Friday, December 10, 2021

Lupine Publishers | Extracellular Proteases from Keratitis Causing Fusarium, Aspergillus and Dematiaceous Species

 Lupine Publishers | Trends in Ophthalmology Open Access Journal 


Abstract

Purpose

Various types of hydrolytic enzymes, like proteases, lipases and phospholipases are important virulence factors produced by pathogenic fungi. In the present study quantification and characterization of proteases produced by different pathogenic AspergillusFusarium and Dematiaceous Species isolated from corneal ulcers was done.

Method

Seven Aspergillus species, twelve Fusarium species and five Dematiaceous Species previously isolated from corneal ulcers were used in the present study. All isolates were grown in Sabarouds Dextrose Broth (SDB) and culture filtrate was obtained after 10 days of growth. Acetone precipitated culture filtrate was used as the source of protease. Characterization of proteases was done by assaying the activity at different pH (6-12), with inhibitors (PMSF, Pepstatin and EDTA) and gelatin zymography.

Result

In Aspergillus spp, maximum specific activity of protease was found in Aspergillus flavus and minimum specific activity was found in Aspergillus niger and Aspergillus tubingensis. In Fusarium spp., proteases from Fusarium solani Species complex (FSSC) showed more activity compared to F. delphinoides. Proteases from Aspergillus spp. and FSSC showed inhibition in presence of PMSF, while EDTA inhibited the proteases from F. delphinoides. In Dematiaceous group, Curvularia spp showed highest activity and were inhibited by PMSF.

Conclusion

It was concluded that fungi causing keratitis produce varying amounts and types of proteases. The difference in the specific activity of extracellular proteases among the isolates could indicate the differences in their pathogenic potential.

Keywords:Mycotic keratitis; Aspergillus spp; Fusarium spp; Proteases; Virulence factors

Introduction

Corneal blindness, in developing countries is predominantly associated with infections. In India, nearly 35-50% of all infectious keratitis are caused by fungi [1]. The term mycotic keratitis refers to a corneal infection caused by fungi. More than 105 species of fungi belonging to 56 genera have been reported to cause fungal keratitis. The most common isolates which are isolated from the eyes of the patients are species of FusariumAspergillus, Candida and other hyaline and Dematiaceous hyphomycetes. The most common risk factor for keratitis is ocular trauma through vegetative material while, other predisposing factors can be prolonged use of topical corticosteroids or antimicrobial agents, systemic diseases such as diabetes mellitus, preexisting ocular diseases and use of contact lenses.

Pathogenic fungi retain several factors which allow their growth in adverse conditions provided by the host and contribute to disease development. These factors are known as virulence factors which favor the infection process and are important determinants of the pathogenic potential of any organism [2]. The pathogenecity of the fungus may be due to fungal cell wall components, toxins, enzymes or pigments produced by fungus. The microbial attributes that confer the potential for virulence fall primarily within several categories, including the ability to enter a host; the ability to evade host defenses; to grow in a host environment; to counteract host immune responses; to acquire iron and nutrients from the environment and to sense environmental change. Production and secretion of hydrolytic enzymes, such as proteases, lipases and phospholipases are among the important virulence traits [3].

Proteases, also termed as proteinases or peptidases, are proteolytic enzymes which function as molecular knives which cut long amino acid sequences into fragments, a process that is essential for the synthesis of all proteins, controlling their size,composition, shape, turnover, and ultimate destruction[4]. These enzymes play a role in nutrition, tissue damage, dissemination within the human organism, iron acquisition and overcoming the host immune system and hence strongly contribute to fungal pathogenicity [3]. Extracellular proteases from Fusarium spp. and Aspergillus spp. cause corneal destruction in experimental rabbit models [2,5]. Proteolytic activities of A. flavus and F. solani in rabbit corneas during active fungal keratitis were investigated in vivo and it was found that the fungal cultures predominantly produced serine proteases in vitro; while, fungal infected corneal homogenates showed the presence of metalloproteases alone [5]. Production of proteases in Aspergillus and Fusarium causing keratitis has also been shown to be correlating significantly with amphotericin B resistance [6]. Further, alkaline protease (Alp1) has also been shown to be one of the abundant proteins in A. flavus exoproteome [7]. Taken together, these studies indicate that proteases can mediate corneal invasion and could also cause corneal melting. However, there is paucity of information regarding their detailed characterization from keratitis causing isolates. Earlier we reported a prospective study to compare different aspects of fungal keratitis such as its clinical features, microbial evaluation, molecular identification, antifungal susceptibility, and clinical outcomes between FusariumAspergillus and Dematiaceous fungi [8]. In the present study detailed analysis of proteases produced by these three groups of fungi is attempted.

