Multimodal Imaging in Bilateral Spontaneous Anterior Capsular Dehiscence

CASE DESCRIPTION A 22-year-old male presented with progressive, painless visual impairment in both eyes. He denied any history of trauma, steroid use, or previous ocular surgery. His general health was unremarkable, and systemic evaluation showed no features suggestive of syndromic associations such as Alport syndrome. On slit-lamp examination, both eyes showed partially absorbed cataracts with central anterior capsular openings. The right eye exhibited a diamond-shaped central capsular opening with membranous lens remnants [Figure 1, yellow arrow]. The left eye displayed an oval-shaped opening with anterior bulging of the underlying lens material [Figure 2, yellow arrow].Figure 1: Anterior segment photograph of the right eye showing a diamond-shaped central anterior capsular opening (yellow arrow)Figure 2: Anterior segment photograph of the left eye showing an oval-shaped central anterior capsular opening with bulging of underlying lens material (yellow arrow)To further characterize the capsular pathology, multimodal imaging was performed. Anterior segment optical coherence tomography (ASOCT) was done in both eyes. However, the capsular details were better appreciated in the left eye using ultrasound biomicroscopy (UBM); hence that image has been provided. ASOCT of the right eye, which had relatively clearer media, revealed a focal defect in the anterior capsule with adjacent curling and resorption of the lens substance [Figure 3]. UBM of the left eye demonstrated a well-defined capsular discontinuity with anterior protrusion of the lens, consistent with lenticonus and dehiscence [Figure 4].Figure 3: ASOCT image of the right eye showing focal discontinuity in the anterior capsule (yellow arrow) with adjacent membranous lens materialFigure 4: UBM image of the left eye showing an anterior capsular defect (yellow arrow) with a dome-shaped protrusion of lens materialDISCUSSION This case illustrates an unusual presentation of bilateral spontaneous anterior capsular dehiscence, likely secondary to undiagnosed anterior lenticonus. There was no history of trauma, steroid use, or prior ocular surgery, suggesting a spontaneous etiology for the observed capsular dehiscence. Although anterior capsular openings may be clinically evident, high-resolution imaging such as ASOCT and UBM provides vital information about the extent, morphology, and nature of the capsular defect. The diagnosis of anterior lenticonus was made based on imaging features, including the anterior bulging of the lens and characteristic oval-shaped defects, in the absence of trauma or surgery. Fundus examination was normal in both eyes. Systemic evaluation, including renal function and audiometric testing, did not reveal abnormalities commonly associated with anterior lenticonus syndromes. From a management perspective, imaging aids surgical planning by delineating the size and edges of the capsular defect, helping anticipate potential challenges in capsulorhexis and intraocular lens implantation. CONCLUSION Spontaneous anterior capsular dehiscence, though rare, should be considered in young patients presenting with atypical cataracts. Multimodal imaging plays an indispensable role in diagnosis, understanding pathophysiology, and guiding management. The ability to document such anomalies also enriches academic knowledge and informs future clinical strategies. 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 Nil. Conflicts of interest There are no conflicts of interest.