Continuous Curvilinear Capsulorhexis Research Articles

Successful Management of Cataract in Patient With Long Anterior Zonules and Small Pupil :A Rare Case

Introduction : Long anterior zonules (LAZ) are rare disease with prevalence was 1–2%, characterized by zonular fibers that extend centrally leading to a small zonule-free zone (ZFZ), which raises the risk of complications during zonular cutting while continuous curvilinear capsulorhexis (CCC). This leads to two options whether to perform phacoemulsification through a small CCC within the small ZFZ or an adequately sized CCC. The objective of this study was to report challenging management of phacoemulsification surgery with LAZ eyes with small pupil
 Case Illustration : A 62 y.o female had visual acuity(VA) 0.7(logMAR) due to corticonuclear cataract in left eye. She had history complicated cataract surgery with secondary sulcus fixated IOL in her fellow eye. The IOP was normal, no phacodenesis and pseudoexfoliative material observed in left eye. The posterior segment was normal. The left eye observed otherwise normal in initial examination. Intraoperatively, after viscomidriasis technique the ZFZ identified in the area of 2.0-2.5 mm from central. Five millimeter CCC can be achieved in the central area and phacoemulsification with the help of CTR (Capsular Tension Ring) safely performed and one piece IOL was implanted in the bag.
 Discussion : On the first postoperative day, VA was improves to 0.4(logMAR), IOL central and clear corneal with minimal inflammation. One week after surgery, the VA 0.3(logMAR) and no sign of IOL decenteration.
 Conclusion : Phacoemulsification in eyes with LAZs can be safely performed with CTR through an adequately sized CCC without significant complications. A combination of early recognising high-risk eye, proficient skills, and surgical instruments can improve outcome.

Influence of posterior capsule abnormalities in pediatric cataract surgery.

To report how to manage posterior capsule abnormalities (PCAs) in pediatric cataracts and evaluate the influence of PCAs during intraocular lens (IOL) optic implantation in Berger space surgeries. Qingdao Eye Hospital of Shandong First Medical University, Qingdao, China. Retrospective case series study. Pediatric patients with PCAs who underwent cataract surgery were evaluated. A video-based analysis of the surgical interventions included the type of crystalline lens opacification, types and management of PCAs, complications during primary posterior continuous curvilinear capsulorhexis (PCCC), need for anterior vitrectomy (AV), and feasibility of IOL optic capture. There were 227 pediatric cataract surgeries performed during the study period, and 76 eyes of 66 children with PCAs were evaluated (33.5%, 76/227). Unilateral cataract with PCAs were found in 50 eyes (22.0%, 50/227) and bilateral were found in 26 eyes (11.5%, 26/227). The PCAs were posterior capsule plaque (19.8%, 45/227), posterior capsule defect (6.2%, 14/227), posterior lenticonus (3.1%, 7/227), and persistent fetal vasculature (4.4%, 10/227). In the PCA cases, primary PCCC was successful in 44.7% of the cases (34/76). An unplanned AV during the surgeries was performed in 47.4% (36) of the 76 eyes. IOL optic implantation in Berger space was achieved in 63.2% of the eyes (48/76). PCAs are often encountered during pediatric cataract surgeries, especially in unilateral cases. The presence of PCAs may complicate a primary PCCC procedure, resulting in an unplanned AV in some cases. IOL optic implantation in Berger space can also be performed fortunately with well-designed and skilled operation.

Case series of spontaneous bilateral absorbed cataracts running in a family

There are only a handful of case reports and studies available regarding spontaneously absorbed cataracts and their management, including the surgical techniques and results following the management. In our study, on retrospective analysis, after a thorough search of the concerned literature, we encountered a series of cases of bilateral spontaneous absorbed cataracts running in a family with no such documentation. This retrospective study included 11 patients (aged between 3 and 65 years and of either sex) of the same family having bilateral absorbed cataracts. All patients underwent best-corrected visual acuity (BCVA); a thorough eye examination; rubella titer estimation; intraocular lens (IOL) power calculation; lens aspiration with or without posterior capsulotomy, anterior vitrectomy (AV), or IOL implantation; and visual rehabilitation. All patients had bilateral absorbed cataracts, which were acquired in an autosomal dominant pattern. Preoperative BCVA distance: 22 eyes had either counting fingers close to the face or counting fingers at 1–2 feet. The presence of high-frequency mixed bilateral nystagmus was noted in four patients. Anterior continuous curvilinear capsulorhexis was possible. Cortical aspiration was uneventful. In the capsular bag, implantation was possible in the majority of cases. No postoperative inflammation was noted, and the IOL was well-centered in all patients. To the best of our knowledge, this is the first study to report a case series of bilateral absorbed cataracts running in an Indian family with no syndromic association, no history of mental retardation, or infection. Anatomic disorganization of the absorbed lens makes surgery in such cases challenging. By using appropriate surgical methods and good visual rehabilitation, satisfactory surgical and visual outcomes can be achieved.

