Anterior Capsular Rim Research Articles

"Stop & drop"- a modified "stop & chop" phacoemulsification technique for cataract surgery.

To introduce a novel technique termed "stop and drop" for creating the first crack in the initial hemi-nucleus, eliminating the need to slip a chopper under the anterior capsular rim during horizontal chopping, hence lowering the risk of capsular or zonular damage. Placing a blunt chopper tip on the upper surface of the hemisection proximal to the capsular edge and pressing it downward to initiate a crack in a pinching manoeuvre. Once a crack has formed, the chopper can slide to the side, widening the crack and assisting the phaco needle to pull out the first fragment. The technique was used in over 100 cases of cataracts successfully. No radial tear, posterior capsule rupture or zonulolysis occurred. "Stop and drop" is an effective and safe technique for performing phacoemulsification. It is not suitable for soft nuclei where the chopper will likely "cheese-wire" through the nuclear material.

Simple technique to avoid inadvertent upside-down implantation of multipiece IOL with injector

The evolution of multipiece intraocular lenses (IOLs) has provided the option of sulcus implantation in situations wherein the bag implantation is not feasible. Multipiece IOLs are implanted in eyes with...

Perfect anterior capsulorhexis using a dented cystitome.

We describe a novel intraoperative technique of measuring and creating an adequate size continuous curvilinear capsulorhexis (CCC) in phacoemulsification, using a dented cystitome as the ruler. A pair of curved tenotomy scissors is used to create a dent on the cystitome at a distance of 2.5 mm length (i.e., half of the desired approximate capsulorhexis diameter). The dented cystitome is used as a guide for making a CCC of approximately 5 mm diameter, which is considered adequate for phacoemulsification. This method of measuring the capsulorhexis helps in achieving a well centered and stable intraocular lens with a 360° overlap of the optic edge by the anterior capsular rim in the postoperative period. Using a dented cystitome for capsulorhexis mandates reliable and consistent results in the hands of the novice as well as the experienced surgeons.

Preserving posterior capsular integrity in post-endothelial keratoplasty posterior capsular opacification.

Endothelial keratoplasty (EK) with pseudophakia often presents with late-onset proliferative after-cataract with posterior capsule distension. We performed a modified technique of capsular bag lavage in 11 eyes with late-onset PCO after EK (4 cases: post-DSAEK, 7 cases: post-DMEK). Anterior capsular rim was separated from the underlying IOL optic using MVR blade. Circumferential relaxing radial nicks were made on the capsular rim to create space for the passage of irrigation-aspiration (IA) probes behind the IOL. Bimanual IA of the flocculent cortical material was performed without damaging the posterior capsule. Air was injected at end of surgery to ensure graft apposition. All cases gained 1-3 lines of Snellen’s acuity and no case developed graft failure, rejection, or endothelial decompensation. An intact posterior capsule is associated with better outcomes post a repeat graft, if required. Our technique helps avoid complications related to a disturbed anterior hyaloid phase and minimizes postoperative inflammation.

Management of late-onset flocculent after-cataract with capsular bag lavage and posterior continuous curvilinear capsulorhexis.

We describe our technique for the management of late-onset liquefied after-cataract (LAC) to ensure long-term visual axis clarity. The densely adherent anterior capsular rim over the intraocular lens (IOL) optic was released with the help of microvitreoretinal blade, and multiple relaxing radial incisions were made on the capsular rim to facilitate easy access to the capsular bag. A thorough capsular bag lavage was performed with the help of bimanual irrigation-aspiration. Posterior continuous curvilinear capsulorhexis (PCCC) was performed after complete aspiration of fluid after-cataract to prevent recurrence. This technique was successfully performed in 14 cases. Postoperatively, IOL was stable and an uncorrected distance visual acuity of >20/32 was achieved in all cases. No recurrence was observed in any case over a follow-up of 1 year. Our technique of capsular bag lavage with PCCC is safe and effective for the management of LAC with optimal visual and anatomical outcomes.

