1) A 75-year-old male presented with gradual decreased vision in both eyes over the past 3 years. He has a history of cataracts surgery in both eyes. 2) Examination found posterior capsular opacification in both eyes, worse in the left eye. The left eye also showed an irregular pupil, RAPD, and a dull fundus reflex. 3) The patient underwent YAG capsulotomy in the left eye. At 1-week follow-up, his vision had improved but was still reduced in the left eye, likely due to underlying retinal pathology. He was advised to continue his current prescription and follow-up as needed.

2. Case history
Name: xxx
Age : 75 years
Sex : Male
Chief Complaints
LE: c/o of gradual decrease in vision for both distance and near
x 3 years
No other specific ocular complaints
Previous Ocular History
BE: h/o cataract Sx done in RE 10 years ago and in LE 3 years
ago.
H/o of wearing spectacles x 15 years.
No h/o of trauma
BE- both eye, RE- right eye, LE- left eye, Sx- surgery
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3. Family history
Not contributory
General health:
H/o DM x 10 years,
H/o HTN x 5 years,
H/o renal problem x 10 years
Recent investigation
Nil
Current medication
T. Amlong o.d, T. Sartel 40 mg o.d, T. Pankareoflat o.d,
T. Shelcal 500 mg o.d, T. Nephrocaps o.d, T. Renerve plus o.d
Allergies
Not aware of
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DM-diabetes mellitus, HTN- hypertension

4. Previous glass precription x 3 years
Not brought
Visual acuity
Distance vision with Snellen chart at 6m
(Without Rx) RE: 6/9 NIP
LE: 1/60 NIP
Near vision with continuous text chart at 40 cm
(Without Rx) RE: N10
LE: N36
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NIP- no improvement with pinhole

5. Objective refraction
RE: -1.00 DS/-1.00 DC x 120 (clear reflex)
LE: +0.00 (very dull reflex)
Acceptance
RE: plano (6/9 NI)
LE: plano (1/60 NI)
Add
RE: +3.00 DS (N6)
LE: +3.00 DS (N36)
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@ 40cm

6. Pupils
RE: irregular, RTL, No RAPD
LE: irregular, RTL, RAPD II
Extra-Ocular Motility test
RE: SAFE
LE: SAFE
Cover test
Distance : ortho
Near : ortho
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SAFE- Smooth, accurate and fully extensive

7. Slit lamp examination
Upper lids
normal
Conjunctiva
pallor
Cornea clear
RTL
PXF
ACD III
RE
LE
Lower lids normal
PCO I PCO IIIPCIOL in situ
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8. IOP with Goldman applanation tonometer @5:00 PM
RE: 16 mmHg
LE: 16 mmHg
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9. Fundus Examination
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Disc vessesl
normal
CDR 0.4
Pallor disc
FR+
Dull FR
RE LE
Media clear Media hazy

10. Diagnosis
BE: Posterior Capsular Opacification
BE: Pseudophakia
RE: Pseudoexfoliation
LE: RAPD II
Advice
OS: Advised to go for YAG- Capsulotomy
Treatment
OS: YAG- Capsulotomy done(9-12-17)
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11. Follow up after 1 week
Visual Acuity
Distance vision with Snellen Chart @6m
(With Rx) RE: 6/9 NIP
LE: 6/18 NIP
Near vision with continuous text chart @ 40 cm
(With Rx) RE: N6
LE: N6 with strain
Previous glass precription (Kryptok bifocals)x 3 years
RE: -0.75 DS
LE: -1.00 DS
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ADD: BE: +3-00 DS

12. Objective refraction
RE: -1.00 DS/-1.00 DC x 120(clear reflex)
LE: -1.00 DS/-1.00 DC x 90(clear reflex)
Acceptance
RE: -0.75 DS (6/9) NI
LE: -1.00 DS (6/18) NI
Add
RE: +3.00 DS (N6)
LE: +3.00 DS (N6 with strain)
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Prefers same RX
@ 40 cm

13. Pupils
RE: irregular, RTL, No RAPD
LE: irregular, RTL, RAPD II
Extra-ocular Motility test
RE: SAFE
LE: SAFE
Cover test
Distance : ortho
Near : ortho
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SAFE-Smooth, accurate and fully extensive

14. Slit lamp examination
Upper lids
normal
Conjunctiva
pallor
Cornea clear
RTL
PXF
ACD III
RE
LE
Lower lids normal
PCO I
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PCIOL insitu

15. IOP with Goldman applanation tonometer @5:00 PM
RE: 12 mmHg
LE: 12 mmHg
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16. Fundus examination
Not done
Advice
Continue to wear same Rx
Review SOS
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Reasons for NI in LE visual acuity might be the reasons of retinal diseases or
amblyopia plus RAPDII and the pallor disc suggests having optic nerve
lesions, neuropatyhy or neuritis ..