Flow capsulorhexis: A novel technique in white and hypermature cataracts.

We described a novel "flow capsulorhexis" technique in white and hypermature cataracts and compared it with the standard "needle decompression capsulorhexis" technique. Six hundred and eight eyes of 420 patients with intumescent or non-intumescent mature white cataracts who had undergone phacoemulsification or manual small incision cataract surgery with "flow capsulorhexis" (Group 1) or "needle decompression capsulorhexis" (Group 2) were assessed. The mean continuous curvilinear capsulorhexis (CCC) completion time was 6.6 ± 3.4 seconds in Group 1 and 10.4 ± 4.2 seconds in Group 2 (P < 0.001). The mean number of times for an ophthalmic viscosurgical device (OVD) supplement was 0.4 ± 0.2 and 1.8 ± 0.8 in Group 1 and Group 2, respectively (P < 0.001). CCC success rate was 95.8% in Group 1 and 87.2% in Group 2 (P = 0.001). The new technique was observed to have better outcomes in terms of surgical time, OVD supplement times, and success rate than the standard needle decompression technique.

The Clinical Outcomes of Manual Continuous Curvilinear Capsulorhexis and Precision Pulse Capsulotomy

Purpose: To compare the safety and consistency of manual capsulorhexis and precision pulse capsulotomy performed using pulsed energy during bilateral cataract surgery and to explore the differences in clinical outcomes.Methods: A total of 101 patients with bilateral cataracts were selected. Precision pulse capsulotomy was performed on one eye and manual continuous curvilinear capsulorhexis on the other. The independent-samples t-test was used to compare the duration of continuous curvilinear capsulorhexis, incisional size and roundness, complications such as radial tears, the cumulative dissipated energy, the visual acuity after surgery, and the corneal epithelial cell count.Results: There was no significant difference in the capsulorhexis time between the pulse energy and manual groups. The extent of capsulorhexis was significantly smaller and the circularity of capsulorhexis was higher in the former group. Complications occurred in two manual capsulorhexis patients but in no pulse energy capsulotomy patient. There was no significant between- group difference in any of postoperative visual acuity, best-corrected visual acuity, or the corneal endothelial cell count.Conclusions: During bilateral cataract surgery on the same patients, precision capsulotomy using pulse energy afforded smaller and more circular capsulorhexis and fewer complications than did manual capsulorhexis. However, there was no significant between- group difference in the postoperative clinical outcomes.

10-Year Outcomes of Pediatric Cataract Surgery with Foldable Intraocular Lens Implantation and Posterior Continuous Curvilinear Capsulorhexis.

We investigated the long-term outcomes of pediatric cataract surgeries performed with modern surgical techniques involving in-the-bag implantation of a foldable intraocular lens (IOL). Data were retrospectively collected from 42 eyes in 30 patients who underwent surgery at 6 years and younger (average 2.5 ± 2.3 years) and were followed up for an average of 12.2 ± 2.4 years (10-17 years). Surgical procedures included anterior continuous curvilinear capsulorhexis (CCC), lens removal, posterior CCC, anterior vitrectomy, and in-the-bag IOL implantation. There were 18 unilateral (2.7 ± 2.3 years) and 12 bilateral cases (2.3 ± 2.3 years), with no significant age difference between groups (p = 0.462). The mean best-corrected visual acuity (BCVA) at the final visit was 0.453 ± 0.488 (logMAR), correlating significantly with the age at surgery (r = -0.307, p = 0.048). The unilateral group had a worse BCVA (0.658 ± 0.615) than the bilateral group (0.298 ± 0.294) (p < 0.001). On average, eyes showed a myopic shift of -6.0 ± 6.3D, which significantly correlated with surgical age (r = 0.402, p = 0.008). While the myopic shift was -8.2 ± 6.1 D in the unilateral group and -4.9 ± 6.4 D in the bilateral group, the net shift for unilateral cases (comparing pseudophakic and fellow eyes) was -4.8 D. Three eyes (7.1%) exhibited suspected glaucoma (increased intraocular pressure), but no glaucoma or other severe complications were noted. IOL exchange surgery was necessary in two eyes (4.8%) due to pronounced myopic drift and significant IOL decentration. Three eyes (7.1%) required surgery for significant visual axis opacification. Contemporary surgical strategies appear to yield promising long-term outcomes in patients with infantile cataracts.

