Anterior Capsulotomy Research Articles

Complete anterior capsule phimosis after routine cataract surgery

A 79-year-old woman with pseudoexfoliation and zonular weakness underwent routine phacoemulsification with 5.5 mm capsulorhexis and implantation of posterior chamber intra-ocular hydrophobic lens (KSSPStaar®). Examination at one-week post-surgery was normal. One-month post-surgery, the vision had decreased to 20/200. Slit-lamp examination showed complete anterior capsular contraction syndrome with a thick central occluding membrane and decentered lens (Figure 1A). No inflammation of the anterior segment was noted. Because of the zonular weakness, YAG laser anterior capsulotomy was chosen rather than further intra-ocular surgery with scissors and cystotome. Radial impacts, performed as usual, failed to clear the thick central membrane, so we detach edit and let the operculum drop away from the visual axis (Figure 1B). This procedure allowed for visual clearance and 20/20 vision recovery.

Visual outcomes and intraoperative complications of small incision cataract surgery performed by junior residents in GMC

To evaluate in intraoperative complications of MSICS performed by Junior Residents and to compare the incidences of major complications in the first six months of training versus last six months of training.It is a retrospective type of study. From March 2018 to February 2019 a total of 293 manual SICS were conducted by the Junior Residents in Department of Ophthalmology. Each of the patients underwent a detailed ophthalmological examination preoperatively and underwent MSICS under peribulbar anesthesia. Consents for surgeries were obtained from each patient.Following intraoperative complications were noted: tunnel related complications, capsulorrhexis related complications, Iridodialysis, posterior capsular rent, zonular dialysis, vitreous leak, surgical aphakia, Descemet membrane detachment, placement of ACIOL, Nucleus drop and IOL drop. The patient’s immediate postoperative vision was also noted. SPSS version 15.0.Tunnel related complications were found in 13.98% patients either as scleral button holing or premature entry. Posterior capsular rents and bag disinsertion were found in total of 11.94% patients owing to which 3.07% were left aphakic. 63.13% patients had visual acuity better than 6/12 by snellens chart on first postoperative day. Performance of adequate anterior capsulotomy, minimal handling of the cornea and avoidance of posterior capsular rent are some of the challenges faced by the residents while learning MSICS. Stepwise supervised training can help a resident doctor master these steps while keeping the complications at acceptably low levels. Stepwise supervised training of residents performing MSICS can minimize complications

Prostaglandin Release After Low-Energy Femtosecond Laser-Assisted Cataract Surgery Without Anti-Inflammatory Drug Premedication

To compare prostaglandin E2 (PGE-2) levels in the aqueous and pupil diameter in patients undergoing low-pulse energy femtosecond laser-assisted cataract surgery (LCS) without non-steroidal anti-inflammatory (NSAID) pretreatment with either fragmentation or capsulotomy performed first. Prospective, randomized, fellow-eye controlled comparison. This study was undertaken at the Department of Ophthalmology, Medical University of Vienna. The population consisted of 140 eyes of 70 patients with bilateral age-related cataract. Bilateral same-day LCS with either anterior capsulotomy before lens fragmentation (Caps-First) in one eye or vice versa (Frag-First) in a random sequence were performed. Aqueous was tapped 5 minutes after LCS and PGE-2 concentration was analyzed. Pupil diameters were recorded immediately before and after femtosecond laser pretreatment. The main outcome measure was PGE-2 concentrations in picograms/milliliter and pupil diameter in millimeters. Mean PGE-2 concentrations were 42.0 ± 63.7 pg/mL in the Caps-First group versus 71.8 ± 160.7 pg/mL with the Frag-First group (P=.186). Mean pupil diameters before and after pretreatment were 7.6 ± 0.8 mm and 7.6 ± 0.8 mm, respectively (P=.871). Mean PGE-2 concentrations and pupil diameters did not show any significant difference between time points or groups. Low-energy femtosecond laser pretreatment did not increase PGE-2 levels in the absence of NSAID pretreatment. This was independent of whether capsulotomy or fragmentation was performed first. Moreover, no pupillary miosis was observed.

