Anterior Capsule Tear Research Articles

Incidence and analysis of intraoperative complications in femtosecond laser-assisted cataract surgery: a large-scale cohort study to establish the learning curve

AimsTo assess the safety of femtosecond laser-assisted cataract surgery (FLACS) based on surgical parameters and intraoperative complications analysis and to determine the length of the learning curve for FLACS.MethodsA prospective...

Double capsulorhexis technique for safe phacoemulsification in intumescent cataract

Intumescent white cataracts are a challenge for novice and experienced surgeons alike. Creating a continuous curvilinear capsulorhexis may pose a problem in these cataracts due to many factors like increased intra capsular pressure, absence of red reflex, poor visibility, fragile or calcified anterior capsule.[1] These cataracts tend to have a shallow anterior chamber and presence of fluid vacuoles or sectoral markings in subcapsular area which can be seen on slit lamp biomicroscopy.[2] Argentinian flag sign, which is a radial tear in anterior capsule, can occur while creating capsulorhexis, due to raised intracapsular pressure.[3] Radial tears extending to the equator, makes phacoemulsification unsafe, since it may lead to further complications such as extension of the tear to posterior capsule, nucleus drop in vitreous cavity and difficulty with IOL placement. This video demonstrates the steps of 2 staged capsulorhexis, to prevent radial extension while operating a type 1 (liquified cortex) intumescent cataract and type 2 (no liquified cortex, only tense fibres) intumescent cataract.[4]

Modified Technique of Setting Capsulotomy Thickness in Reducing Capsulotomy-Related Complications During Femtosecond Laser-Assisted Cataract Surgery: A Prospective, Comparative Cohort Study.

Although uncommon, incomplete capsulotomy, anterior capsule tags and anterior capsule tears are still encountered during femtosecond laser-assisted cataract surgery (FLACS), resulting in surgical complications. This highlights the need to improve femtosecond laser-assisted capsulotomy technique to reduce capsulotomy-related complications. Therefore, the purpose of this study was to investigate the efficacy of a newly developed, modified technique of setting capsulotomy irradiation thickness in lowering the incidence of capsulotomy-related complications in FLACS. This open-label prospective, comparative cohort study included 440 eyes (220 patients) treated with FLACS using the LenSx laser system (Alcon Laboratories, Inc. Fort Worth, TX, USA). Varying capsulotomy irradiation thicknesses were applied in each eye of the same patient. In Group 1, capsulotomy irradiation thickness was set between the upper edge of the highest point of the anterior capsule and the lower edge of the lowest point of the anterior capsule (modified technique). In Group 2, this was set between the center of the highest point of the anterior capsule and the center of the lowest part of the anterior capsule (conventional technique). Incidence rates of incomplete capsulotomy, anterior capsule tags and tears, and posterior capsule tears were compared. Preoperative baseline characteristics showed no significant differences. Mean total of the irradiation thicknesses was 877.1 ± 81.9µm in Group 1 and 808.9 ± 80.0 in Group 2, with a statistically significant difference (P < 0.001). Incidences of incomplete capsulotomy were 1.8% and 7.7%, anterior capsule tags were 2.3% and 8.6%, and anterior capsule tears were 0% and 3.2% in Groups 1 and 2, respectively. These differences were statistically significant (P = 0.006, 0.005, and 0.015, respectively). No posterior capsule tears were reported in either group. The modified technique for capsulotomy in FLACS may significantly reduce the occurrence of capsulotomy-related complications, maximizing the benefits of FLACS.

Intraoperative complications of cataract surgery using a low-energy femtosecond laser: Results from a real-world high-volume setting.

In this study, we report data on intraoperative complications occurring after cataract surgery in a high-volume single-center setting using a low-energy, mobile femtosecond laser. We retrospectively reviewed the medical records of patients who underwent femtosecond laser-assisted cataract surgery (FLACS) in our hospital between August 2015 and December 2019. Among the sample of 1,806 eyes of 1,131 patients (903 left and 903 right eyes), the mean age was 75.8 years (range, 21-99 years). The overall intraoperative complication rate was 0.28% (n = 5), with three cases of anterior capsule tear (0.17%) and two cases of posterior capsule tear (0.11%). No further complications occurred. This study underlines the safety of low-energy femtosecond-assisted cataract surgery in a real-world setting with a very low rate of intraoperative complications.