Comparison between Posterior Capsular Opacification Following Implantation of Hydrophilic &amp; Hydrophobic Acrylic IOLs

Background Nowadays, care of a cataractous patient greatly exceeds surgical removal of the opacified lens. In a step forward to the welfare of the elderly, special concern is given for posterior capsular opacification (PCO), which remains one of the most common complications after cataract surgery. Aim of the Work The aim of that work was to compare the incidence of posterior capsular opacification in patients who underwent hydrophilic IOLs versus hydrophobic IOLs implantation. Patients and Methods The present study was conducted at the Ophthalmology Outpatient Clinic, Ophthalmology Department, Ain Shams University, and assessed patients, who underwent uneventful phacoemulsification cataract surgery and hydrophilic or hydrophobic acrylic nonheparinized IOL implantation. Surgeries were done by equal caliber experienced surgeons. ―In-thebag‖ fixation of a square-edged IOL and continuous curvilinear capsulorhexis with cortical cleanup was performed. Patients’ data were collected from the electronic medical records. Results The study revealed that neither the IOL material nor the general medical condition significantly delayed the onset of PCO development. However, we need to collect more clinical records of cases and conduct multicenter logistic regression analyses on a larger sample using a prospective study design. Conclusion The present study found no significant difference between the incidence PCO development between hydrophobic and hydrophilic IOLs. Moreover, the patients’ general conditions did not show a significant association with PCO incidence.

The Ganesh-Grewal cystitome maker - A step in standardizing cataract surgery.

A well-centered, adequately sized continuous curvilinear capsulorhexis (CCC) is a prerequisite for successful cataract surgery. A perfect capsulorhexis ensures safe and effective performance of various steps of surgery as well as a correctly positioned intraocular lens (IOL) with optimal rotational stability. Ganesh and Grewal (GG) cystitome maker is a step toward standardizing the creation of a cystitome to reduce variations and complications associated with the crucial step of CCC in cataract surgery. We conducted a study to measure the repeatability and precision of cystitomes made by the GG cystitome maker versus those made manually with a needle holder. The results showed that the cystitomes made with GG cystitome maker had a lesser degree of variation. This indicates a more repeatable cystitome, which will inadvertently help in reducing the error caused by the instrument in making a good CCC during cataract surgery.

Cataract surgery following penetrating keratoplasty in children.

Following penetrating keratoplasty, cataract surgery warrants certain modifications to ensure maximum survival of the graft. To emphasize the intraoperative challenges and surgical manipulations to be followed. The surgeon makes a superior sclerocorneal tunnel avoiding the graft host junction. Dispersive viscoelastic is used. Continuous curvilinear capsulorhexis is done. Cataractous lens aspirated with a low flow rate. The intraocular lens is placed in the bag. Superior peripheral iridectomy and primary posterior capsulorhexis are done. The wound closed with two interrupted 10-0 nylon sutures. Graft host junction integrity is maintained. Ensure 1. Good intraoperative corneal visibility, 2. Avoid graft host junction for main port incision 3. Generous dispersive viscoelastic use/soft shell technique to protect the corneal endothelium, 4. Avoid phaco energy in case of soft cataracts/low phaco energy and flow rates, 5. Phaco probe to be meticulously oriented away from corneal endothelium, 6. Primary posterior capsulorhexis to be done as in any pediatric cataract surgery, 7. Make sure of the graft host junction integrity at the end of the surgery, 8. Restrict to a single port whenever possible. https://youtu.be/tu4R5JangYs.

Assessing the validity of flap motility sign in predicting the extent of anterior capsular tears in phacoemulsification.

