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Year : 2019  |  Volume : 12  |  Issue : 1  |  Page : 55-57  

Histopathology and surgical approach in cataract associated with true exfoliation of the lens capsule

1 Glaucoma Department, Anand Eye Institute, Hyderabad, Telangana, India
2 L. V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Web Publication30-Jan-2019

Correspondence Address:
Dr. Tarannum Mansoori
7-147/1, Nagendra Nagar Colony, Habsiguda, Hyderabad - 500 007, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.OJO_187_2016

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True exfoliation is a delamination of the superficial layer of anterior lens capsule, which appears as a transparent membrane in the anterior chamber. It is a rare occurrence, and most of the reported cases have been associated with a history of exposure to excessive heat, ocular trauma, or inflammation. We report pre- and post-operative anterior segment observations, surgical approach and histopathology of the excised lens capsule in a patient who presented with bilateral true exfoliation without any contributory history. This case highlights findings from light microscopy which demonstrated a lamellar separation of the anterior lens capsule and partial detachment of anterior capsule with reduced intensity of periodic acid Schiff's staining in the detached portion, confirming the diagnosis of true exfoliation.

Keywords: Histopathology, phacoemulsification, true exfoliation

How to cite this article:
Mansoori T, Senthil S, Vemuganti GK. Histopathology and surgical approach in cataract associated with true exfoliation of the lens capsule. Oman J Ophthalmol 2019;12:55-7

How to cite this URL:
Mansoori T, Senthil S, Vemuganti GK. Histopathology and surgical approach in cataract associated with true exfoliation of the lens capsule. Oman J Ophthalmol [serial online] 2019 [cited 2022 Aug 18];12:55-7. Available from: https://www.ojoonline.org/text.asp?2019/12/1/55/251033

   Introduction Top

True exfoliation or lamellar delamination of the lens capsule is a rare disorder characterized by thickening of the lens capsule, with splitting of the superficial portion of the anterior lens capsule from the deeper layers, which extends and creates a floating membrane in the anterior chamber. It was first described in glassblowers in 1922[1] and other reports documented the condition in steelworkers and blacksmiths, who are exposed to the prolonged infrared radiation from extremely hot materials. Other causes include advanced age,[2],[3],[4],[5] iridocyclitis,[6] trauma, glaucoma,[3],[5] idiopathic[7] or altered capsule proteins, inherent in the lens.[7]

   Case Report Top

A 65-year-old male, farmer by occupation, presented with complaint of a gradual decrease in vision in both his eyes over a period of 6 months. He denied any history of trauma or systemic illness. His best-corrected visual acuity was 20/40, N10 in both eyes. Intraocular pressure was 14 and 10 mm of Hg in the right and left eye, respectively. Slit lamp examination revealed grade 3 nuclear cataract, thin transparent membrane arising from the anterior capsule, attached at one end, floating and undulating in anterior chamber, in both the eyes [Figure 1]. There were no iris transillumination defects, pseudoexfoliation, phacodonesis, or evidence of uveitis. Gonioscopy showed open angles till sclera spur and no evidence of pseudoexfoliation. Fundus was normal with 0.7:1 cup-disc ratio, healthy neuroretinal rim, and large size discs. He underwent phacoemulsification with posterior chamber intraocular lens implantation in the right eye.
Figure 1: Slit lamp photograph showing nuclear cataract and a thin transparent membrane (arrow) arising from the anterior lens capsule

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Surgical procedure

Under local anesthesia, sclerocorneal tunnel was made. Anterior capsule was noted to be thin and care was taken to perform capsulorrhexis with the leading edge of rhexis bypassing the margin of true exfoliation. Anterior capsule along with the floating membrane was removed and sent for the histopathology. Gentle hydrodissection was performed, central de-bulking of the hard nucleus, followed by chop in situ and lateral separation was done, and phacoemulsification was completed. Non-foldable 5.5 mm poly (methyl methacrylate) lens was implanted in the bag. At 1 week postoperative visit, the best-corrected visual acuity was 20/20 in the right eye, and the posterior chamber intraocular lens was well centered in the capsular bag.

Histopathology revealed a folded lens capsule with lens epithelial cells (LECs). In one area, there was a marked thickening of the lens capsule with a lamellar slit, which was highlighted by periodic acid Schiff's (PAS) staining [Figure 2].
Figure 2: Histopathology showing marked thickening of the lens capsule, with a second layer of capsule, suggesting a lamellar split (arrow)

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   Discussion Top

The exact mechanism for the development of true exfoliation of lens capsule remains unclear. It is postulated that the iris absorbs the infrared radiation which is and transmitted to the lens capsule resulting in degenerative epithelial changes. LEC's particularly those, which are actively dividing near the lens equator are susceptible to radiation, and their mitotic activity is temporarily inhibited. Subsequent generations of epithelial cells (on the resumption of mitotic activity) are aberrant and functionally impaired. The extent of the damage of the lens capsule directly correlates with the dose and duration of radiation.[8] Using transmission electron microscopy, Karp et al.[9] observed degenerative cellular changes and partial detachment of the anterior portion of the lens capsule with reduced intensity of PAS staining in the detached portion of the lens capsule in true exfoliation. Cooke et al.[10] support the hypothesis that the damage to the epithelial layer and vesicular degeneration of the capsule may be significant in true exfoliation of the lens capsule.