Drill-and-prechop technique: modification of the drill-and-crack technique for mature cataracts

BackgroundThere are some techniques for disassembly of hard nuclear. It is challenging in hard cataract surgery through microincision. The classic chop or prechop techniques often do not succeed,resulting in incomplete nuclear segmentation. The authors describe a new chop technique for removing hard nucleus cataracts in coaxial microincisional cataract surgery.MethodsWe create a deep hole (drill) in the central nucleus with the phaco tip and divide the nucleus (prechop) with the Nagahara chopper and the modified capsulorhexis forceps inside the hole. The chopper and the modified capsulorhexis forceps are spread apart laterally after they approach at the center of the nucleus, to create a complete fracture across the entire nucleus. Since January 2022, we have completed 27 eyes of 25 patients with hard nucleus cataract using this technique.ResultsComplete segmentation of the hard nuclear into two hemispheres was implemented with this drill and prechop technique in all cases. The effective phaco time and ultrasound energy decreased. No intraoperative complication such as iris injury, anterior capsule tears, zonulysis, or posterior capsule rupture with vitreous loss occurred during surgery.ConclusionsThis technique simplifies the previous prechop techniques especially for hard nucleus in microincisional cataract surgery. The technique is efficient, safe and simple.

Femtosecond laser-assisted anterior capsulotomy in children undergoing cataract surgery: a large case series

ObjectiveTo evaluate safety and postoperative visual outcomes of low-energy femtosecond laser-assisted (FLA) anterior capsulotomy in paediatric cataract surgery.Methods and analysisWe report a retrospective single-centre consecutive case series of 51 eyes...

Intraoperative complication rates in cataract surgery performed by resident trainees and staff surgeons in a tertiary eyecare center in Hungary.

To compare the incidence of intraoperative complications during primary phacoemulsification (phaco) surgery between resident surgeons (residents) and staff surgeons (specialists) and to objectively determine the difficulty of stages in phaco surgery. This retrospective study included cases of phaco cataract surgery performed between January and December 2019. There were no exclusion criteria. For each patient, demographics, clinical history, case complexity, type of surgeon, and operative details were reviewed. Primary outcomes included intraoperative complication rates and the objective measure of difficulty in the steps of the surgery performed by residents and specialists. A total of 3272 cases were included; 7.4% (n=241) of cases were performed by residents. The overall complication rate was 5.4% (n=177). The intraoperative complication rate was significantly higher (P<0.001) in residents (n=33, 13.7%) than in specialists (n=144, 4.8%). The most frequent complications were posterior capsule tear (n=85, 2.6%), anterior capsule tear (n=50, 1.53%), zonular fiber loss (n=45, 1.38%), and dropped nucleus (n=15, 0.46%). Objectively, the most difficult steps during surgery were phaco in 66 (60.0%), capsulorhexis in 21 (19.1%), irrigation/aspiration in 13 (11.8%), hydrodissection in 9 (8.2%), and intraocular lens (IOL) implantation in 1 (0.9%) case. Intraoperative complication rates are higher in residents than in specialists. The order of objective difficulty in phaco surgery steps is in line with the subjective findings of other surveys, revealing that the most challenging parts of phaco surgery are phaco and capsulorhexis.

Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy.

To investigate outcomes of femtosecond laser (FL)-assisted cataract surgery (FLACS) and refractive lens exchange (RLE) in patients with prior radial keratotomy (RK). Single clinical practice. Retrospective observational case series. All patients with prior RK undergoing FLACS- or FL-assisted RLE surgeries over a 6-year period were reviewed. Inclusion criteria were diurnal stability and stable manifest refraction. Exclusion criteria were any other incisional corneal surgery, macular or glaucomatous pathology, or vision loss due to any other cause. Data collected included demographics, visual acuity, laser settings, and complications. Main outcome measures were intraoperative and postoperative complications and visual outcomes. Safety and efficacy indices were evaluated. 16 eyes of 9 patients were included. Mean age and follow-up time were 59.9 ± 9.9 years (range 44 to 75 years) and 3.3 ± 2.5 months, respectively. The mean number of RK cuts was 11.8 ± 5.3 (range 8 to 20). Mean preoperative uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 0.9 ± 0.4 logMAR (Snellen 20/160) and 0.2 ± 0.3 logMAR (Snellen 20/30), respectively. 2 intraoperative anterior capsule tears were identified. 1 postoperative intraocular lens dislocation occurred. Postoperatively, the mean UDVA and CDVA were 0.2 ± 0.2 logMAR (20/30) and 0.1 ± 0.1 logMAR (20/25), respectively. The safety index was 1.6, and the efficacy index was 1.2. FLACS- or FL-assisted RLE surgery in RK patients has a high risk for anterior capsule tear and should be avoided. Thickened incisional scars are potential sources of incomplete laser penetrance. Toric lens implantation in RK eyes provide unpredictable astigmatic correction and should also be avoided.

