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LoBue SA, Rizzuti AE, Martin CR, Albear SA, Gill ES, Shelby CL, Coleman WT, Smith EF. Preventing the Argentinian flag sign and managing anterior capsular tears: A review. Indian J Ophthalmol 2024; 72:162-173. [PMID: 38273682 PMCID: PMC10941923 DOI: 10.4103/ijo.ijo_1418_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/09/2023] [Accepted: 10/25/2023] [Indexed: 01/27/2024] Open
Abstract
The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.
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Affiliation(s)
- Stephen A LoBue
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, Willis-Knighton Medical Center, Shreveport, LA, USA
| | - Allison E Rizzuti
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Curtis R Martin
- Department of Ophthalmology, Willis-Knighton Medical Center, Shreveport, LA, USA
| | - Sinan A Albear
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Ekjyot S Gill
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, UCLA Stein Eye Institute, Los Angeles, CA, USA
| | - Christopher L Shelby
- Department of Ophthalmology, Willis-Knighton Medical Center, Shreveport, LA, USA
| | - Wyche T Coleman
- Department of Ophthalmology, Willis-Knighton Medical Center, Shreveport, LA, USA
| | - Edward F Smith
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Abbas AA, Bu JJ, Chung J, Afshari NA. Recent developments in anterior capsulotomy for cataract surgery. Curr Opin Ophthalmol 2022; 33:47-52. [PMID: 34854828 DOI: 10.1097/icu.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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. SUMMARY 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.
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Affiliation(s)
- Anser A Abbas
- Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Jennifer J Bu
- Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
| | - Jinkwon Chung
- Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
- Department of Ophthalmology, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Natalie A Afshari
- Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California, USA
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An JH, Jun JH. Thermal Profile of Pulse Precision Capsulotomy: In vivo and in vitro Infrared Thermography Study. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:429-437. [PMID: 34488257 PMCID: PMC8666254 DOI: 10.3341/kjo.2021.0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to elucidate the thermal safety of precision pulse capsulotomy (PPC) via in vivo and in vitro evaluation of the thermal profile using infrared thermography. Methods This prospective observational study enrolled 15 eyes from 15 participants who underwent cataract surgery using the Zepto PPC. All patients underwent temperature measurements of the incision site and the entire cornea using an infrared thermographer during the capsulotomy procedure. To accurately analyze the temperature change of the Zepto PPC, infrared thermography was performed with the Zepto handpiece while exposed to air and then in porcine eyes. Moreover, in each case, the difference in temperature change according to the use of an ophthalmic viscosurgical device (OVD) was also checked to determine the temperature buffering effect. Results In the clinical evaluations, the mean temperature elevation around the corneal incision and time duration from baseline to peak temperature during the Zepto capsulotomy were 4.0 ± 1.9℃ and 4.43 ± 1.26 s, respectively, with a mean peak temperature of 32.6 ± 2.0℃. The mean peak temperature and rise time of the naïve Zepto nitinol ring, as measured from the bottom side, were 109.0 ± 22.9℃ and 43.40 ± 11.06 s in the experimental procedures, respectively. In the porcine eyes, the mean elevation of temperature and rise time of the Zepto nitinol ring were 6.2 ± 1.6℃ and 11.67 ± 2.08 s with the use of OVDs, and 10.5 ± 3.3℃ and 14.00 ± 3.61 s without OVDs, respectively. Conclusions Zepto PPC has the potential to generate extremely high thermal energy, according to an in vitro study. However, the temperature rise of the Zepto capsulotomy can be minimized by using OVDs.
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Affiliation(s)
- Jae-Hong An
- Department of Ophthalmology, Keimyung University School of Medicine, Daegu, Korea
| | - Jong-Hwa Jun
- Department of Ophthalmology, Keimyung University School of Medicine, Daegu, Korea
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Precision Pulse Capsulotomy During Combined Penetrating Keratoplasty With Cataract Surgery and Intraocular Lens in Small Nondilating Pupil. Eye Contact Lens 2021; 47:219-222. [PMID: 33734128 DOI: 10.1097/icl.0000000000000734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate precision pulse capsulotomy (PPC) in an open-sky procedure and to evaluate its use during triple procedure keratoplasty in small nondilating pupils. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Factors Affecting Posterior Capsule Opacification in the Development of Intraocular Lens Materials. Pharmaceutics 2021; 13:pharmaceutics13060860. [PMID: 34200928 PMCID: PMC8230425 DOI: 10.3390/pharmaceutics13060860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023] Open
Abstract
Posterior capsule opacification (PCO) is the most common complication arising from the corrective surgery used to treat cataract patients. PCO arises when lens epithelial cells (LEC) residing in the capsular bag post-surgery undergo hyper-proliferation and transdifferentiation into myofibroblasts, migrating from the posterior capsule over the visual axis of the newly implanted intraocular lens (IOL). The developmental pathways underlying PCO are yet to be fully understood and the current literature is contradictory regarding the impact of the recognised risk factors of PCO. The aim of this review is firstly to collate the known biochemical pathways that lead to PCO development, providing an up-to-date chronological overview from surgery to established PCO formation. Secondly, the risk factors of PCO are evaluated, focussing on the impact of IOLs’ properties. Finally, the latest experimental model designs used in PCO research are discussed to demonstrate the ongoing development of clinical PCO models, the efficacy of newly developed IOL technology, and potential therapeutic interventions. This review will contribute to current PCO literature by presenting an updated overview of the known developmental pathways of PCO, an evaluation of the impact of the risk factors underlying its development, and the latest experimental models used to investigate PCO. Furthermore, the review should provide developmental routes for research into the investigation of potential therapeutic interventions and improvements in IOL design in the aid of preventing PCO for new and existing patients.