Material and Methods

 

Fungal Isolates

Clinical isolates of fungi (n=24); belonging to Fusarium spp. (n=12); Aspergillus spp. (n=7) and Dematiaceous spp. (n=5) isolated in the previous study and were available in the lab [8,9]. All isolates were identified using the ITS region sequencing and sequences were deposited in NCBI. Name and GenBank accession no of fungi (n=25) used in the present study are: Fusarium delphinoides (n=4) [Cc26- KM017139, Cc52- JQ910153, Cc 119- KM017141, Cc132- KM017140]; Fusarium solani Species complex (FSSC) (n=8) [Cc50-KM017134, Cc149- JQ910159, Cc163- KM017142, Cc167-KM017143, Cc172-KM017144, Cc204-KM017135, Cc215- KM017137, Cc256-KM017138]; Aspergillus flavus (n=1) [Cc59- JQ910160]; Aspergillus sydowii (n=1) [Cc73-JQ910152]; Aspergillus niger (n=1) [Cc101- JQ910154]; Aspergillus terreus (n=1) [Cc112- KM017145]; Aspergillus tubingensis (n=1) [Cc117-JQ910156]; Aspergillus tamarii (n=1) [Cc129- JQ910158]; Aspergillus fumigatus (n=1) [Cc249- KM017131]; Curvularia lunata (n=3) [Cc70- KM017133, Cc90-JQ910155, Cc157-KM017132]; Phomopsis phoenicicola (n=1) [Cc58- HQ650813]; Phaeoacremonium rubrigenum (n=1) [Cc79-KM017136].

Growth of Fungi

The isolates were first grown on Sabouraud’s Dextrose Agar (SDA) (Himedia Laboratories, India) and after 7 days of growth, approximately 10 mm disc was cut from the SDA plate and inoculated in 100 ml of Sabouraud’s Dextrose Broth (SDB) in 500 ml conical flask. The fungus was grown on SDB for 10 days at 30±2 ºC in static condition.

Extraction and Precipitation of Proteases

After 10 days of fungal growth, the culture filtrate was collected using sterile Whatman filter paper in a sterile bottle. The obtained culture filtrate was then subjected to precipitation using chilled acetone. To 1 ml of fungal culture filtrate 4 ml of chilled acetone was added drop wise. Culture filtrate – acetone mixture was then kept at -26 ºC over night for precipitation. Next day, the precipitate was collected through centrifugation at 5000 RPM for 15 minutes at 4 ºC. Resultant precipitate was dissolved in Phosphate buffered Saline (PBS) (50 μl PBS/ml of initial culture filtrate used for precipitation) and used for azocaesin assay and gelatin zymography. Protein estimation of concentrated extract was done by the method of Lowry et al. [10].

Specific Activity Measurement by Azocasein Assay

Azocasein (Sigma Aldrich, USA) was dissolved at a concentration of 5 mg/ml in assay buffer containing 50 mM Tris (Sigma Aldrich, USA) (pH 7.4), 0.2M NaCl (Himedia Laboratories, India), 5mM CaCl2 (Himedia Laboratories, India), 0.05% Brij 35 (Himedia Laboratories, India), and 0.01% sodium azide (Himedia Laboratories, India). The azocasein solution (400μl) was mixed with 100μl of precipitated culture supernatants and incubated in a 37°C water bath for 90 min. The reactions were stopped by adding 150μl of 20% trichloroacetic acid (Sigma Aldrich, USA), and the reaction mixtures were allowed to stand at the ambient temperature for 30 min. Tubes were then centrifuged for 3 min at 8,000g, and 50μl of each supernatant was added to 500μl of 1 M NaOH (Himedia Laboratories, India). The absorbance at 436nm of released azo dye was determined. One unit of enzyme activity was defined as an increase of 0.1 absorption unit after incubation for 1 hour. Specific activity was calculated as Units/ mg.