23-gauge vitrectomy with intraocular foreign body removal via the limbus: An alternative approach for select cases

Purpose:To study the outcome of removal of retained intraocular foreign bodies (RIOFBs) via limbus using 23-gauge transconjunctival sutureless vitrectomy (TSV).Materials and Methods:In this prospective, non-comparative interventional case series, fourteen eyes of 14 patients fulfilling the inclusion criteria were enrolled. They underwent 23-gauge TSV for management of posterior segment RIOFB and reviewed at 1 day, 7 days, 6 weeks, 3, 6 and 12 months. Eyes with penetrating eye injury involving cornea or limbus (corneal injury not so severe to hinder vitrectomy), cataract associated with anterior and/or posterior capsular tear requiring cataract surgery and posterior segment RIOFB with minimal posterior segment involvement were included. Main outcome measures include success in removal of RIOFB without enlarging sclerotomy, ability to preserve capsular support, improvement in visual acuity and complications, if any.Results:All eyes underwent the successful RIOFB removal through limbal port without enlarging scleral ports. None of the eyes required suturing of the sclera, cornea or conjunctiva. Anterior capsular rim could be preserved in all eyes except one. Postoperatively follow up ranged from one year in 8, 6 months in 4 and 3 months in 2 eyes. The mean logMAR visual acuity at 3, 6, and 12 months showed significant improvement. There were no intraoperative complications. Postoperative complications include microscopic hyphema and loose blood in vitreous cavity in one eye.Conclusion:The advantages of 23-gauge TSV for removal of RIOFB may be passed on to select cases. RIOFB removal through limbal route obviated the need for scleral port enlargement and preserved capsular support for early visual rehabilitation.

Contributions of the Capsulorrhexis to Straylight

To quantify the effect of the capsulorrhexis on straylight and to determine optimal capsulorrhexis size. Fifty-six pseudophakic eyes with intact capsulorrhexis were included in the study. Straylight was measured with a straylight meter before and after pupil dilation. Capsulorrhexis and pupil diameter were measured and opacity of the anterior capsule was graded (on a scale of 0-5) with the slitlamp. Capsulorrhexis size and opacity were compared with the difference in straylight values between natural and dilated pupils. The mean capsulorrhexis diameter was 4.5 mm (range, 2.9-6.2 mm). Most anterior capsular rims were opaque in the area of contact with the intraocular lens (62.5% higher than grade 1). Mean straylight before pupil dilation was log(s)=1.25 (range, 0.68-2.13), which increased to 1.46 (range, 0.88-2.22) after pupil dilation, which corresponds to a 62% increase (P <.001). The effect of capsulorrhexis size and opacity on the increase in straylight in scotopic conditions can be quantified by the following formula: Deltas = 19 x (grading of anterior capsular rim) x (fraction of pupil area covered by rhexis). The influence of size and opacity of the capsulorrhexis via straylight is described in a quantitative model. Capsulorrhexis size must be greater than 4 mm to prevent functional problems at night.

Prevention of Anterior Capsule Contraction by Anterior Capsule Relaxing Incisions with Neodymium:Yttrium–Aluminum–Garnet Laser

To examine the effect of two or three neodymium:yttrium-aluminum-garnet (Nd:YAG) laser relaxing incisions made in the anterior capsular rim on prevention of anterior capsule contraction after cataract surgery. Randomized clinical trials. One hundred patients scheduled for bilateral cataract surgery were randomized to one of two groups: two or three relaxing incisions in the left eye and no incisions in the right eye, and relaxing incisions in the right eye and no incisions in the left eye. The anterior capsule opening area was measured using Scheimpflug photography immediately after capsulotomy and at one, three, and six months after capsulotomy, and the percentage reduction was calculated. The degree of intraocular lens (IOL) decentration and tilt and of posterior capsule opacification (PCO) also were examined. There was no significant difference in the anterior capsule opening area between fellow eyes at baseline (P > or = .1770). In patients who underwent two incisions, no significant difference was found between fellow eyes in the opening area (P > or = .4098) or in the percentage of reduction (P > or = .8730) throughout follow-up. In patients who underwent three incisions, the opening area in eyes with capsulotomy was significantly greater than that in eyes without capsulotomy (P < or = .0154), and the percentage reduction was significantly smaller in eyes with capsulotomy than in eyes without capsulotomy (P < or = .0016). No significant differences were found in the IOL decentration and tilt, or in PCO. Three relaxing incisions made in the anterior capsule decrease the anterior capsule contraction, whereas two incisions do not.

