Anterior zonulotomy: Rescue technique for capsulorhexis tear-out

Continuous Curvilinear Capsulorhexis - A Practical Review

BACKGROUND

Continuous curvilinear capsulorhexis (CCC) has become the gold standard technique for anterior capsulotomy, a cardinal development in modern cataract surgery. CCC enables safer and relatively convenient access to the crystalline lens, however it is more challenging to master than older methods. Understanding the physics underlying this procedure is key to achieving the desired results and avoiding complications.

PURPOSE

To review and present the established information about CCC, and to create a practical guide to this important step in cataract surgery.

METHODS

A literature review was conducted using PubMed, Embase, Cochrane and Scopus databases, with emphasis on up-to-date information. The first part of this review describes the evolution of CCC and discusses the different approaches, the various instruments available, tips and pearls and the general setup for best results. The second half covers more recent innovations and common complications, and strategies to prevent or manage them. This paper provides a practical review of all aspects of CCC.

Phacoemulsification in eyes with long anterior zonules

PURPOSE

To study the safety of phacoemulsification in eyes with long anterior zonules (LAZs).

SETTING

Institute.

DESIGN

Retrospective interventional case series.

METHODS

All patients with clinically proven LAZs who had undergone phacoemulsification by a single surgeon from January 2014 to December 2018 were included. All cases of LAZs with cataract extraction by procedures other than phacoemulsification or combined with any other ocular surgery were excluded. Sixty-five eyes of 52 patients were analyzed. Phacoemulsification with capsulorhexis that involves sacrificing the LAZs was performed. The primary outcome measures were the incidence of capsulorhexis extension or the need to rescue intraoperatively and the rate of intraoperative complications. Secondary outcomes assessed were the percentage of eyes within ±0.5 diopters (D) and ±1 D of the target refraction.

RESULTS

Sixty-five eyes (52 patients) were analyzed; the mean age of patients was 67.3 ± 7.4 years. The successful completion of an adequately sized capsulorhexis without extension or rescue was seen in 100% of cases. The incidence of intraoperative complications was 1.5% (posterior capsular rupture in 1 eye). The mean postoperative corrected distance visual acuity was 0.05 ± 0.1 (logarithm of the minimum angle of resolution) at a mean of 26.8 ± 7.6 days. The mean spherical equivalent was -0.15 ± 0.7 D. Eyes within ±0.5 D and ±1.00 D of the target refraction were 77% and 94%, respectively.

CONCLUSIONS

Phacoemulsification in eyes with LAZs can be safely performed through an adequately sized capsulorhexis by sacrificing, ie, cutting or breaking, the anteriorly inserted zonules 360 degrees without significant intraoperative complications.

Techniques of anterior capsulotomy in cataract surgery

Optimal outcomes of a cataract surgery largely depend on the successful performance of an anterior capsulotomy. It is one of the most important steps of modern cataract surgery which reduces the risk of capsular tears and ensures postoperative stable intraocular lens (IOL). Anterior capsulotomy is considered ideal if it is round, continuous, well-centered, and overlaps the implanted IOL around its circumference. If any of these features is missing, it can be a cause of impedance for desired surgical and visual outcomes. Manual can opener and manual capsulorhexis are the routine standard techniques employed for manual extracapsular cataract extraction and phacoemulsification, respectively. Recent increasing use of femtosecond laser cataract surgery has allowed cataract surgeons to obviate inherent inaccuracies of manual anterior capsulotomy techniques. There is an ongoing quest to find an ideal, risk free, and surgeon-friendly technique of anterior capsulotomy that can be employed for surgery in all types of cataracts.

Visual and refractive outcomes following management of anterior capsular tears with a capsulorrhexis relaxing incision

OBJECTIVE

To evaluate the refractive outcomes after anterior capsular tear (ACT).

DESIGN

Retrospective case-control study.