Adjusted femtosecond laser capsulotomy distance in white cataracts to decrease incomplete capsulotomy: a randomized comparative cohort study.

To compare safety and effectiveness between standard position and adjusted distance pre- and post-anterior capsule of femtosecond laser capsulotomy in white cataracts surgery. Selected white cataracts that underwent LenSx femtosecond laser capsulotomy were randomized into groups A (standard position, with 300µm symmetrically pre- and post-anterior capsule), B (increased distance with 400µm symmetrically pre- and post-anterior capsule), and C (unsymmetrical distances of 200µm pre- and 400µm post-anterior capsule, respectively). All these surgeries were performed by the same experienced surgeon. Complications, including incomplete capsulotomy and capsule tears, were recorded. In addition, femtosecond capsulotomy and phacoemulsification parameters, IOLs centrality and corrected distance visual acuity were assessed. A total of 113 eyes were included in this study. There were 8 (21.6%) incomplete capsulotomy and 1 anterior capsule tear in group A. Meanwhile, only 2 eyes (5.1%) had incomplete capsulotomy with none showing capsule tear in group B. In group C, only 1 eye (2.7%) had incomplete capsulotomy and no capsule tear occurred. Mean femtosecond laser capsulotomy time was longer in group B compared with groups A and C. Average cumulative dispersed energy, IOL centrality and corrected distance visual acuity were similar in all groups. Appropriate adjustment on femtosecond laser capsulotomy distance by reducing pre-anterior capsule and increasing post-anterior distance, may decrease incomplete capsulotomy and be more effective in white cataracts surgery. Clinical trial registration number: ChiCTR2100043863.

Lens capsule-related complications in femtosecond laser-assisted cataract surgery: a study based on video analysis

PurposeTo analyse the occurrence and potential causes of lens capsule-related complications during femtosecond laser-assisted cataract surgery (FLACS).MethodsThis prospective consecutive cohort study included the first 1600 eyes (from 1140 consecutive patients)...

Fish-shaped anterior capsular rupture with anterior subcapsular cataract following blunt trauma in a young man

A 20-year-old man presented with a history of blunt trauma by a rubber ball to his right eye. His visual acuity in the affected eye was 20/120 for distance and N36 for near. The lens showed anterior capsule tear with anterior subcapsular cataract, which did not progress to maturation even after 1 month. Following initial conservative management, phacoemulsification with a three-piece monofocal intraocular lens (IOL) implantation was performed and best-corrected visual acuity (BCVA) of 20/20 was achieved. This represents one of the few cases of blunt trauma presenting as an isolated anterior capsule rupture and anterior subcapsular cataract without mature cataract formation.

Precision Pulse Capsulotomy During Combined Penetrating Keratoplasty With Cataract Surgery and Intraocular Lens in Small Nondilating Pupil.

To demonstrate precision pulse capsulotomy (PPC) in an open-sky procedure and to evaluate its use during triple procedure keratoplasty in small nondilating pupils. This single-center retrospective case series study included 10 eyes (from 10 patients) with corneal opacity and poorly dilated pupils who were scheduled to undergo triple procedure keratoplasty. The main outcome measures were capsulotomy performance of the PPC device and intraoperative complications. Secondary outcome measures included postoperative best-corrected visual acuity, intraocular pressure, and other postoperative complications. Complete free-floating capsulotomy was achieved in all 10 eyes. There were no cases of anterior capsule tears or tags. There were no postoperative complications that occurred in association with the PPC device. The PPC device facilitates creation of a smooth, round, and appropriately sized anterior capsulotomy in open-sky surgeries, particularly in presence of small nondilating pupils.