Characterization of Proteases

For characterization of proteases; the effect of pH and inhibitors was studied using the precipitated enzyme extracted from all fungi. Effect of pH: The effect of pH on enzyme activity was studied by incubating the enzyme in azocasein solution of respective pH. Azocasein activity was studied at 6 different pH ranging from acidic to basic i.e. pH 3, pH 5, pH 7.4, pH 8, pH 10 and pH 12. Effect of enzyme inhibitors: To understand the type of enzyme produced, specific enzyme inhibitors were used and azocasein assay was carried out. PMSF (Sigma Aldrich, USA) (inhibitor of serine protease at final concentration of 0.5mM), EDTA (Himedia Laboratories, India) (inhibitor of metallo protease at final concentration of 1mM) and Pepstatin (Sigma Aldrich, USA) (inhibitor of aspartyl proteases at final concentration 1μM) was used to check the type of proteases present in fungal isolates. Proteases samples were incubated with inhibitor for 1 hour and same concentration of inhibitor was also added in azocasein solution in which the azocasein assay was carried out. Azocasein assay was done by the method described earlier.

Gelatin Zymography

Zymography was performed using gelatin (Sigma Aldrich, USA) as a substrate (0.1%) and 12% of polyacrylamide (Sigma Aldrich, USA). Twelve percent SDS- polyacrylamide gel was prepared with 0.1% gelatin. Enzyme units (0.2) were taken, mixed with 6X loading dye and electrophoresed. After electrophoresis, the gel was incubated in incubation buffer (50mM Tris, 5 mM CaCl2 and 1 μM ZnCl2) containing 2.5 % Triton –X 100 (Himedia Laboratories, India) for 1 hour. The gel was washed twice with deionized water and again kept in same buffer at 37°C for 2 hours. The gel was again washed with deionized water and kept overnight for staining with (0.5%) Commassie Brilliant blue R (Himedia Laboratories, India). The gel was de-stained with destaining solution (methanol: water: acetic acid, 4:5:1v/v) to observe the bands of enzyme activity. The bands of substrate degradation were observed as colorless bands against blue background. Zymography in presence of inhibitors was also done. The proteases samples were pre-incubated with desired concentration of three inhibitors i.e. PMSF, pepstatin and EDTA for 1 hour and then loaded into gel for zymography.

Results

Aspergillus Proteases

Proteases produced by Aspergillus species showed activity at all pH tested (Table1). The optimum pH of proteases from A. niger, A. terreus, A. tubingensis and A. fumigatus was pH 10. Proteases from A. flavus and A. sydowii showed high activity at pH 8; whereas, A. tamarii presented the activity of proteases at broad pH range. Out of 7 Aspergillus species used in the present study, A. flavus and A. tamarii illustrated more activity i.e. 274.25±1.49 units/mg and 275.9±2.1 units/mg, respectively as compared to rest of the species. A. niger and A. tubingensis showed relatively less specific activity which was 6.24±1.36 units/mg and 6.59±0.33 units/mg respectively at pH 10. The specific activity of A. sydowii was 80.19±0.60 units/mg at pH 8. In A. fumigatus, and A. terreus the specific activity was 11.5±0.05 units/mg and 59.84±0.36 units/mg respectively at pH 10. The results showed that the proteases produced by all Aspergillus species were mainly alkaline proteases. The in vitro inhibition assays showed that proteases from all 7 species were inhibited in presence of all 3 inhibitors with a significant difference with p value at least < 0.05. The proteases inhibition pattern in tube assay and zymography gels for A. flavus and A. tamarii was similar, where the maximum inhibition was observed in presence of PMSF followed by pepstatin and EDTA (Figures 1a & f & h & m). In A. terreus, the inhibition was highest in PMSF followed by EDTA and Pepstatin in tube assay (Figure 1d). However, in zymography, inhibition was only in presence of PMSF (Figure 1k). The proteases from A. fumigatus showed maximum inhibition by pepstatin in both in vitro assay and zymography gel (Figures 1g & 1n). However, in A.niger pepstatin showed highest inhibition in tube assay while, PMSF showed maximum inhibition in zymography gel (Figures 1c & 1j). Similar discrepancy was seen in A. tubingensis, the proteases were inhibited maximum in presence of EDTA in tube assay but were inhibited by PMSF in zymography gel (Figures 1e & 1l). These results suggest that the type of proteases produced by Aspergillus is mainly serine proteases, followed by aspartyl and metallo proteases.