Clinical experience with an anti-dysphotopic intraocular lens.

PURPOSE:Report experience regarding an anterior capsulotomy fixated intraocular lens (IOL) designed to prevent negative dysphotopsia (ND).METHODS:A prospective, nonrandomized clinical study was done at Péterfy Sándor Street Hospital-Clinic, and Jenő Manninger National Trauma Institute, Budapest, Hungary. The Morcher (Masket) 90S IOL has a circumferential groove on the optic that captures the anterior capsulotomy. Thus, part of the optic projects over and anterior to the capsule edge, while the bulk of the IOL is fixated within the capsular bag. We implanted the first version of the 90S IOL into the 40 eyes of 38 patients. These 40 eyes made up the primary investigational cohort. An additional 22 eyes received a modified version of the 90S IOL. The main outcome measure was the presence of ND. There was also a control group of 40 patients who received a single-piece monofocal aspheric hydrophobic acrylic IOL (877 FAB, Medicontur, Budapest, Hungary).RESULTS:None of our 66 test patients experienced ND during the follow-up period. After specific questioning, six patients reported nondebilitating PD that improved or disappeared completely in 5 cases. For the 40 eyes of the control group, there were 10 cases of ND on the first postoperative day and in 2 cases ND persisted for more than 1 year postoperatively.CONCLUSION:The 90S IOL can be used successfully to prevent ND. Since it is fixated by the anterior capsulotomy, additional advantages such as prevention of anterior capsule contraction, limited tilt, stable toric axis, perfect centration on the visual axis, and a more predictable lens position, among others, may be expected, and are under investigation.

Efficacy of Gamma Knife Radiosurgery in Refractory Obsessive-Compulsive Disorder: An Indian Experience

Background Obsessive-compulsive disorder (OCD) is a chronic debilitating psychiatric condition with adverse impact on patient's sociooccupational health. Refractoriness to pharmacotherapy and psychotherapy is not uncommon. Gamma Knife radiosurgery (GKRS) is the comprehensively used and reviewed treatment modality in refractory OCD worldwide. In India, the past two decades of increasing GKRS availability has failed to create the necessary local awareness of its usefulness in refractory OCD. Limited native literature deepens the problem. Objective To analyze our experience with GKRS in refractory OCD, and report the safety and efficacy/long-term outcome in patients using the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS). Materials and Methods A retrospective review of patients receiving GKRS for refractory OCD between 2000 and 2020 was carried out. Case files of the eligible ( n = 9) patients were reviewed for clinical, radiotherapeutic, and outcome data. Additionally, patients were contacted via telephone to enquire about their experiences, and to obtain retroactive consent for GKRS in June 2021. Information obtained was collated, computed, and analyzed. Results Male-to-female sex ratio was 8:1. Mean age at the time of GKRS and mean duration of OCD prior to GKRS was 30.1 ± 9.4 and 10.2 ± 5.8 years, respectively. Mean baseline Y-BOCS score was 29.6 ± 4.7. Our first patient received cingulotomy, while the rest underwent anterior capsulotomy. Median margin dose (50% isodose) was 70 Gy. Also, 23.8 ± 7.7 was the mean Y-BOCS score at the last follow-up (median = 30 months). Overall, 44.4% patients showed full/partial response (≥25% reduction in Y-BOCS score) at the last follow-up. In anterior capsulotomy (eight patients), patients with moderate/severe OCD showed better response (4/5 responders) than those with extreme OCD (0/3 responders). Single case of cingulotomy resulted in no response (<25% reduction in Y-BOCS score). No adverse radiation effects were noted. Also, 55.6% patients gave retroactive consent telephonically. Conclusion GKRS is a safe and effective noninvasive treatment modality for refractory OCD. Ventral anterior capsule is the preferred target. Maximum radiation doses of 120 to 160 Gy are well tolerated. Extremely severe OCD cases fared poorer. Proper awareness about the availability and efficacy of GKRS in refractory OCD is required in India.