Capsulorhexis is an integral step of cataract surgery, and continuous curvilinear capsulorhexis is crucial during phacoemulsification to prevent intraoperative complications. However, sometimes during phacoemulsification in complicated and hard cataract cases, rhexis extension may occur, resulting in posterior capsular rent, nucleus drop, cortex drop, and aphakia. It may not always be possible to continue with phacoemulsification in all cases. In this perspective, the authors describe a novel flap motility sign (FMS) to predict the extent of anterior capsular tear during phacoemulsification. A total of 21,678 patients underwent phacoemulsification for three years, from July 2016 to June 2019. One hundred and twenty-one patients had an anterior capsular tear. There were 102 cases (84.3%) with pre-equatorial tears and 19 cases (15.70%) with postequatorial tears. All pre-equatorial flaps were everted and fluttering, and all postequatorial flaps were inverted and nonfluttering. Posterior capsule rupture (PCR) was observed in all 19 cases of postequatorial flaps (100%). No PCR was observed in patients with fluttering and everted flaps (0%). In-the-bag and scleral-fixated intraocular lens implantations succeeded in pre-equatorial and postequatorial tears, respectively. There was no case of a nucleus drop. This study validates FMS as a predictor for identifying the extent of anterior capsular tears, thereby determining the endpoint of safe phacoemulsification and the site for intraocular lens implantation. Pre-equatorial tears allow for the continuation of safe phacoemulsification and in-the-bag intraocular implantation. Postequatorial tears necessitate timely conversion to small-incision cataract surgery or extracapsular cataract extraction.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Evaluation of continuous curvilinear capsulorhexis based on a neural-network.

Continuous curvilinear capsulorhexis (CCC), as a prerequisite for successful cataract surgery, is one of the most important and difficult steps in phacoemulsification. In clinical practice, the size and circularity of the capsular tear and eccentricity with the lens are often employed as indicators to evaluate the effect of CCC. We present a neural network-based model to improve the efficiency and accuracy of evaluation for capsulorhexis results. The capsulorhexis results evaluation model consists of the detection network based on U-Net and the nonlinear fitter built from fully connected layers. The detection network is responsible for detecting the positions of the round capsular tear and lens margin, and the nonlinear fitter is utilized to fit the outputs of the detection network and to compute the capsulorhexis results evaluation indicators. We evaluate the proposed model on an artificial eye phantom and compare its performance with the medical evaluation method. The experimental results show that the average detection error of the proposed evaluation model is within 0.04mm. Compared with the medical method (the average detection error is 0.28mm), the detection accuracy of the proposed evaluation model is more accurate and stable. We propose a neural network-based capsulorhexis results evaluation model to improve the accuracy of evaluation for capsulorhexis results. The results of the evaluation experiments show that the proposed results evaluation model evaluates of the effect of capsulorhexis better than the medical evaluation method.

Relationship between anterior capsule opening and direction of intraocular lens decentration.

To compare intraocular lens (IOL) decentration between patients in whom the continuous curvilinear capsulorhexis (CCC) completely covers the IOL optic and those in whom it incompletely covers the IOL optic and determine how an incompletely covered CCC affects the IOL position. A tertiary hospital in Japan. Single-center retrospective study. This study included 57 eyes of 57 patients (mean age 70.8±6.2 years) that underwent phacoemulsification and IOL (SN60WF; Alcon Laboratories, Fort Worth, TX) implantation in the bag between April 2010 and April 2015. The patients were classified based on whether the CCC completely (CC group) or incompletely (NCC group) covered the IOL optic using an anterior eye segment analysis system (EAS-1000; NIDEK, Gamagori, Japan). The IOL decentration of the groups was analyzed using EAS-1000 at 1 week, 1 month, 3 months, and 6 months postoperatively and compared. The relationship between the NCC location and IOL direction at 3 months postoperatively was analyzed. The NCC group (25 eyes) had a significantly higher amount of IOL decentration than the CC group (32 eyes) at 1 week, 1 month, 3 months, and 6 months postoperatively (P < .05). There was a correlation between the direction of IOL decentration and NCC location, and IOL decentration in the NCC group occurred in the opposite direction to the NCC area. An anterior capsule opening that completely covers the IOL optic is important to control IOL decentration.