 

Fusarium Proteases

In Fusarium, the proteases from F. delphinoides showed activity at broad pH range between pH 3 to pH 8 (Table 1). The specific activity of proteases for different F. delphinoides isolates was ranging between 1.42±0.04 units/mg in Cc 119 to 3.36±0.74 units/mg in Cc132. In case of FSSC the value of specific activity was highly variable among species and the proteases were active at broad pH range. Isolate no Cc50 and Cc256 of FSSC showed highest specific activity of 35.56±0.58 units/mg and 35.59 ± 1.31 units/mg respectively at alkaline pH range (pH 7.4 to pH 10) and the lowest specific activity was observed in Cc149 (1.92 ± 0.18 units/mg) at pH 10. The results showed that the proteases in F. delphinoides were acidic to neutral, and the proteases from FSSC were variable in alkaline range.

The proteases extracted from all four F. delphinoides showed inhibition in presence of EDTA in both tube assay and zymography (Figure 2). The results indicate that the proteases present in F. delphinoides are mainly metallo proteases. All eight FSSC proteases were inhibited in presence of PMSF (Figure 3). In case of Cc163, Cc167, Cc 215 and Cc 256 the inhibition was noticed in presence of all the three inhibitors i.e. PMSF, Pepstatin and EDTA. However, in rest of the four species, the inhibition was found only in presence of PMSF, which showed that the majority of proteases in Cc50, Cc149, Cc 172 and Cc204 are serine proteases. Zymography indicated that, the proteases from FSSC showed the inhibition in presence of PMSF only, and no difference was found with other inhibitors (Figure 3i).

Dematiaceous Proteases

In Dematiaceous group of fungi, the proteases were studied in three Curvularia lunata, one Phomopsis phoenicicola and one Phaeoacremonium rubrigenum. Proteases from all three C.lunata isolates had activity at all pH, with slight more activity at pH 8 and pH 10 (Table 1). The maximum activity of proteases was illustrated by Curvularia isolates Cc 70, Cc 90 and Cc 157 was 67.38±2.09 units/ mg, 67.56±3.38 units/mg and 75.03±2.34 units/mg respectively. Proteases obtained from P.phoenicicola showed high activity at pH 7.4 with the specific activity of 3.15±0.19 units/mg (however, it had activity at broad pH range) and P. rubrigenum proteases presented maximum activity (4.76±0.21 units/mg) at pH 8. The tube inhibition assays from C. lunata isolates (Cc90 and Cc157) showed inhibition in presence of PMSF, followed by pepstatin and no inhibition in presence of EDTA (Figure 4). However, zymography gels showed inhibition only by PMSF (Figure 4d). In tube inhibition assays for proteases from P. phoenicicola and P.rubrigenum, inhibition was noted by pepstatin and EDTA respectively. However, slight inhibition was observed in zymography gels (Figures 4g & h). The results of the specific activity of proteases produced by 24 different isolates suggests that; the number of extracellular proteases was more in Aspergillus and Curvularia species compared to Fusarium species. The overall summary of proteases from different isolates is given in Table 2.