Treatment Outcomes of Gamma-Knife Radio Surgery in Refractory Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a common disease that has negative effects on functionality, and 10% of the patients do not respond to first-line treatments. Gamma-knife radiosurgery (GKRS) has been used in patients with treatment-resistant OCD, but the data on long-term outcomes are still unsatisfactory. In this study, 12 patients who underwent GKRS between 2005 and 2020 were evaluated retrospectively. Anterior capsulotomy was performed using two 4-mm isocenters at the midputaminal point of the anterior limb of the internal capsule on each side with a maximum radiation dose of 140-180 Gy. Patients were followed up with the Yale-Brown Obsession and Compulsion Scale (Y-BOCS), Montgomery-Asberg Depression Rating Scale (MADRS), and Brief Psychiatric Rating Scale (BPRS) on the first, third, and sixth months. After the procedure, a 35% reduction was observed in the overall Y-BOCS scores, and full response rate was 50%. There was a 49.5% decrease in the MADRS scores and a 57.8% decrease in the BPRS. GKRS is an effective and non-invasive procedure with favorable side effects in treatment-resistant OCD with selected patients.

Femtosecond laser-assisted intraocular lens exchange.

Intraocular lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining curvilinear capsulotomy is particularly important when the desired outcome is bag-to-bag IOL exchange. Similarly, when the posterior capsule is open, properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9 to 5.0 mm, and the energy was set at 4 to 10 μJ depending on diffusiveness of the anterior capsule. The femtosecond laser was adapted to create a secondary anterior capsulotomy to facilitate IOL exchange.

HYDROGEL INSERT MISMATCH - A RARE CAUSE OF FAILED FEMTOSECOND LASER Assisted CATARACT SURGERY

Background: Femtosecond laser-assisted cataract surgery (FLACS) offers high level of precision and automates the three major steps of cataract surgery - corneal incisions, anterior capsulotomy and lens fragmentation. An ideal dock is required for optimal outcomes in FLACS. However dock failure can occur due to various factors. Here, we report a case of failed FLACS due to mismatch of hydrogel insert. Case description: FLACS with toric intraocular lens (IOL) implantation was planned in right eye for a 57 year old male who was diagnosed with immature cataract in that eye. Due to mismatch between the corneal curvature and the hydrogel insert, multiple attempts were required to achieve dock which resulted in folds on the hydrogel insert, causing incomplete anterior capsulotomy and nuclear fragmentation. During surgery, capsulorhexis and nuclear fragmentation was completed manually. Rest of the surgery was uneventful. Conclusion: The choice of hydrogel insert should depend on the corneal curvature. Appropriate usage of hydrogel insert based on the keratometry readings will result in enhanced outcomes.

C.2 The use of magnetic resonance guided focused ultrasound for refractory psychiatric illness

Background: Obsessive compulsive disorder (OCD) and major depressive disorder (MDD) are common, often refractory, neuropsychiatric conditions for which new treatment approaches are urgently needed. Magnetic resonance guided focused ultrasound (MRgFUS) is a novel surgical technique permitting incisionless ablative neurosurgery. Methods: We examined the safety profile, clinical response, and imaging correlates of MRgFUS anterior capsulotomy (MRgFUS-AC) in patients with refractory OCD (n=7) and MDD (n = 10). Results: There were no serious adverse clinical or radiographic events. 5/7 OCD patients and 3/10 MDD patients met pre-established clinical response criteria. Neurocognitive performance improved on several measures of executive function (p&lt;0.05). By 6 months, there were significant reductions in cerebral glucose metabolism, and reductions in the bilateral tracts connecting the thalamus with the orbitofrontal cortices, anterior cingulate cortex (p&lt;0.05). Preoperative functional connectivity between the right ventral striatum and hippocampus was predictive of eventual clinical response (p-FDR&lt;0.05). Conclusions: MRgFUS-AC is safe and demonstrates important evidence of efficacy in treatment resistant psychiatric disease, particularly OCD. The procedure was associated with structural and metabolic changes in brain networks implicated in affective regulation, Resting-state fMRI offers the ability to predict response, and potentially select patients most likely to improve.