Intra and post-operative complications observed with femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: a systematic review and meta-analysis

BackgroundIn this analysis, we aimed to systematically compare the complications which were associated with femtosecond laser-assisted cataract surgery (FLACS) versus the conventional phacoemulsification surgery (CPE).MethodsCommonly used search databases, specifically MEDLINE, Cochrane Central, EMBASE, and http://www.clinicaltrials.gov were carefully searched for English publications comparing FLACS versus CPE. The selected endpoints which were assessed included incomplete capsulotomy, anterior capsulotomy tag, anterior capsule tear, posterior capsule tear, injury to the descemet’s membrane, zonular dialysis, vitreous loss, macular or corneal edema, and elevated intra-ocular pressure. Statistical analysis was carried out by the latest version of the RevMan software (version 5.3) and represented by risk ratios (RR) with 95% confidence intervals (CI).ResultsA total number of 7156 participants were included. Three thousand five hundred and fifty four (3554) participants were assigned to the FLACS group. The risks for incomplete capsulotomy, anterior capsulotomy tag, and anterior capsular tear were significantly higher with FLACS (RR: 22.42, 95% CI: 4.53–110.82; P = 0.0001), (RR: 33.07, 95% CI: 6.53–167.56; P = 0.0001) and (RR: 4.74, 95% CI: 2.59–8.68; P = 0.00001) respectively. The risks for macular/corneal edema (RR: 2.05, 95% CI: 1.18–3.55; P = 0.01) and elevated intra-ocular pressure (RR: 3.24, 95% CI: 1.55–6.78; P = 0.002) were also significantly higher with FLACS. However, the risks for impaired descemet’s membrane (RR: 0.95, 95% CI: 0.61–1.47; P = 0.80), zonular dialysis (RR: 0.40, 95% CI: 0.06–2.72; P = 0.35), vitreous loss (RR: 0.09, 95% CI: 0.01–1.63; P = 0.10) and posterior capsular tear (RR: 1.45, 95% CI: 0.23–9.16; P = 0.69) were not significantly different.ConclusionsThe current results showed that FLACS did not improve intra/post-operative complications in comparison to CPE. Further larger studies should confirm this hypothesis.

Precision pulse capsulotomy in challenging cataract surgery cases.

PurposeTo evaluate the use of the precision pulse capsulotomy (PPC) device for challenging cataract surgery cases.Patients and methodsThis single-center retrospective case series study comprised of 43 eyes (from 35 patients) that were challenging cataract surgery cases with poorly dilated pupils, anterior subcapsular opacity, white cataract, brunescent cataract, and corneal opacity. This was conducted at the Busan Sungmo Eye Hospital (Busan, Republic of Korea) to assess the performance of the PPC device through a 2.2-mm clear corneal incision width, followed by the phacoemulsification technique and intracapsular intraocular lens fixation. The main outcome measurement was the anterior capsulotomy performance of the PPC device and the development of intraoperative complications. At postoperative 2 months, visual acuity, endothelial cell count, and refractive error were measured.ResultsNo cases of anterior capsule tears or tags occurred. All 43 eyes received circular, 360-degree, free-floating, and appropriately sized anterior capsulotomies. During 2 months of follow up, no postoperative complications occurred in association with the PPC device.ConclusionThe PPC device facilitated the creation of a precise, round, appropriately sized anterior capsulotomy in challenging cataract surgery cases. Further investigations are required to understand the long-term safety and efficacy of the PPC device.

The Clinical Relationship of Anterior Capsular Tears and Vertical Spacing in the Femtosecond Laser Capsulotomy Procedure.