 

Discussion

In the present study, extracellular protease activity was quantified from three most common keratitis causing fungal pathogens; Aspergillus spp., Fusarium spp., and Dematiaceous fungi. Among the three, Aspergillus isolates produced the highest amount proteases while, Fusarium and Dematiatous produced moderate amounts. Proteases from Aspergillus spp. causing keratitis to have been reported only from Aspergillus flavus [5,11,12]. The exoproteome analysis of a keratitis causing A. flavus showed that nearly 50% of the exoproteins possess catalytic activity and one of these, an alkaline serine protease (Alp1) is abundant and present in multiple proteoforms [7]. Proteases from none of the other species has been studied from keratitis causing isolates. We have quantified proteases from A. sydowii, A. niger, A. terreus, A. tubingensis, A. tamarii and A. fumigatus. Proteases from soil isolates of Aspergillus are extensively studied and described from A. niger [13], A. tamarii [14], A. fumigatus [15], A. flavus, A. terreus [16] and A. tubingensis [17]. Total extracellular protease activity for some isolates (A. sydowii, A. tubingensis, A.terreus) was higher than the reported isolates; while, it was less for certain isolates (A. flavus, A niger, A. tamarii). However, these differences could be because of the differences in the isolates used and conditions for their growth. Large variations in occurrence and abundance of proteases in seven Aspergillus spp. was shown using genome mining and comparative proteomics [18]. Serine proteases were the largest group in the protease spectrum across Aspergillus spp. The alkaline nature of extracellular proteases from all Aspergillus spp. in the present work corroborates with most of the published reports.

Extracellular enzymes such as lipase, deoxyribonuclease (DNase), α-amylase, protease, cellulase and pectinase produced by the Fusarium isolates from keratitis were screened on solid media supplemented with the corresponding substrates [19]. The authors showed significant differences in protease activity between clinical and soil isolates. Fusarium proteases have been documented in rabbit model for keratitis [5]. However, detailed characterization regarding the types, number and amount of proteases are lacking from keratitis causing Fusarium isolates. In the present work, preliminary characterization of proteases from four F. delphinoides and eight F. solani isolates was done. Our results showed the presence of extracellular metalloprotease in F. delphinoides. In two F. solani isolates (CC50 and CC149), serine proteases were found while, the rest showed the presence of serine, aspartyl and metallo protease. To the best of literature search, there are no reports of proteases in F. delphinoides. Proteases have been reported earlier from soil and plant pathogenic isolates; F. solani [20], F. oxysporum [21] and F. venenatum [22]. Hence, species of Fusarium are known to produce different types and amounts of extracellular proteases. Most of these studies report the presence of one major serine protease in Fusarium spp. Zymography results in the present study indicate the presence of more than one type of high molecular weight protease in Fusarium. These results warrant further detailed studies on purification and identification of these proteases.

In Dematiaceous group, our results indicate the presence of serine and aspartyl proteases in Curvularia spp, aspartyl proteases in P. phoenicicola and serine and metallo protease in P. rubrigenum. Serine protease from C.lunata has been reported [23], but presence of aspartyl proteases was not found. Molecular and immunological characterization of subtilisin like serine proteases was carried out in C. lunata, and the protease was proved as a major allergen responsible for inflammation and asthma [24]. To the best of our knowledge there are no studies on extracellular proteases in P. phoenicicola species, but P. azadirachtae has been explored for the production of extracellular enzymes like polygalacturonase, laccase, protease and xylanase [25].

Our study showed that serine proteases were the major proteases found in isolates of all the groups (AspergillusFusarium and Dematiaceous) of fungi. Among the three groups; Aspergillus spp. had the highest level of proteases, followed by Fusarium and Dematiaceous group. These results corroborate with our clinical findings of patients from which these fungi were isolated [9]. Aspergillus had the maximum number of worsened cases; followed by Fusarium and then Dematiaceous group; suggesting that Aspergillus spp. are more virulent compared to the other two [9]. The serine proteinases and can degrade elastin, collagen, fibrin and fibrinogen. Many studies have correlated the extracellular proteases production with virulence of fungi [26-28]. Hence, collagenase activity may be a mediator of the severe corneal destruction. Recently, we showed the presence of extracellular serine proteases using the ex vivo goat cornea model using Fusarium as the pathogen [29-31]. Further studies to identify the proteases in ongoing.

