Zonular Apparatus Capsular Bag Insufficiency with Spontaneous Posterior Capsule Rupture

Zonular apparatus capsular bag (ZACB) insufficiency causes late postoperative spontaneous in-the-bag intraocular lens (IOL) dislocation, a serious complication of cataract surgery. Spontaneous posterior capsule rupture (SPCR) with IOL dislocation is a rare complication. This study reports and discusses clinical features and outcomes of ZACB insufficiency with SPCR.

We retrospectively reviewed 7 cases of SPCR that developed after cataract surgery at Nippon Medical School Musashi Kosugi Hospital between March 2021 and February 2025. Clinical records and surgical videos were examined to collect data on patient age, sex, associated systemic and ocular conditions, medications, dates of IOL implantation and explantation, signs and symptoms prompting explantation, and surgical outcomes. The stage of capsular rupture and location of intraocular lens dislocation were classified on the basis of intraoperative findings.

The anterior capsule rim and zonule were intact in 5 SPCR cases, with the exchanged IOL fixated in the sulcus. Two cases of SPCR exhibited both anterior and posterior capsule dislocation requiring intrascleral IOL fixation. The average age of the patients was 52 years (range: 29-83 years; 6 men, 1 woman), and 5 (4 men, 1 woman) had atopic dermatitis. Time since the initial cataract surgery ranged from 10 to 20 years (mean, 13.8 years).

Most SPCR cases were associated with atopic dermatitis, with minor trauma possibly contributing to ZACB insufficiency. Capsule morphology was preserved in most SPCR cases, with the exception of posterior capsule rupture.