To evaluate the frequency of anterior capsule tears and capsule edge irregularities in femtosecond laser anterior capsulotomy, including the effect of optimized vertical spacing settings. Three thousand eight hundred thirty-four cases were examined and grouped according to the femtosecond laser capsulotomy settings using manufacturer default settings with a vertical spacing of 10, 15, and 20 µm. Capsulotomy edge irregularities and anterior capsule tears were recorded intraoperatively. The anterior capsule tear rates for the 10, 15, and 20 µm groups were 0.79%, 0.35%, and 0.09%, respectively. The capsule edge irregularity rates for the 10, 15, and 20 µm groups were 6.25%, 1.13%, and 1.15%, respectively. The treatment times for the 10, 15, and 20 µm groups were 1.6, 0.7, and 0.8 second, respectively. The risk reduction of anterior capsule tears positively correlated with the 15 and 20 µm group settings. The anterior capsule tear rate difference between the 10 and 20 µm group settings was statistically significant. Capsule edge irregularity rates were reduced in the 15 and 20 µm group settings. Eye movement was monitored in the 20 µm group and was observed in 9 of 13 patients with capsule edge irregularities. Anterior capsule tear rates are low with femtosecond laser cataract surgery. The rate can be further reduced with optimization of the settings, including an increase in vertical spacing. [J Refract Surg. 2019;35(5):280-284.].

Lens capsule-related complications of femtosecond laser–assisted capsulotomy versus manual capsulorhexis for white cataracts

Comparison of lens capsule-related complications resulting from femtosecond laser-assisted capsulotomy and manual capsulorhexis in patients with white cataracts. Eye Center, Second Affiliated Hospital, Zhejiang Medical School, Hangzhou, China. Prospective consecutive nonrandomized comparative cohort study. Selected patients were divided into a femtosecond laser-assisted cataract surgery group (FLACS group) and a conventional phacoemulsification cataract surgery group (CPCS group). Each case was recorded as either a type I or type II white cataract. Here, type I was characterized by the presence of a liquefied cortex, whereastype II had a solid cortex. Five experienced phacoemulsification surgeons conducted all surgeries. Lens capsule-related events, including anterior capsule tears, posterior capsule ruptures (PCRs), incomplete capsulotomies, and irregular capsulorhexes were recorded; surgical parameters, postoperative visual acuities, and intraocular lens (IOL) decentrations were evaluated. The study comprised 132 eyes of 132 patients (66 in each group). Anterior capsule tears were significantly more common in the CPCS group than the FLACS group (12.1% versus 0%). All 8 cases of anterior capsule tears were type I cases. Six FLACS cases developed incomplete capsulotomies, four of which were type I cases. The incidences of PCRs and vitreous loss were the same. Capsulotomy produced better circularity index and diameter stability than capsulorhexis. IOLs were better centered in the FLACS group than the CPCS group. The mean ultrasound power, absolute phaco time, effective phaco time, and postoperative visual acuities were similar in both groups. Compared with CPCS, FLACS decreased the risk for anterior capsule tears in white cataracts, especially in type I cases. However, it did not reduce the incidence of PCR. Incomplete capsulotomy during FLACS could happen in white cataracts. Using FLACS on white cataracts enabled more precise capsulotomies and better-centered IOLs.

Consecutive drilling combined with phaco chop for full thickness segmentation of very hard nucleus in coaxial microincisional cataract surgery

BackgroundThe complete disassembly of nuclear is the most challenging step in hard cataract surgery through microincision. The classic phaco chop technique often does not succeed, resulting in incomplete nuclear segmentation. The authors describe a technique to improve the efficacy and safety of the initial chopping.MethodsThe consecutive drilling combined with phaco chop technique was devised for very hard cataract through a microincision of 1.8–2.2 mm. 3–4 holes are consecutively drilled into the endonucleus with the phaco tip bevel down, at an angle of approximate 60 degrees and depth of approximately two-thirds of the lens thickness. The initial drilling approaches the capsulorhexis edge and the last drilling approaches the lens geometric center. The nucleus is deeply impaled with the last drilling and firmly engaged with high vacuum, and then chopped with chopper centripetally from the lens equator. The chopper and phaco tip are spread apart laterally after they approach at the center of the nucleus, to create a complete fracture across the entire nucleus. This technique has been adopted in 80 eyes of 65 patients with cataract harder than nuclear opalescence 5 on the Lens Opacities Classification System III scale or mature white cataract with a hard nucleus in the past 12 months.ResultsIn all cases, full thickness segmentation of the hard nuclear including the posterior plate was achieved with this consecutive drilling combined with phaco chop technique. Phacoemulsification and intracapsular implantation of intraocular lens was safely performed in each case. No intraoperative complication such as iris injury, anterior capsule tears, zonulysis or posterior capsule rupture with vitreous loss occurred during surgery. No postoperative complication such as fibrin formation, synechias, severe endothelial cell loss, or endophthalmitis was observed in any case at 6 months postoperatively.ConclusionsThe technique is an efficient, safe, simple, and swift procedure for full-thickness nuclear segmentation, delivering advantage of microincisional phacoemulsifcation for hard cataract with few ocular complications.