Conclusion

To conclude, fungal isolates showed the presence of various types of proteases in varying amounts. Proteolytic activity leads to severe corneal destruction and hence, there is a need to identify these proteases. Identification of such proteases could help in identifying molecules which inhibit them. Future strategies should encourage the development of compounds to combat virulence mechanisms as potential targets against drug resistant organisms.

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Friday, December 3, 2021

Lupine Publishers | Capsule Contraction Syndrome: Incidence, Pathogenesis, Prevention and Treatment Alternatives

 Lupine Publishers | Trends in Ophthalmology Open Access Journal 


Abstract

Capsule contraction syndrome (CCS) is a rare but serious complication after cataract surgery. Several systemic and ocular factors such as Pseudoexfoliation syndrome, uveitis, high myopia, diabetes mellitus, advanced age, trauma, and previous vitreoretinal surgery promote capsular contraction. Surgical factors including small capsulorhexis size, IOL materials and design play an important role to development of CCS and IOL dislocation. Surgical enlargement of the anterior capsule can be performed in severe cases as an initial treatment or when the YAG capsulotomy is ineffective.

Keywords:Capsule contraction syndrome; Capsule shrinkage; Capsulectomy; YAG capsulotomy

Introduction

Capsule contraction syndrome (CCS) develops due to myofibroblastic metaplasia of the anterior cuboidal lens epithelia cells (LECs) and transformation to actine positive smooth muscle. This fibrotic change cause anterior capsular opacification (ACO) and capsular contraction that leads to significant shrinkage of both capsulectomy opening and equatorial capsular bag diameter. Progressive contraction of anterior myofibroblastic cells can cause imbalance between centrifugal and centripetal forces on the zonules which may results in malposition of the capsulectomy opening, angulation of the haptics or optic edges of IOL even the entire IOL. It may cause the capsular complex displacement or total IOL luxation into the vitreous cavity due to zonular dehiscence. ACO, the most innocent form of CCS without capsular bag shrinkage, obstructs peripheral retinal examination [1-3].

Incidence and Presenting Time

Even the peripheral ACO seen frequently after the phaco surgery the CCS presented with the reduction in the free optic zone and even complete occlusion of the capsulorhexis incision due to capsulorrhexis phimosis or IOL decantation is an uncomment complication. According to Zinkernagel et al. [4]. retrospective study the incidence of CCS was 1.5%, they observed 4 eyes with visually significant CCS out of 268 eyes. Tsinopoulos et al. [5] had been reported the insidence of CCS was 5%. They observed ACO with capsulorrhexis phimosis and IOL decentralization in eight eyes with a single-piece hydrophilic acrylic aspheric IOL out of 243 eyes, two to four months after surgery. The incidence of surgical intervention for repositioning or IOL exchange because of IOL dislocation was ranged between 0.2% and 3%. Mönestam et al. [6] reported 0.6% of the patients need reposition surgery for dislocated IOL 10 years after initial surgery.

CCS usually develops 3 to 6 months after phacoemulsification surgery as an reparation reaction of anterior capsule opening. Kumar et al. [7] reported two cases with the ages of 83 and 74 year has IOL dislocation within the bag 3 and 6 months after surgery, respectively.

