Epicapsular stars: a case report and literature review of the morphologic spectrum

Epicapsular stars are rare congenital pigment deposits located on the anterior lens capsule and are generally considered remnants of the tunica vasculosa lentis or persistent pupillary membrane. Most reported cases are asymptomatic and discovered incidentally during routine ophthalmic examination. Owing to their rarity, the morphologic spectrum and clinical significance of epicapsular stars remain incompletely characterized. A 21-year-old man presented for a routine ophthalmic examination without visual complaints. Slit-lamp biomicroscopy revealed multiple brown stellate pigment deposits on the anterior lens capsule of the left eye. Immediately after pharmacologic mydriasis, the distribution and morphology of the deposits appeared unchanged, and no iris attachment was seen. Uncorrected visual acuity was 0.8 in the right eye and 1.0 in the left eye; refraction and best-corrected visual acuity were not recorded. No associated ocular abnormalities were identified, and the patient was managed conservatively with observation. A structured literature search identified 27 previously published independent cases. Including the present patient, 28 cases were analyzed. Reported ages ranged from 8 to 66 years. Most cases were unilateral, asymptomatic, and managed conservatively. Morphologic appearances included stellate, embroidery-like, rice-granule/paddy-grain, clustered, leaf-like, and dense central confluent patterns. Four reports attributed visual impairment or amblyopia to central deposits, and one patient underwent surgical intervention. Reported associations included aniridia, iris or iridofundal coloboma, gonio-dysgenesis, and neurofibromatosis. Epicapsular stars are uncommon congenital anomalies of the anterior lens capsule with diverse morphologic appearances. Although typically benign and visually insignificant, dense central lesions may interfere with the visual axis and result in visual impairment. Recognition of the morphologic spectrum and associated clinical features may facilitate accurate diagnosis and appropriate management of this rare entity.