In-the-bag toric intraocular lens implantation in the case of an anterior capsule tear: a case series.

To analyze the outcomes of in-the--bag toric intraocular lens implantation for anterior capsular tears during phacoemulsification. The cohort of this re-trospective, consecutive, interventional case series included eight patients. One patient was excluded as the tear was used to enlarge the rhexis. The mean preoperative astigmatism was -1.67D (± 0.98) and the mean preoperative unaided logMAR visual acuity was 0.62 (± 0.76). The mean angle between the anterior capsule tear and the closest intraocular lens haptic was 51.25° (range, 30°-90°). The final unaided logMAR visual acuity was 0.16 (± 0.21) and the final cylinder was -1.1 D (± 0.59). The mean follow-up duration was about 2 ± 1.2 months. In this case series, no lens had to be explanted or rotated postoperatively. Placement of a toric intraocular lens in the presence anterior capsule tear was safe in all patients. An angle of at least 30° remained between the tear and the intraocular lens haptic. Placement of toric intraocular lens in the presence of an anterior capsule tear may be safe, at least in cases with a 30° angle between the anterior capsule tear and the intraocular lens haptic.

Intraoperative performance and ultrastructural integrity of human capsulotomies created by the improved precision pulse capsulotomy device

To investigate the intraoperative performance and the ultrastructural features of anterior capsulotomy performed with the improved Zepto precision pulse capsulotomy (PPC) device. Launceston Eye Institute, Launceston, Tasmania, Australia. Prospective, consecutive case series. Intraoperative observation of performance and complications were made on consecutive eyes having capsulotomies with the improved PPC device. The capsulotomy specimens were examined under scanning electron microscope and compared with manual continuous curvilinear capsulorhexis and femtosecond laser-assisted cataract surgery specimens. The study comprised 52 eyes. Intended capsulotomy occurred in 50 eyes with 2 device failures. Complete free-floating capsulotomies were achieved in 48 eyes (96%). Anterior capsule tears occurred in 2 eyes (4%). The ability of the PPC device to create complete free-floating capsulotomies improved; however, the radial tear rate remained high. The ultrastructural features in exvivo human capsulotomy specimens still showed areas of irregular capsule margin with frayed edges.

A Comprehensive Surgical Curriculum Reduced Intra-operative Complication Rates of Resident-performed Cataract Surgeries

To evaluate the impact of a comprehensive cataract surgery curriculum on the incidence of intraoperative complications. We retrospectively compared the total number of cataract surgeries that the residents performed in all of the teaching sites, and the incidences of intraoperative complications (anterior capsule tear, posterior capsule rent, vitreous loss, anterior vitrectomy, zonular dialysis, iris trauma, hemorrhage, dropped lens fragment, corneal wound burn, incorrect intraocular lens) for the surgeries performed at Massachusetts Eye & Ear by residents in the pre-intervention group (residents graduating in 2004 and 2005), before the implementation of a surgical curriculum, and the residents in the post-intervention group (residents graduating in 2014 and 2015). Ophthalmology residency program at a major academic institution. Residents graduating in 2004, 2005, 2014, and 2015. We reviewed 4373 charts. 2086 of those surgeries were performed at Massachusetts Eye & Ear. The incidence of posterior capsule rent/vitreous loss/anterior vitrectomy was lower in the post-intervention group (1.4% versus 7.7%, p<0.0001). Other complications were also lower in the post-intervention group. Implementation of a comprehensive cataract surgery curriculum focusing on pre-operative, intra-operative and post-operative interventions, with an emphasis on patient outcomes resulted in a decrease in the rate of intraoperative complications.