Cochener et al. [8] reported that capsular shrinkage was faster at 30 to 150 days which shows slowly continuous progression 5 months after the surgery. Choi et al. [9] reported that the area of free optic zone of the anterior capsule significantly decreased from 1 week to 2 months postoperatively and further slowly but continuous reduction was observed from 2 months to 6 months in 236 eyes. According to their study the mean areas of the anterior capsule opening was 20.69±1.50 mm2 at 1 week which decreased to 17.17±3.23 mm2 at week 2, in a single-piece hydrophilic acrylic IOL which has a two-loop plate haptic at a 180° interval around the optic while free anterior optic zone was 21.43±1.09 mm2 at week 1, shrinked to 19.86±1.58 mm2 6 months after surgery in another type of hydrophilic acrylic IOL which has hydrophobic surface properties and a plate-shaped haptic. Their observation showed that the reduction was greatest in the first post-operative 2 months. But Coelho et al. [10] reported a 58-year-old patient with subluxation of the IOL, at postoperative third year. Long term observations of showed that CCS is a choronic progressive exaggerated reparative process of anterior capsule.

Pathogenesis

Prostoglandines, interleukins; IL-1 and IL-6, basic fibroblast growth factor, produced by residual lens epithelial cells (LES), increased in humor aqueous after cataract surgery that stimulate proliferation of cuboidal lens epithelial cells by alterations in cell to cell contact interactions. Transforming growth factor-βs (TGF- βs), is the key cytokine in developing scar formation in capsular opening, it elevates in the aques humor after surgery. TGF-βs upregulates TGF-βRII, the type II receptor for TGF-β2, expression in LECs which might play an important role in transdifferentiation of LECs into myofibroblasts [11-14].

Zhang et al. [12] observed shrunken membrane consisted of multiple layers of spindle-like LECs proliferation and excessive fibrous extracellular matrix in histopathological examination of contracted anterior capsule. Their study indicated that TGF-β2 concentrations in humor aques in high myopic eyes with CCS were higher than those without high myopia. Eyes had dense cataract had also higher TGF-β2 expression in aqueous humor after cataract surgery and it can increase the risk of CCS. According to their study eyes with high myopia and dense cataract have predisposition for CCS by increasing TGF-β2.

Risk Factors

Contraction of capsular opening due to myofibroblastic metaplasia, was strongly correlated with several ocular and systemic factors which either increased inflammatory reaction on anterior chamber or leading to instability of the blood-aqueous barrier such as diabetes mellitus, uveitis, retinitis pigmentosa. Zonular weakness due to advanced age, trauma, high myopia, certain connective tissue disorders and previous vitreo-retinal surgery are predispositing factors for IOL displacement in CCS. Pseudoexfoliation syndrome (PEX), has dual predisposition factor as increased anterior chamber inflammation by increased vascular permeability and has fragile zonules with weak stretching capability that cause zonular dehisces [2,3,7,9,13-16].

Surgical risk factors such as small capsulorhexis size, insufficient residual lens epithelial cells cleaning, increased surgical trauma, IOL design and materials play important role in the pathogenesis of CCS [2,16-21]. Weak adhesion between anterior capsule and IOL optic may allow space for active proliferation and migration of LECs. Increasing LECs exposure to several cytokines in the aqueous humor cause excessive synthesis of extracellular matrix, increase the fibrotic proliferation and finally anterior capsular shrinkage. IOL with hydrophobic acrylic optic material have shown stronger attachment to anterior capsule and by this way it prevents epithelial cells proliferation and migration on the optic surfaces. Hydrophilic optic have less adhesion to anterior capsule comparing to hydrophobic acrylic IOL and shown more frequent capsular phimosis than hydrophobic varieties [19,20]. IOL with silicone or hydrogel optics have the weakest anterior capsuler adhesion and shown the most frequent CCS. One-piece acrylic IOLs with sharpoptic edge prevents LES migration on the optic surfaces comparing to round-edge optics. On the other hand, Sacu et al. [21] reported that neither the material nor the haptic design of hydrophobic IOLs affected the development of CCS.

Prevention and Treatment

To prevent CCS, several preventing manipulation should be taken such as polishing of the posterior capsule, cortical material and anterior capsular epithelial cells removal as much as possible, careful attention should be paid to perform surgery with minimal trauma. Postoperative inflammation should be reducing with correct treatment. Close monitoring is essential for early diagnosis, because fibrotic contraction and malposition present with refractive error change and visual acuity detoriation [3,8,15,16].