PARTICIPANTS

After ethics approval, the surgical operative records of 4301 consecutive patients undergoing cataract surgery by a single surgeon were reviewed for cases of ACT.

METHODS

All ACTs were managed using a balancing incision of the capsulorrhexis margin 180 degrees away from the tear. If the patient's other eye had undergone cataract surgery by the same surgeon, it was included as a control.

RESULTS

Fifty-one eyes of 51 patients were complicated by ACT (incidence = 1.2%). The mean age of patients in the study was 64.2 ± 12.1 years. Of the 51 patients with ACT, 34 underwent contralateral surgery. These eyes were used as the control group. There was no significant difference in preoperative visual acuity (p = 0.683) or proportion of eyes that received in-the-bag intraocular lens placement (p = 0.347) between groups (ACT = 92.2%; control = 97.1%). In 3 ACT eyes, the tear extended into the posterior capsule (5.9%), and although this did not occur in control eyes, this difference was not statistically significant (p = 0.150). There was no difference in best-corrected final logMAR visual acuity between groups (p = 0.424) or postoperative spherical equivalent between ACT (-0.23 ± 1.2D) and control (-0.15 ± 0.62D) eyes (p = 0.985).

CONCLUSIONS

Cataract extraction complicated by ACT can result in equivalent visual and refractive outcomes as in uncomplicated surgery. The technique used in this study prevented extension of ACT to the posterior capsule in 94.1% of cases.

Flap motility as a sign of posterior capsule rupture in peripherally extended anterior capsular tears

Purpose

To describe various types of anterior capsular tears and an early diagnostic, flap motility, as a sign of posterior capsular rupture following posterior extension of radial tears.

Design

This was a prospective study carried out in 4,331 eyes that underwent phacoemulsification in a private practice setting from April 2015 to February 2016. Twenty six consecutive cases of anterior capsular tears were included. Morphological features of anterior capsular tears and resultant complications were evaluated. Parameters studied were surgical step during which the tear occurred, shape of tear, its extension in relation to the equator, and flap nature and motility in tear extending up to equator.

Main outcome measures

The main outcome measures were motility and nature of flaps in anterior capsular radial tears and the relation to posterior capsule rupture.

Results

Based on shape, extent, and angulation, anterior capsular tears were categorized into 5 types: Type I, pre-equatorial radial tear (26.92%); Type II, post-equatorial radial tear (3.85%); Type III, Argentinean flag sign pre-equatorial tear (57.69%); Type IV, Argentinean flag sign post-equatorial tear (7.69%), and Type V, mini punch (3.85%). Flaps were either seen to be everted and fluttering or inverted and non-fluttering. In all cases with everted fluttering flaps no posterior capsular rupture (PCR) was observed, while in cases with inverted non-fluttering flaps a PCR was observed (p<0.05).

Conclusion

Everted and fluttering flaps of the anterior capsular tears indicate pre-equatorial tear, while inverted and non-fluttering flaps indicate posterior capsule rupture following tear extension beyond the equator.

Intraoperative management of anterior capsular tear

PURPOSE OF REVIEW

The article reviews the current literature on intraoperative techniques to properly manage anterior capsular tears during cataract surgery.

RECENT FINDINGS

Femtosecond laser-assisted cataract surgery creates a more consistent capsulorhexis than traditional capsulotomies, but can also present with new challenges. Irregularities, like microadhesions and tags, can lead to anterior tears if not properly treated. New technology, like the Zepto (Mynosys, Fremont, CA, USA) pulse precision capsulotomy, may produce a smoother edge and reduce the incidence of capsular tears. However, there are novel rescue techniques in the case that a tear-out does occur.

SUMMARY

Anterior capsular tears can occur at any stage of cataract surgery. The proper management of these tears will prevent them from extending into the posterior capsule and compromising the structural integrity of the capsular bag. This is essential for endocapsular placement of artificial lenses and for optimal visual outcomes for the patient.