Posterior Capsular Contraction after Cataract Surgery: A Posterior Capsular Phimosis?

A 56-year-old female underwent cataract extraction in his right eye by phacoemulsification through a continuous curvilinear capsulorhexis, complicated by a posterior rupture, managed and followed by in-the bag lens implantation without complications.

30G needle aspiration - A modified technique of capsulorhexis in pediatric cataract with high intra-lenticular pressure.

This surgical technique describes a modification of the continuous curvilinear capsulorhexis (CCC) to achieve an adequate-sized capsulorhexis in pediatric cataracts with high intralenticular pressure. Performing CCC in pediatric cataracts is challenging, especially when the intralenticular pressure is high. This technique involves 30 G needle decompression of the lens to reduce positive intralenticular pressure and subsequent flattening of the anterior capsule. This minimizes the chances of extension of CCC without using any special equipment. This technique was used in two eyes of two patients (age 8 and 10 years) with unilateral developmental cataracts. Both surgeries were performed by a single surgeon (PKM). In both eyes, a well-centered CCC was achieved with no extension, and a posterior chamber intraocular lens (IOL) was placed in the capsular bag. Thus, our technique of 30 G needle aspiration could be extremely useful to achieve an adequately sized CCC in pediatric cataracts with high intralenticular pressure, especially for beginner surgeons.

A safe and successful capsulorhexis technique for the intumescent cataracts; modified two-stage continuous curvilinear capsulorhexis

BackgroundCapsulorhexis is the most important step in intumescent cataract due to the high risk of radial extension of the capsular tear during the cataract surgery. The aim of this study is to present modified the two-stage capsulorhexis technique for intumescent cataract.Materials and methodsThe two-stage capsulorhexis technique was used in this study. A small size capsulorhexis approximately 1.5-2 mm diameter was created in the first stage. Liquefied cortex was aspirated with a 25 G cannula to equalize anterior chamber pressure and intracapsular pressure after the small size capsulorhexis. In the second stage, a 5–6 mm capsulorhexis size was performed for a safe phacoemulsification.ResultsA total of 73 consecutive patients with intumescent cataract were evaluated in this study. There were 39 male cases and 34 female cases. Mean age was 66 years ± 8 (between 53 and 84 years). A well centered complete continuous curvilinear capsulorhexis approximately 5–6 mm size was achieved in 72 of 73 cases (98.6%). Peripheral extension of capsulorhexis occurred in one eye during the second stage capsulorhexis. In this case, the capsule was cut with Vannas scissors and the capsulorhexis was completed. The rest of surgery was continued with a standard procedure and in-the-bag IOL implantation was done.ConclusionsThis technique facilitates the creation of a safe capsulorhexis compared to the one-stage capsulorhexis technique. Surgeons may consider this technique to perform a safe phacoemulsification in the intumescent cataracts.

Capsular Bag Distension Syndrome after Uneventful DMEK for Fuchs Corneal Endothelial Dystrophy

Capsular bag distension syndrome (CBDS), or capsular block syndrome, is a rare complication (< 1%) following cataract surgery with continuous curvilinear capsulorhexis, phacoemulsification, and intraocular lens (IOL) implantation in the capsular bag. It is characterized by accumulation of cloudy fluid between the IOL and the posterior lens capsule. The signs or symptoms can develop in the early or late postoperative period and have been reported even 20 years after cataract surgery [1]. The entrapped fluid leads to poor visual acuity. A myopic refractive shift in 80% of patients and hyperopic shift in 20% of patients have been reported [2]. In some cases, elevation of intraocular pressure (IOP) has been described.

Intraocular Lens Tilt and Decentration after Cataract Surgery with and without Primary Posterior Continuous Curvilinear Capsulorrhexis.