Recent developments in anterior capsulotomy for cataract surgery.

Successful anterior capsulotomy is an important step in cataract surgery. This article reviews the various anterior capsulotomy techniques available to surgeons to optimize the step, including those that have become available since the introduction of femtosecond-laser-assisted cataract surgery (FLACS). Studies comparing the relative advantages of each technique will be emphasized. Manual continuous curvilinear capsulorhexis (CCC) and FLACS remain the two most widely studied techniques for achieving anterior capsulotomy. Each technique has been shown to be effective for a wide range of patients and cataract surgery complications. Meta-analyses have shown that FLACS provides similar results to manual CCC for long-term cataract surgery outcomes. Several alternative methods for anterior capsulotomy have been described, which aim to provide some of the advantages of laser capsulotomy at a lower cost; among these, precision pulse capsulotomy (PPC) and selective laser capsulotomy (SLC) have been investigated the most in the literature so far. Cataract surgeons have an increasing number of techniques for anterior capsulotomy available. Manual CCC and FLACS remain the most widely used, and most well studied. The latest techniques, PPC and SLC, have shown promise in the few studies performed since they were introduced.

Interstitial laser anterior capsulotomy for obsessive–compulsive disorder: lesion size and tractography correlate with outcome

BackgroundAnterior capsulotomy is a well-established treatment for refractory obsessive–compulsive disorder (OCD). MRI-guided laser interstitial thermal therapy (LITT) allows creation of large, sharply demarcated lesions with the safeguard of real-time imaging.ObjectiveTo...

Common and differential connectivity profiles of deep brain stimulation and capsulotomy in refractory obsessive-compulsive disorder.

Neurosurgical interventions including deep brain stimulation (DBS) and capsulotomy have been demonstrated effective for refractory obsessive-compulsive disorder (OCD), although treatment-shared/-specific network mechanisms remain largely unclear. We retrospectively analyzed resting-state fMRI data from three cohorts: a cross-sectional dataset of 186 subjects (104 OCD and 82 healthy controls), and two longitudinal datasets of refractory patients receiving ventral capsule/ventral striatum DBS (14 OCD) and anterior capsulotomy (27 OCD). We developed a machine learning model predictive of OCD symptoms (indexed by the Yale-Brown Obsessive Compulsive Scale, Y-BOCS) based on functional connectivity profiles and used graphic measures of network communication to characterize treatment-induced profile changes. We applied a linear model on 2 levels treatments (DBS or capsulotomy) and outcome to identify whether pre-surgical network communication was associated with differential treatment outcomes. We identified 54 functional connectivities within fronto-subcortical networks significantly predictive of Y-BOCS score in patients across 3 independent cohorts, and observed a coexisting pattern of downregulated cortico-subcortical and upregulated cortico-cortical network communication commonly shared by DBS and capsulotomy. Furthermore, increased cortico-cortical communication at ventrolateral and centrolateral prefrontal cortices induced by DBS and capsulotomy contributed to improvement of mood and anxiety symptoms, respectively (p < 0.05). Importantly, pretreatment communication of ventrolateral and centrolateral prefrontal cortices were differentially predictive of mood and anxiety improvements by DBS and capsulotomy (effect sizes = 0.45 and 0.41, respectively). These findings unravel treatment-shared and treatment-specific network characteristics induced by DBS and capsulotomy, which may facilitate the search of potential evidence-based markers for optimally selecting among treatment options for a patient.

Динамические показатели УБМ при переднем капсулярном контракционном синдроме

The article presents the results of UBM studies of patients with anterior capsular contraction syndrome (CS). Purpose. Тo use the UBM method to study the state of the ciliary body (CB) and the capsular bag of the lens in patients with CS. Material and methods. The study included 42 patients with capsular CS. The UBM HI-scan ultrasound biomicroscope (Optikon, Italy) was used. Results. The reduction of the capsule bag of the lens was accompanied by a significant decrease in the diameter of the anterior capsulotomy opening, IOL decentration and its displacement towards the posterior pole of the eye, stretching or damage to the zonula ciliaris, and an increase in the CB thickness. In 2 cases, ruptures of the CB and its separation from the place of attachment to the radix iridis were recorded. Conclusion. UBM is an effective assessment method for CS, which allows us to study the state of the capsule bag of the lens and CB, evaluate the effectiveness of laser treatment and predict the risks associated with a high probability of complications. Key words: capsular contraction syndrome, anterior capsule, lens, laser, UBM, ciliary body.