Postage stamp multiple anterior capsulorhexisotomies in pediatric cataract surgery

BackgroundCapsule related complications are common following pediatric cataract surgery. We report a new technique of multiple anterior capsulorhexisotomies after lens aspiration and intraocular lens (IOL) implantation.MethodsAfter performing automated lens aspiration, an IOL was implanted into the capsular bag. A bent 26 gauge needle was introduced through one side port and multiple small cuts were made in one half of the circumference of the anterior capsular rim by making a radial movement of the needle tip centripetally over the margin of the anterior capsular rim. The needle was again introduced through the other side port and multiple similar cuts were made in the other half thereby creating nearly 20 – 30 cuts at the margin of the anterior capsular rim.ResultsThe mean size of the primary capsulorhexis was 4.33 ± 0.20 mm. A uniform enlargement of the capsulorhexis could be performed in all the eyes without peripheral extension in any of the eyes. There was no damage to the posterior capsule and no scratch mark on the IOL. In one eye, the primary capsulorhexis was slightly eccentric, though it was covering the IOL optic all around. The rhexisotomies in this eye were limited to the capsular rim that was overlapping more on the IOL optic (sectoral anterior capsulorhexisotomies).ConclusionThe technique of postage stamp anterior capsulorhexisotomies is a feasible technique in pediatric cataracts.

Anterior high-frequency capsulotomy: advantages and problems

Since the clinical test phase, the author performed consistently more than 500 capsulotomies in his cataract surgeries by means of a radio-frequency current, using an instrument developed by Klöti et al. Some problems in the application of the instrument and their possible solution are discussed from the practical view of the user. The method proved as easy and safe to use especially in certain difficult cases. The main problem seems to be a reduced stability of the anterior capsular rim compared to the cases performed by capsulorhexis.

Capsulotomy Rate in Silicon Plate Haptic and Prolene Loop IOLs

OBJECTIVE: To compare the incidence of YAG posterior capsulotomy between eyes' implanted with silicone prolene loop and plate haptic lenses, and to compare the incidence of posterior capsulotomy in the short-term (median implantation time of 10.5 months) and long-term (median implantation time of 30 months) in the patients implanted with the plate haptic lens. STUDY DESIGN: Retrospective study comparing the incidence of capsulotomy in patients from Anaheim Eye Medical Group having undergone outpatient cataract surgery by the same surgeon using endocapsular phacoemulsification and implantation with capsulorhexis with an intact anterior capsular rim and bag. PATIENTS: Two groups of plate haptic silicone lens implanted patients, one group of 141 and another of 301 patients, were compared to 253 patients implanted with the prolene loop silicone lens over the same implantation and follow-up times. In the second part of the study, 503 patients were studied. Of the 442 patients with a median follow-up time of 10.5 months, five had capsulotomies. The remaining 498 patients had a median implantation time of 30 months with a capsulotomy rate of 1.4%. RESULTS: The incidence of posterior capsulotomy in patients implanted with silicone plate haptic lenses was 1.1% with a median implantation time of 10.5 months compared to 7.1% in the prolene loop group with a median implantation time of 12 months (significance level of <0.0001). The incidence of capsulotomy in the plate haptic group with a median implantation time of 10.5 months was 1.1% and those with a median implantation time of 30 months was 1.4%, indicating a reduction in the rate of capsulotomy in the long term. CONCLUSIONS: The incidence of capsulotomy is lower in silicone plate haptic lenses when compared to silicone prolene loop lenses. The low incidence of capsulotomy in plate haptic lenses decreases with the passage of time.

Complications of Capsulorhexis using ECCE in Dense Cataracts

OBJECTIVE:To determine the problems of performing capsulorhexis in dense cataracts. STUDY DESIGN: Prospective. SETTING: The Princess Alexandra Eye Pavilion, Edinburgh. PATIENTS: The first 72 patients with the criteria of a dense cataract operated on between August 1989 and March 1991. All cataracts were age-related or diabetic. MAIN OUTCOME MEASURES: (1) Incidence of intact continuous tear capsulorhexis. (2) Complications: zonule rupture, capsule rupture, vitreous loss, decentration. RESULTS: Superior zonular rupture was the main problem occurring in 5.6% of all cases. An intact anterior capsular rim was achieved in only 59.72% of these dense cataracts. CONCLUSION: Until viscoexpression of the nucleus is proven to be better, capsulorhexis in denser cataracts should only be used with phacoemulsification.

