Standardizing anterior lens capsule graft reporting: A call for reproducibility, suture-based fixation, and biobanking

Beniwal et al.[1] recently reported the anterior lens capsule (ALC) as a biological patch for small corneal perforations, with favorable early outcomes that broaden its potential use. Building on that observation, this brief commentary addresses the central issue it exposes: inconsistent and incomplete reporting of key variables when ALC is used as a graft. Our focus is to delineate a concise set of reporting elements—donor source, harvesting/processing, storage, handling and orientation, fixation method, and outcome measures—to improve reproducibility, comparability, and safety across studies. Notably, Beniwal et al.[1] did not specify whether the ALC grafts were autologous (from the same patient) or allogeneic (from a donor). Their article mentions that cataract surgery patients were screened for viral markers before the capsule was used in ulcer patients, implying an allogeneic donor source—an important detail that should be stated explicitly.[1] Likewise, the method of capsule harvesting was only partly described (simply noting the use of FLACS). Yet, the supplementary video of the procedure shows the transplanted capsule patch folded multiple times with irregular, frayed edges, rather than a neat double fold. This observation suggests deviations in technique or handling that differ from the ideal, smoothly circular capsulorhexis one would expect from a FLACS or precision pulse capsulotomy (Zepto) device.[2–4] Such variability underlines why authors must disclose the exact harvesting method and any modifications. Differences in how the capsule is obtained—manual continuous curvilinear capsulorhexis versus femtosecond laser versus Zepto—can affect its size, edge quality, and structural integrity. Each of these factors may influence graft performance, yet they are often omitted in reports. To ensure reproducibility and allow comparisons across studies, it is vital that future publications standardize the reporting of key parameters whenever ALC grafts are used. At minimum, authors should clearly document the donor type (autologous, allogeneic—with donor screening, consent, age, lens status, exclusion criteria, and traceability/ID specified—or xenogeneic with species and pathogen testing), the capsule harvesting method (how the ALC was obtained, e.g., manual capsulorhexis, FLACS, or Zepto, including the resulting capsule dimensions and shape), any decellularization technique applied (with specific protocols if used to remove lens epithelial cells), the preservation or storage protocol for the capsule (how it was stored or prepared, including medium, duration, and temperature – for example, fresh use, cryopreservation, or lyophilization), the transfer and handling of the graft (measures to maintain sterility and avoid damage, folding, or desiccation during placement), and any quality control measures performed (such as vital dye staining to assess capsule integrity, microscopic inspection for tears or residual cells, evaluation of biological factor longevity (e.g., basement membrane proteins and growth factors) and confirmation of acellularity if a decellularization method was employed). Additionally, the orientation of the ALC graft—specifically whether the anterior or posterior surface faced the host tissue—should be clearly documented as this may influence adhesion, epithelial migration, and overall biocompatibility. Such orientation details are absent in many reports but may be critical for graft behavior, influencing not only host cell adhesion and migration in culture but also the inflammatory response and integration in vivo, as has been demonstrated in amniotic membrane transplantation where basement-membrane orientation affects epithelialization and healing outcomes.[5] Each of these elements can significantly influence the clinical outcome and safety of ALC grafting, yet current literature shows inconsistent reporting on these details. The proposed checklist [Table 1] provides a concise summary of key domains to be reported in all future studies.Table 1: Checklist for standardized reporting of lens capsule graftsThe importance of consistent methodology was highlighted in a recent narrative review of lens capsule applications. That review found that variability in capsule harvesting techniques and the lack of standardized protocols are hindering broader clinical adoption of ALC grafts.[6] The article emphasized the necessity of standardizing capsule harvesting and preservation methods—potentially in collaboration with eye banks—to improve tissue availability and consistency.[6] For instance, if an allogeneic ALC graft is used, decellularization is crucial to remove residual lens epithelial cells that could incite inflammation. In a comparative study, Yu et al.[7] evaluated several decellularization methods and identified 10% sodium chloride solution followed by sterile water as the most effective approach for creating an acellular human ALC, while still preserving the capsule’s structural integrity. Such findings underscore the importance of reporting any decellularization protocol used; employing an optimal, validated method can enhance graft biocompatibility and should become standard practice in allograft preparation. In the report by Beniwal et al., the ALC patches were secured over the corneal wounds with a tissue adhesive (cyanoacrylate glue).[1] It is worth noting that the lens capsule’s biomechanical resilience also permits suturing as an alternative means of fixation. An ex vivo feasibility study demonstrated that a human anterior lens capsule can be successfully sutured with 10-0 nylon, without tearing or “cheese-wiring” the delicate tissue.[8] The capsule tolerated multiple needle passes and knot tying when handled carefully, reaffirming that it behaves as a robust, elastic membrane.[8] This finding suggests that future surgical techniques could directly suture an ALC graft in place (for example, anchoring it over a corneal defect or affixing it during glaucoma filtering surgery), rather than relying solely on glue. Consequently, whether a graft is glued, sutured, laser-welded (indocyanine green-assisted),[9] or otherwise secured is another technical detail that should be transparently reported[6,8] as graft configuration (e.g., a folded, irregular patch versus a taut sutured layer) might behave differently under stress and thus influence clinical outcomes. We also wish to highlight the potential for using the ALC graft as a tectonic patch from within the anterior chamber, analogous to a Mini-DSAEK approach for macroperforations, as described by Vasquez-Perez et al.[10] This underscores the versatility of the ALC and the importance of defining its preparation and application in varied contexts. Looking ahead, authors are strongly encouraged to include all the above details in any forthcoming reports on ALC grafting. Just as established guidelines exist for reporting outcomes of corneal transplants or implantable devices, a basic set of ALC graft preparation parameters should be expected in published studies. Establishing such reporting standards is not a mere academic exercise but a necessary step toward reproducible surgical outcomes and patient safety. Importantly, standardized preparation and documentation will also lay the groundwork for developing lens capsule biobanking programs. It is foreseeable that eye banks could begin to collect and preserve ALC tissue (similar to how amniotic membrane is banked) to make this underutilized biomaterial readily available to surgeons.[6] So far, no eye bank has initiated systematic harvesting of lens capsules, partly due to the absence of agreed-upon protocols for processing and storage.[6] By converging now on best practices—including donor screening, decellularization, storage conditions, and quality assurance—the ophthalmic community can create a foundation for “capsule banks” and unlock the full potential of lens capsule transplantation. Establishing lens capsule biobanking requires compliance with the prevailing national or regional tissue banking frameworks and the technical standards issued by recognized professional organizations and eye bank associations. Essential elements include validated processing protocols, microbial safety testing, donor eligibility screening, documentation of consent, and robust traceability systems. Practical challenges also arise from ensuring adequate infrastructure for tissue handling and storage, maintaining the biological integrity of key basement membrane components and growth factors over time, and verifying acellularity or sterility following any processing steps. These prerequisites highlight that meaningful implementation depends not only on scientific feasibility but also on coordinated regulatory oversight and standardized quality systems. In conclusion, Beniwal et al.[1] have pioneered a creative use of the ALC in corneal perforation repair. To build on this innovation, future studies must adopt standardized reporting of ALC graft parameters. Such rigor will facilitate cross-comparison of outcomes, ensure safety through transparency, and accelerate progress toward tissue banking of lens capsules. Ultimately, embracing uniform preparation protocols is essential for translating the promise of ALC grafting into widespread clinical practice.