Role of Preoperative Nd:YAG Laser Anterior Capsulotomy in Mature Intumescent Cataracts.

The aim of this study was to examine the role of preoperative Nd:YAG laser anterior capsulotomy in preventing intraoperative complications in mature intumescent cataracts. A prospective, interventional, observational study. A total of 52 eyes of 52 patients were selected in this prospective study. Preoperative Nd:YAG laser anterior capsulotomy was performed in all eyes with 1 shot of 1.2 mJ and a gush of the liquified cortex was noted. Anterior chamber depth was measured using anterior segment optical coherence tomography and intraocular pressure using Goldmann applanation tonometer were measured pre- and post-laser. Intraoperative complications and surgeon's operative comfort were noted. There was a mean increase in anterior chamber depth by 0.24 mm and a mean decrease in intraocular pressure by 1.61 mm Hg postlaser. No intraoperative complications were noted except for capsulorhexis extension in 1 eye (1.92%). The surgeon experienced a good control while performing the capsulorhexis and overall an uneventful surgery. Preoperative Nd:YAG laser anterior capsulotomy is a safe and effective technique in reducing intralenticular pressure and avoiding intraoperative complications in mature intumescent cataracts.

1 Neurosurgery for severe OCD: the past, present and future

Obsessive compulsive disorder (OCD) is a common disorder thought to have a prevalence of 1-2%. The majority of patients are helped by treatments such as exposure and response prevention therapy and medication. A significant minority fail to benefit from optimal treatment and are severely disabled with respect to everyday function.Such patients may be candidates for a neurosurgical approach. This talk will trace the development of neurosurgery for severe OCD beginning with leucotomy/lobotomy which was practiced in the early part of the 20th Century and left an unfavourable legacy. Advancements in neurosurgery have allowed techniques such as anterior cingulotomy and anterior capsulotomy to be practiced at present and will be compared. Deep brain stimulation for severe OCD was introduced as an alternative to ablation neurosurgery but the optimal target for electrode placement remains under debate and will be discussed with reference to a study directly comparing DBS of two emerging targets within the same patients. Finally, methods of target refinement will be discussed which may improve patients outcome in the near future.

Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration. To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo. A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies. A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery. LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.

Surgical outcomes with high and low pulse energy femtosecond laser systems for cataract surgery

Currently, there is no clear consensus in cataract surgery if low compared to high energy femto-lasers may enable better capsulotomy quality and induce lower inflammatory response. Therefore, the aim of this study was to compare the intra-operative outcomes achieved with high and low pulse energy femtosecond laser systems for cataract surgery. The charts of 200 eyes of 200 patients aged 68.3 ± 10.3 years who had undergone femtosecond laser-assisted cataract surgery using either group 1 high pulse energy: LenSx (Alcon Laboratories) (N = 100) or group 2 low pulse energy: FEMTO LDV Z8 (Ziemer) (N = 100) laser were reviewed retrospectively. Integrity of anterior capsulotomy, classified as (1) complete (free-floating or with minor microadhesions), (2) incomplete and (3) with capsular tears, intraoperative completeness of the clear corneal incisions (CCI, main incision and side port), incidences of intraoperative miosis and incidence of subconjunctival hemorrhage were evaluated and compared between the two groups. The proportion of complete capsulotomies was significantly higher in the group 2 than the group 1 (100% vs 94%; p = 0.03). The incidences of intraoperative miosis (0% vs 19%) and subconjunctival hemorrhage (1% vs 63%) were significantly lower in the group 2 than the group 1 (p < 0.001). Completeness of the main incision was comparable (97% vs 95%; p = 0.721) between the two groups. Although not statistically significant, the completeness of side-port incision was slightly better in the group 2 than the group 1 (91% vs 86%). Low energy laser system performed significantly better in terms of completeness of capsulotomy, intraoperative miosis and sub-conjunctival hemorrhage, compared with high energy laser; the CCI outcomes were comparable.