CCS may initially present with pseudophakic lenticular astigmatism due to IOL folding or displacement of the optic or irregular astigmatism due to capsular opacification [22]. Page and Whitman [23] reported that patient’s refractive error shift of up to 1.0 D in either sphere or cylindrical, indicates the possibility of early capsular contraction that affecting the IOL position. They recommended neodymium yttrium–aluminum–garnet (Nd YAG) laser capsulotomy for preventing further contraction. Nd:YAG laser can create radial opening in the edge of capsular phimosis and perform significant circular enlargement, it can be effective in resolving the capsular synechiae of the haptics [24]. Deokule et al. [25] reported that the Nd YAG laser capsulotomy was successful in 78% cases out of 32 patient and failed in 7 cases (22.0%). They observed re-phimosis 5 cases and progressive IOL decentration in 2 cases. Kim et al. [26] reported a case underwent YAG anterior capasulotomy due to a total occlusion of the anterior capsulorhexis opening and the capsulotomy site remained clear 2 years after the treatment. In contrast Altintas et al. [27] reported a significant re-fimosis in case with Behçet ‘s disease, several months after Nd- YAG capsulotomy with prominent folding of both haptic and optic edge over the central part of IOL and they had to perform surgical capsulectomy for recalcitrant capsular closure.

Wang et al. [28] presented a 63-year-old woman who had ciliary body detachment and secondary hypotony in both eyes caused by CCS, successfully treated with Nd: YAG laser. They reported that timely Nd: YAG laser anterior capsulotomy relaxes the contracted capsule, resolves the ciliary body detachment and prevents serious complications. Nd-YAG laser capsulotomy can prevent further capsular contraction in eyes with different IOL type in many cases (Figure 1a &1b & 2).

 

Even the Nd: YAG capsulotomy is the first choice for capsular phimosis it may have several complications such as IOL pitting, anterior chamber inflammation and secondary glaucoma due to residual fibrotic material in the anterior chamber. Cystoid macular oedema may occur when the excessive laser energy was used mainly in thick membrane [29].

Gerten and coworker [30] and Schweitzer et al. [31] suggested femtosecond laser for capsulotomy extension that may offer advantages over the, Neodymium: YAG laser in CCS. Timothy et al. [32] reported that if the patient had a significant refractive change, such as more than 1.0 D of refractive spheric or astigmatic change, a YAG capsulotomy may not help for refractive correction or prevention of the further contraction. In this situation, they recommend surgical intervention such as a viscodissection and exiting of the fibrotic capsule. Surgical treatment can be performed as tangential cuts with the microscissors or manual extension of the capsulorhexis by oblique cutting with curved microscissors than peeling the fibrotic capsule. Excitation and enlarging the anterior capsule with vitrector are another choice to restore clear visual axis [33].

Page and Whitman [32] reported that insertion of a Capsule Tension Ring (CTR) could be most effective in correcting the IOL position and preventing further contraction in eyes with severe CCS. In contrast Altintas et al. [33] reported a case, age of 8 had ectopic lens and pupilla, developed CCS with significant reduction of total equatorial diameter of capsular bag, folding of both haptics over the optics and banding over each other both ends of CTR one year after cataract surgery even without posterior capsular opacification. According to their presentation CTR does not prevent development of CCS. Similarly, Sudhir et al. [34] and Moreno-Montañés et al. [35] reported capsulorhexis phimosis in eyes with endocapsular ring implantation. CTR may increase resistance to tractional force from capsular contraction, it does not always prevent capsular shrinkage. Furthermore Altintas et al. [36] reported three cases with PEX at the age of 72, 76, 79 who developed severe CCS and IOL subluxation with capsular tension ring (CTR) in the fibrotic capsular bag 3, 2.5 and 8 years after uneventful phacoemulsification respectively. This observation showed that CTR does not prevent IOL subluxation in long term follow up in eyes with the PEX (Figure 3).

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