To evaluate intraocular lens (IOL) tilt and decentration and their effects on high-order aberrations (HOAs) after cataract surgery with and without primary posterior continuous curvilinear capsulorrhexis (PPCCC). Fujian Provincial Hospital, Fujian, China. Prospective, intraindividual, randomized, comparative clinical trial. This study enrolled 64 eyes of 32 patients with age-related cataract who underwent bilateral cataract surgery and IOL implantation. In randomized order, all patients had phacoemulsification cataract surgery with PPCCC in one eye (PPCCC group) and routine cataract surgery in the contralateral eye (NPCCC group). IOL decentration, tilt, HOAs, modulation transfer function, and point spread function were measured at 1 day, 1 week, 1 month, and 3 months after surgery using OPD-Scan III. 52 eyes of 26 patients were available for analysis. The mean overall decentration in NPCCC group was significantly higher than in PPCCC group at 3 months (0.302±0.157 mm vs 0.187±0.099 mm, P<0.001). Under 3-mm pupil, internal spherical aberration (SA) 1 day after surgery, and coma 1 week after surgery were lower in PPCCC group compared with NPCCC group (0.15±0.10 μm vs 0.30±0.21 μm, P<0.001, and 0.34±0.18 μm vs 0.47±0.31 μm, P=0.03, respectively). IOL decentration was significantly correlated with ocular and internal coma, ocular and internal SA, and internal HOAs at 5-mm pupil (R=0.083 and R=0.099, R=0.650 and R=0.613, R=0.418, respectively, all P<0.01). Less IOL decentration was observed in PPCCC group at 3 months after surgery, indicating that PPCCC may result in better IOL centrality.

Safety of the bag-in-the-lens implantation regarding the development of clinically significant pseudophakic cystoid macular edema: A retrospective case series study.

To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the 'bag-in-the-lens' lens (BIL) implantation technique and to examine the influence of associated risk factors for clinically significant pseudophakic macular edema (CSPME), both ocular and systemic. This retrospective study included 2419 first-operated eyes of 2419 adults who underwent phacoemulsification cataract surgery using the BIL implantation technique between January 2013 and December 2018 in the Antwerp University Hospital, Belgium. The significance of several risk factors (age, gender, previous history, intra- and postoperative complications) was examined by extraction of electronic medical files. The 3-month incidence of CSPME in the subgroup without risk factors was 0.00% (95% CI: 0.00 -NA). The 3-month incidence of CSPME in the subgroup with risk factors was 0.57% (95% CI 0.22-1.29%). The 3-month incidence of CSPME in the total population of 2419 patients was 0.29% (95% CI: 0.11-0.65%). The risk factors most significantly associated with CSPME included renal insufficiency (hazard ration [HR]: 5.42; 95% CI: 1.69-17.44; P = .014), exudative age-related macular degeneration (HR: 74.50, 95% CI: 25.75-215.6; P < .001) and retinal vein occlusion (HR: 22.48, 95% CI: 4.55-111.02; P = .005). In the absence of risk factors, the incidence of CSPME was zero. We can conclude that Primary Posterior Continuous Curvilinear Capsulorhexis (PPCCC) does not increase the risk for CSPME. Non-inferiority of the BIL implantation regarding the development of CSPME, relative to the traditional 'lens-in-the-bag' (LIB) implantation, confirms that BIL is a safe surgical technique. This study also illustrates a previously undescribed risk factor for developing CSPME, namely renal insufficiency.

To study the learning curve of capsulorhexis in manual small incision cataract surgery among postgraduate residents in central India.

To evaluate the learning curve of continuous curvilinear capsulorhexis (CCC) and to assess the number of surgeries required to master it among residents in a postgraduate teaching institute. The present prospective observational study was based on the completion time and complication rates related to CCC performed using various techniques by 10 students in the 2nd (JR2) and 3rd-year (JR3) of residency. CCC was performed either by a cystotome or capsulorhexis forceps or by a combined method in 253 eyes, of which 160 eyes (63.2%) were operated by JR3 and 93 (36.8%) by JR2. The complication rates were studied with respect to the number of capsular extensions, posterior capsular rent (PCR), zonular dehiscence, need for senior surgical assistance, and nucleus drop. The average time required for the completion of CCC was 412 ± 90.5 s. The average number of times residents required to fill the anterior chamber with viscoelastic was 6.9 ± 1.4. The average size of CCC was 7 ± 0.66 mm. Extended CCC was the most common complication. JR2 required assistance from a senior surgeon in 47 eyes (50.5%), whereas JR3 required assistance in 39 eyes (24.4%) (P = 0.0001). The rate of PCR was not significantly different in JR2 (7.5%) and JR3 (8.8%). CCC is a difficult step to master in the trainee. Focusing and practicing on this step will help to reduce the complications and maximize proficiency. Approximately 6-eight surgeries are required to master CCC.