In our case, histopathology revealed marked thickening of the lens capsule with lamellar separation, part of which was separated, similar to the findings by Karp et al.,[9] confirming the diagnosis of true exfoliation. True exfoliation of the lens capsule should be suspected when a patient has a floating membrane extending from the anterior surface of the lens into anterior chamber, which can be easily missed as the capsule is transparent and very thin. If it is identified before surgery, creating a partial thickness capsulorrhexis or extension of the capsulorrhexis and related intraoperative complications can be avoided.

Cashwell et al.[3] reported age-related true exfoliation of the lens capsule in seven patients (11 eyes, mean age, 85.4 years) during a 6-year period, and none had a history of ocular trauma or extended exposure to an extreme heat source. They found glaucoma in 7/11 eyes and speculated that there could be a possible connection between glaucoma and true exfoliation of the lens capsule. However, the small number of patients makes any conclusions regarding the relationship highly speculative.

Wong et al.[5] reported 24 eyes of 18 Chinese patients with true exfoliation syndrome, of which, seven eyes (29.2%) had preexisting glaucoma, and 5 (20.8%) had laser peripheral iridotomy (LPI) before the diagnosis. The common factor for all patients was advanced age (mean age, 80.5 ± 6 years). LPI in their series was performed with sequential argon and neodymium: Yttrium aluminum garnet lasers. The relation between LPI and true exfoliation remains questionable. The possible explanation of true exfoliation in cases after LPI could be that the condition could have been missed before mydriasis or the thermal energy from the laser was absorbed by the iris which possibly transmitted to the lens and damaged the underlying lens epithelium.

Another study[4] reported true exfoliation of the lens capsule in 6/278 cases in their series. They supported the notion that it is more often associated with advanced age (mean age, 85 years). Age-related degeneration of the LECs compromises the integrity of the lens capsule, causing vesicles to form, which coalesces to form larger vacuoles, and hence, delamination of the anterior portion of the lens capsule may occur.

In our case, apart from the patient's age, history of chronic exposure to the intense sunlight because of patient's occupation could have played a role in capsular delamination. As true exfoliation was identified preoperatively, capsulorrhexis was performed with caution and partial or extended capsulorrhexis was prevented.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Elschnig A. Detachment of the zonular lamella in glassblowers. Klin Monbl Augenheilkd 1922;69:732-4.  Back to cited text no. 1
Dvorak-Theobald G. Pseudo-exfoliation of the lens capsule: Relation to true exfoliation of the lens capsule as reported in the literature and role in the production of glaucoma capsulocuticulare. Am J Ophthalmol 1954;37:1-12.  Back to cited text no. 2
Cashwell LF Jr., Holleman IL, Weaver RG, van Rens GH. Idiopathic true exfoliation of the lens capsule. Ophthalmology 1989;96:348-51.  Back to cited text no. 3
Ng AL, Marcet MM, Lai JS, Yeung JC. Age-related true exfoliation of the lens capsule: Phacoemulsification surgery results. Case Rep Ophthalmol 2015;6:401-7.  Back to cited text no. 4
Wong AL, Chan TC, Fong AH, Lam BN, Yuen HK. Clinical characteristics and surgical outcomes of phacoemulsification in true exfoliation syndrome. J Cataract Refract Surg 2014;40:82-6.  Back to cited text no. 5
Yamamoto N, Miyagawa A. True exfoliation of the lens capsule following uveitis. Graefes Arch Clin Exp Ophthalmol 2000;238:1009-10.  Back to cited text no. 6
Anderson IL, van Bockxmeer FM. True exfoliation of the lens capsule. A clinicopathological report. Aust N Z J Ophthalmol 1985;13:343-7.  Back to cited text no. 7
Meades K, Versace P. True exfoliation of the lens capsule. Aust N Z J Ophthalmol 1992;20:347-8.  Back to cited text no. 8
Karp CL, Fazio JR, Culbertson WW, Green WR. True exfoliation of the lens capsule. Arch Ophthalmol 1999;117:1078-80.  Back to cited text no. 9
Cooke CA, Lum DJ, Wheeldon CE, Teoh H, McGhee CN. Surgical approach, histopathology, and pathogenesis in cataract associated with true lens exfoliation. J Cataract Refract Surg 2007;33:735-8.  Back to cited text no. 10


  [Figure 1], [Figure 2]

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