17. Posterior Capsular Opacification (PCO)
• After or secondary cataract
• Multifactorial physiological
causes
Incidence
• Occurs upto 50% of after complicated Cataract Sx 1,2
• Higher rate in children upto 100%1,2,
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18. PCO
Fibrosis type Pearl type
1.Proliferation 2.Migration of cells 3. Differentiation of cells
1.Complicated
Cataract surgery
2.IOL material and
designs
3. Size and
position of CCC
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Pathogenesis of PCO
Residual LECs
CCC- continuous curvilinear capsulorehexis

19. 4/18/2018 19

20. 4/18/2018 20

21. Symptoms
• Gradual decrease in vision
• Glare
• Monocular diplopia
Signs
• Decreased visual acuity if the PCO blocks the visual axis
• Soemmering ring1
• Elschnigs pearl
• Fibrosis PCO
4/18/2018 21Capsular fibrosis

22. 4/18/2018 22

23. Gradings of PCO3,5
Grades Severity PCO
0 None No PCO
1 Slight PCO not reaching the edge of optic
2 Moderate PCO reaching the edge
3 Pronounced PCO beyond the edge but visual axis is clear
4 Severe PCO on the visual axis
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24. 4/18/2018 24

25. EPCO Gradings of PCO2
Grade Severity PCO
o None Clear lens
1 Minimal Mild caspsule wrinkling, homogenous lay
er of LECs
2 Mild Honeycomb pattern, denser layer of LECs
3 Moderate Elschnigs pearl, thick layer of LECs
4 Severe Very Thick elschnig pearl with darkening
effect and severe PCO
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EPCO-Evaluation of posterior capsular opacification

26. Treatment
• In pediatrics, anterior vitrectomy with membranectomy.
• In children, anterior vitrectomy and posterior capsulotomy
• In adults, Nd YAG: Posterior Capsulotomy
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27. Nd YAG: Capsulotomy
Opening of capsule with laser
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1. Cruciate opening 2. Circular opening

28. 4/18/2018 28

29. Complications of YAG- Capsulotomy1,2,3,4,5
• Corneal oedema
• IOL damage or subluxation
• Elevation of IOP
• Vitreous floaters
• Cystoid Macular Edema
• Retinal Detachment
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30. Reference
1. Brad Bowling, Kanski’s Clinical ophthalmology- a systemic approach, 8th Edition
2. Wejde, G. (2005). Posterior capsule opacification and postoperative endophthalmitis
following cataract surgery: Predictive and protective factors. Institutionen för klinisk
neurovetenskap/Department of Clinical Neuroscience.
3. Wahab, S., Ahmed, J., & Hasan, K. S. (2011). Pars plana surgical capsulotomy for po
sterior capsular opacification (PCO). JPMA-Journal of the Pakistan Medical Associat
ion, 61(1), 14.
4. Elkin, Z. P., Piluek, W. J., & Fredrick, D. R. (2016). Revisiting secondary capsulotom
y for posterior capsule management in pediatric cataract surgery. Journal of America
n Association for Pediatric Ophthalmology and Strabismus {JAAPOS}, 20(6), 506-5
10.
5. Na, Y. H., Shin, J. Y., Lee, J. H., Kim, J. H., & Lee, D. H. (2016). Incidence of Poster
ior Capsular Opacification Based on Low and High Fluid-dynamic Parameters. Journ
al of the Korean Ophthalmological Society, 57(10), 1555-1562.
6. Hashemi, H., Mohammadi, S. F., Majdi, M., Fotouhi, A., & Khabazkhoob, M. (2012)
. Posterior capsule opacification after cataract surgery and its determinants. Iran J Op
hthalmol, 24, 3-8.
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