presenting feature in cases with secondary glaucoma.[1] “Volcano sign” on anterior segment optical coherence tomography is a hallmark of anterior capsular rupture.[2] The lens if intact, appears hydrated and swollen.

It is helpful to discern and establish the etiology of the rupture. The causes include trauma (penetrating, surgical, or blunt),[1] systemic conditions like Alport's,[2],[3],[4] and Marshalls syndrome,[5] polar cataract,[8] steroids,[9] and even fellow eyes of hypermature cataract.[1] In children, the causes are usually syndromic associations, additional causes being anterior polar cataract[4] or suspected anterior lentoconus[6] and posterior fetal vasculature.[9]

The most well-studied entity causing anterior capsular rupture is Alport's syndrome, with about 15 cases being reported so far.[2],[3],[4] Anterior capsular rupture could be the presenting sign of systemic disease. The anterior lenticonus, in such cases, results in progressive lenticular myopia, which may result in spontaneous anterior lens capsule rupture, with or without rapid cataract formation. Even ruptures without lenticonus can develop due to the subclinical weakness and thinness of the capsule. Hence, in certain patients, the lens integrity is maintained. So, the first thing we should do in a patient with anterior capsular rupture after excluding trauma is urinalysis for hematuria and auditory examination for sensory neural hearing loss supported by a thorough nephrological assessment, including renal biopsy if necessary. Further genetic testing is also warranted to establish the inheritance in confirmed cases of Alport's syndrome.

Pathogenesis mainly involves an inherent weakness of the capsule by defects in type IV collagen, an essential component of the basement membrane of the lens. These defects could be genetic, like in cases of Alport's syndrome. Further imbibition of fluid by this thin and defective capsule leads to increased hydration and capsular rupture. Electron microscopy of the thin capsule in these cases can confirm numerous internal dehiscence's containing vacuoles and fibrillar material, especially at the poles.[11]

Where there is no herniation of lens material into the anterior chamber, absence of inflammation, and normal intraocular pressure, the surgery can be withheld for some time. In cases of Alport's syndrome, progressive bulla formation, its expansion' and then rupture are described.[3] Hence, where small cracks or defects are seen even with a crystalline lens, very close follow-up is required as these cases will develop cataract quickly due to hydration and/or develop larger ruptures, making the surgery difficult.[12] Surgery in such cases can be challenging and becomes more difficult due to the fragility of capsule. In cases of anterior lens capsule rupture, the surgical approach depends on the size and extent of the capsular rupture. Most of the patients with trauma have a linear rupture, providing adequate access to allow phacoaspiration and IOL implantation. In spontaneous rupture due to other causes, a capsulorhexis may have to be fashioned around, or incorporated into, the usually small central defect.[13] In cases with small defects or where we want to avoid spontaneous rupture of the capsule, another alternative is initiation of capsulorhexis at the midperiphery rather than a conventional continuous curvilinear capsulorhexis.[14] Fortunately, the lens is generally not cataractous or hard enough, and just aspiration on low machine parameters may suffice. We should limit hydrodissection and avoid capsular polish in such cases due to the fragility of the capsule. In smaller children doing a posterior capsulotomy simultaneously may be even more difficult. If posterior capsulorhexis is needed because of the child's age, endocapsular IOL implantation or anterior optic capture of the IOL maybe a reasonable approach. A close follow-up in such cases is essential to look out for inflammation, opacification, and phimosis of the capsule.

  References Top

Scott JG. Spontaneous rupture of the lens capsule. Br J Ophthalmol 1953;37:58-60.  Back to cited text no. 1
Lohchab M, Arora R. Bilateral spontaneous lens capsule rupture in Alport's syndrome. Indian J Ophthalmol 2019;67:406.  Back to cited text no. 2
[PUBMED]  [Full text]  
Oto S, Aydin P. Rupture of the anterior lens capsule in Alport syndrome. J AAPOS 1999;3:381-2.  Back to cited text no. 3
van der Westhuizen DP, Stuart KV. Bilateral spontaneous anterior lens capsule ruptures in a child: A rare presentation of Alport syndrome. Am J Ophthalmol Case Rep 2020;20:100896.  Back to cited text no. 4
Sabti K, Chow D, Fournier A, Aroichane M. Spontaneous rupture of the lens capsule in a case of Marshall syndrome. J Pediatr Ophthalmol Strabismus 2002;39:298-9.  Back to cited text no. 5
Chaurasia S. Bilateral spontaneous rupture of the anterior capsule. J Cataract Refract Surg 2008;34:1413-5.  Back to cited text no. 6
Hemalatha C, Norhafizah H, Shatriah I. Bilateral spontaneous rupture of anterior capsules in a middle-aged woman. Clin Ophthalmol 2012;6:1955-7.  Back to cited text no. 7
Gaviria JG, Johnson DA, Scribbick FW III, Gallardo MJ. Spontaneous anterior capsular rupture associated with anterior polar cataract. Arch Ophthalmol 2006;124:134-5.  Back to cited text no. 8
Sukhija J, Ram J, Brar GS, Bandhyopadhyaya S. Spontaneous rupture of anterior lens capsule. Indian J Ophthalmol 2006;54:216-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
Bayar SA, Pinarci EY, Karabay G, Akman A, Oto S, Yilmaz G. Clear lens phacoemulsification in Alport syndrome: Refractive results and electron microscopic analysis of the anterior lens capsule. Eur J Ophthalmol 2014;24:345-51.  Back to cited text no. 10
Wilson ME Jr, Trivedi RH, Biber JM, Golub R. Anterior capsule rupture and subsequent cataract formation in Alport syndrome. J AAPOS 2006;10:182-3.  Back to cited text no. 11
Agrawal N, Nayak DP, Haripriya A, Bhuwania P. Phacoemulsification with toric IOL implantation in Alport syndrome with anterior lenticonus having spontaneously ruptured anterior capsule. Eur J Ophthalmol 2015;25:e78-80.  Back to cited text no. 12
Sukhija J, Saini JS, Jain AK. Phacoemulsification and intraocular lens implantation in an Alport's syndrome patient with bilateral anterior and posterior lenticonus. J Cataract Refract Surg 2009;29:1834-6.  Back to cited text no. 13
Thrishulamurthy CJ, Saiprasad D. Bilateral symmetrical spontaneous anterior capsule rupture of the cataractous lens in a child. Indian J Ophthalmol Case Rep 2022;2:391-3.  Back to cited text no. 14
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