Continuous curvilinear (circular) capsulorhexis and planned extracapsular cataract extraction--are they compatible?

The successful use of continuous curvilinear (circular) capsulorhexis (CCC) in planned extracapsular cataract extraction (ECCE) is dependent on the feasibility of safe nuclear delivery through the smaller anterior capsular opening. Experimental evidence supports the proposition that the anterior capsular rim can stretch without tearing to dimensions which allow for safe nucleus delivery. Clinical reports of accidental intracapsular expression during nucleus delivery in CCC seemingly contradict the experimental evidence. This paper examines this apparent contradiction and presents clinical evidence in the form of a series of 210 cases of planned ECCE with CCC. The technique used and a detailed analysis of the operative complications are presented. The results indicate that using a modified technique for nucleus delivery, CCC and planned ECCE are fully compatible techniques.

Surgical complications and visual acuity results in 536 cases of plate haptic silicone lens implantation

Implantation of a plate haptic intraocular lens was planned in 536 cases. This paper reports the uncorrected and corrected visual acuities and complications in 33 patients in whom there were surgical complications that prevented implantation of the plate haptic lens. Excluding five patients (15%) who had pre-existing pathology, 21 (75%) had uncorrected acuity of 20/40 or better and 27 (96%) had corrected acuity of 20/40 or better five to six weeks postoperatively. The plate haptic lens can only be used with capsulorhexis and an intact anterior capsular rim and posterior capsule. Two alternative backup lens styles-a loop lens for placement in the torn bag or the sulcus and an anterior chamber lens-have to be in the operating room for each surgery.

Morphologie der Kapselsackschrumpfung in Abhängigkeit von der Kapseleröffnungstechnik, vom Linsendesign und von der Sulcus-/Saccusfixation

Over a period of several months the dynamics and morphology of capsular retraction were analyzed with various capsulotomy techniques and IOL types implanted into the capsular bag or the sulcus. The techniques compared were peripheral and intermediate canopener capsulotomy, intermediate and small letter-box capsulotomy, intermediate and small capsulorrhexis with and without superior incisions. The posterior chamber IOLs implanted were one-piece and three-piece C-loop lenses and, in a limited pilot study, one-piece disk lenses. The authors' results indicate that capsular retraction and the stable position of the implant depend on the type, form, and size of the capsulotomy, the type of IOL and its fixation in the bag or sulcus. Any irregularity of the anterior capsule induces irregular capsular retraction with the risk of IOL decentration. Free-floating anterior capsular flaps may induce formation of iridocapsular synechiae. Contact between the anterior capsular rim and the posterior capsule results in capsulocapsular adhesions, capsular wrinkling, and capsular opacification of the contact zone. In order to avoid these capsulocapsular adhesions the diameter of the IOL optics should exceed that of the capsular opening in endocapsular implantation. However, peripheral capsulocapsular adhesions are necessary to stabilize IOL haptics, which for this reason must be of open design. Capsulocapsular adhesions may inhibit migration of lens epithelial cells in secondary capsular opacification. The ideal anterior capsulotomy technique seems to be the symmetrical, small, circular, continuous capsulorrhexis, if endocapsular implantation is desired. However, the technique is mainly designed for phacoemulsification, as a small capsulorrhexis inhibits nuclear expression in extracapsular cataract extraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous-tear capsulotomy and insertion of a silicone bag lens

Opacification of the posterior capsule and lack of intraocular lens fixation have been recurring problems and have resulted in a gradual shift from sulcus-fixated silicone lenses to bag-fixated silicone lenses. Postoperative capsular contraction, however, can cause capsular tearing in the periphery and intraocular lens decentration. A new method of combining a small circular capsulotomy, cataract removal without anterior capsular rim tearing, and meticulous bag placement of the silicone lens seems to allow centering and secure fixation of the silicone lens.