Separation of the anterior layer of the lens capsule, also known as
true exfoliation and capsular delamination, has become an increasingly rare
clinical finding. Although its pathogenesis is not precisely known, the condition
has been associated with age, trauma, and exposure to toxins and/or to thermal
radiation.1 An association with occupational
infrared radiation exposure was accepted after Elschnig2 described
the classic clinical findings in 2 glassblowers and Kubik3 and
others4,5 noted the condition
in blacksmiths, puddlers, chainmakers, and steelworkers. With improved safety
standards, the condition is now reported less frequently in association with
occupational hazards. Capsular delamination remains of interest particularly
because there may be mild subclinical forms of the condition,6 and
because modern cataract surgery is dependent on successful anterior capsule
An 81-year-old man who under treatment for a cardiac arrhythmia and
hypertension reported blur and glare in both eyes. There was a family history
of cataracts and glaucoma. His career involved more than 20 years in a steel
mill. During 4 of these years, he experienced frequent and intense prolonged
exposure to the heat of the blast furnaces.
On ophthalmic examination, his best-corrected visual acuity was 20/70
OU. The patient had hyperopia of 4 diopters. Bilateral cataracts were present,
having combined cortical and nuclear elements. Within the central anterior
chamber in both eyes was a folded cellophane-like membrane fixed to the anterior
lens capsule's surface, unassociated with any evidence of inflammation (Figure 1). The degree of delamination was
approximately symmetrical. There were no other abnormal deposits on the lens
capsule or the iris, no unusual pigmentation of the angle, and no phacodonesis.
Results of tonometry, fundus, and optic nerve examinations were all normal.
Preoperative appearance of a diaphanous
membrane (arrows) in the anterior chamber that is attached to the lens.
The patient underwent bilateral cataract extraction with a 2-month interval
between procedures. The phacoemulsification technique was standard except
for a larger than usual capsulorrhexis and the submission of the capsule specimens
for histopathologic study. The diaphanous membrane was gently teased to the
side and the deeper capsular layer was dissected with a bent 30-gauge needle.
There were no complications in either operation. Two years postoperatively,
the uncorrected vision was 20/25 OU with a mild astigmatism with the rule
noted on refraction. The posterior capsules remained clear and the anterior
capsular edges appeared normal.
Findings from the histopathologic examination of the specimens revealed
delamination of the lens capsule that was best illustrated by transmission
electron microscopy (Figure 2).
The capsule was moderately electron dense with a laminated granular appearance.
The splitting of the capsule was documented with the anterior layer thinner
than the posterior layer.
Electron microscopy ultrastructural
appearance of a 3-µm-thick layer (asterisk) that is split from the anterior
lens capsule. Note surface-parallel vacuolization of the anterior capsule
extending beyond the split (original magnification ×12 000).
Multiple reports exist of capsular delamination specimens from successful
intracapsular and extracapsular cataract surgery.4,7,8 In
this case, the curvilinear capsulorrhexis technique was successful. With the
exception of the manipulation required to take the surgical specimen, the
cases were routine and without complication. To our knowledge, no series to
date has reported a rate of complication in cataract extraction with capsular
delamination, but the true incidence of complications associated with this
finding will be difficult to establish because of its rarity.
While capsular delamination is rare, mild and subclinical forms of the
condition may be more prevalent than currently recognized. In a series of
10 cases, Wollensak and Wollensak6 reported
the appearance of a double contour visible at the capsulorrhexis edge. Pathologic
analysis of the capsulorrhexis specimens by light and electron microscopy
revealed the double contour to result from a characteristic step formation
at the capsulorrhexis edge. In 7 of 10 of these cases, these authors also
noted surface-parallel splits in the outer third of the capsule. They postulated
that the double contour and microscopically evident surface-parallel splits
may represent a subclinical form of true exfoliation that results from zonular
traction on the superficial capsule over less elastic deeper layers in older
patients. These findings suggest that true exfoliation may represent one extreme
of a continuum representing different degrees of capsular delamination. Although
Wollensak and Wollensak reported anecdotally that the incidence of radial
capsular tears appeared lower when a double contour was seen, no evidence
currently exists regarding the relative strength or weakness of the capsulorrhexis
with the double contour. Likely, the finding goes unnoticed in most cases.
No double contour was observed after curvilinear capsulorrhexis in our case.
Perhaps this is because the delamination did not extend to the capsulorrhexis
edge, although evidence for shearing of the capsular layers beyond the edge
of true exfoliation is suggested by the vacuolization of the capsule seen
ultrastructurally beyond the split (Figure
Although associations with trauma, toxins, inflammation, and heat are
well recognized, the underlying etiology of true exfoliation of the lens capsule
remains uncertain. Small case series of patients without a history of trauma
or heat exposure suggest aging may be a major factor.9 It
has also been suggested that capsular protein abnormalities may play a role.10 In this case, however, a volunteered history of
prolonged exposure to the heat of a blast furnace provided the most likely
etiologic factor related to both the cataract and delamination of the anterior
capsule. Clinically, diaphanous transparent membranes were similar to those
reported as glassblower's cataracts. Fortunately, occupational safety standards
and protective engineering have made true exfoliation from infrared exposure
The authors have no financial interest in this article.
Corresponding author: James S. Kelley, MD, 6565 N Charles St, Suite
302, Baltimore, MD 21204 (e-mail: email@example.com).
James S. Kelley, Tony Tsai, Mary B Kansora, W. Richard Green. Capsulorrhexis in Capsular Delamination. Arch Ophthalmol. 2002;120(11):1581–1582. doi:
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