Lens particle glaucoma as a presenting feature of Hallermann–Streiff syndrome

Hallermann–Streiff syndrome (HSS), an asymmetric second branchial arch defect affects growth, cranial and dental development. A 40-year-old lady with HSS developed severe pain and redness in her right eye due to raised intraocular pressure (IOP; 51 mmHg). A ruptured anterior capsule with cortical lens matter and granulomatous reaction was seen in anterior chamber (AC) along with absorbed cataract. Treatment with antiglaucoma medications, steroids followed by AC wash, anterior capsulotomy with anterior vitrectomy normalized IOP and inflammation reduced. Lens particle glaucoma is a rare presentation of HSS. Therefore, early cataract surgery is recommended that also avoids the risk of suppression amblyopia.

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized, Single-Blind, Controlled Trial

BackgroundThe direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy. MethodsThis single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively. ResultsNinety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively. ConclusionThis study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule’s role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.

Comment on: Comparison of femtosecond laser-assisted cataract surgery and conventional cataract surgery: a meta-analysis and systematic review.

We read with interest the review of femtosecond laser–assisted cataract surgery (FLACS) and conventional cataract surgery (CCS) by Kolb et al.1 We feel that it is necessary to highlight the area about the reporting of posterior capsular complications. The article states that posterior capsule ruptures were reported in 0.42% of eyes with FLACS and 0.27% of eyes with CCS and a statistically significant difference was not found. A link to Supplemental Digital Content was then provided for those reading the article online.1 What is not evident to those reading the printed article with no access to the various links was that 75% of the posterior capsular complications occurred with the use of 2 of the 5 FLACS systems. Further subgroup analysis revealed that there was an unequal distribution of patients with 1 group reporting more than 60% of the patients who had posterior capsular complications. Readers of the printed copy would, therefore, accept the statement that there was no statistically significant difference in capsule rupture rates between FLACS and CCS as presented in the abstract. Those who accessed the article with links online would be directed to explore the evidence base and would rather accept the statement in the text that posterior capsule rupture seemed less with FLACS, which was of clinical importance even if statistical importance is missed. A recent prospective randomized trial showed a statistically significant decrease in posterior capsule rupture in patients undergoing FLACS.2 This is not unexpected because it has been suggested that most surgeons who convert from manual cataract surgery to FLACS are likely to note a decrease in their posterior capsule rupture rate.3,4 This study states that “visual and refractive results are the most important endpoints for patients' satisfaction.” The importance of this statement cannot be overemphasized. A ruptured posterior capsule predisposes to cystoid macular edema, retinal detachment, and secondary surgery. Patients now have a larger choice of intraocular lenses (IOLs), including multifocal IOLs and extended-depth-of-focus IOLs, the success of which depends on correct lens placement in the bag. A ruptured posterior capsule unable to support an IOL in the presence of a capsulorhexis either too large or too small to offer optic capture can lead to a very unsatisfied patient postoperatively. FLACS offers an anterior capsulotomy of precisely predetermined size, position, and circularity to cover the implanted IOL. This allows for anterior optic capture with haptics positioned in the ciliary sulcus if needed.5 The meta-analysis offers a review of trials published about the different outcomes between FLACS and CCS. It cannot be used as guidance in cases that have been excluded from the studies that would be uniquely suited for FLACS, such as those with intumescent cataracts or those with loose zonular fibers making capsulorhexis difficult. The achievement of a precise anterior capsulotomy, low rate of posterior capsular complications, and the decrease in ultrasound energy needed to remove a cataract should play a part in the decision whether to use FLACS, especially for surgeons who have a complication rate of more than 1%, in trainees, or when tackling difficult cases.