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Reddy JC, Devta S, Vupparaboina KK, Ali MH, Vaddavalli PK. Early results of circularity and centration of capsulotomy prepared by three different methods. Int J Ophthalmol 2021; 14:76-82. [PMID: 33469487 DOI: 10.18240/ijo.2021.01.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/12/2020] [Indexed: 01/19/2023] Open
Abstract
AIM To compare the difference of capsulotomy produced by precision pulse capsulotomy (PPC), manual (M-CCC), and femtosecond laser assisted capsulotomy (FLAC) in relation to intraocular lens (IOL) centration, circularity and its effect on visual outcomes. METHODS Prospective, non-randomized comparative study conducted at LV Prasad Eye Institute, Hyderabad, India. Sixty eyes of 52 patients were grouped into 3 (FLAC, PPC and M-CCC) based on capsulotomy techniques used. Twenty consecutive eyes with uneventful phacoemulsification and with no comorbidities affecting the capsulotomy or visual outcome were included in each group. The main outcome measure was IOL centration in relation to capsulotomy and pupil. Secondary outcome measures were post-operative visual acuity, manifest refraction and aberration profile between groups. RESULTS At 5wk the visual, refractive outcomes and endothelial cell density were comparable between the 3 groups. The median circularity index of FLAC was statistically significantly different to M-CCC or PPC (1-10) groups (P<0.01) but PPC (11-20) was comparable to FLAC. Decentration of IOL center in relation to capsulotomy was seen only between the PPC (1-10) group and FLAC group (P=0.02). The IOL was well centered in relation to the pupil in all the groups (P=0.46). The quality of vision parameters like the higher order aberrations, spherical aberration, coma, trefoil, modular transfer function, and Strehl ratio were comparable between the groups. CONCLUSION Our study shows that despite differences in the morphology of capsulotomy produced by PPC, M-CCC, FLAC a well-centered IOL can be achieved. The measured capsular morphology parameters do not affect visual outcomes.
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Affiliation(s)
- Jagadesh C Reddy
- Cataract and Refractive Services, Cornea Institute, L V Prasad Eye Institute (LVPEI), Hyderabad 500034, India
| | - Soumya Devta
- Cataract and Refractive Services, Cornea Institute, L V Prasad Eye Institute (LVPEI), Hyderabad 500034, India
| | - Kiran Kumar Vupparaboina
- Senior Scientific Officer, Srujana Centre for Innovation, L V Prasad Eye Institute (LVPEI), Hyderabad 500034, India
| | - Mohammad Hasnat Ali
- Biostatistician, Clinical Epidemiology and Biostatistics, L V Prasad Eye Institute (LVPEI), Hyderabad 500034, India
| | - Pravin K Vaddavalli
- Cataract and Refractive Services, Cornea Institute, L V Prasad Eye Institute (LVPEI), Hyderabad 500034, India
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Bang SP, Jun JH. Comparison of postoperative axial stability of intraocular lens and capsulotomy parameters between precision pulse capsulotomy and continuous curvilinear capsulotomy: A prospective cohort study. Medicine (Baltimore) 2019; 98:e18224. [PMID: 31770285 PMCID: PMC6890305 DOI: 10.1097/md.0000000000018224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The aim of this study was to verify the safety and stability of precision pulse capsulotomy (PPC) by comparison of the axial stability of the intraocular lens (IOL) and the capsulotomy parameters during 6 months of follow-up after cataract surgery using PPC or the conventional method (continuous curvilinear capsulorhexis, CCC). DESIGN Prospective observational study. SETTING Tertiary referral center. SUBJECTS Fifty nine eyes of 59 candidates for cataract surgery. INTERVENTIONS PPC (33 eyes) or CCC (26 eyes). OUTCOME MEASURES The anterior capsule opacification grade and effective lens position (ELP) were measured 1 week and 1, 3, and 6 months postoperatively. RESULTS No significant difference in the mean anterior capsule opacification grade or the effective lens position was found between the PPC and CCC groups at any time point; however, the standard deviation and root mean square of the effective lens position were significantly lower in the PPC group than in the CCC group during follow-up (P = .002 and P = .011, respectively). There was a significantly lower discrepancy between the intended vs achieved capsulotomy area and better circularity in the PPC group than in the CCC group at all time points. CONCLUSIONS The overall variability in effective lens position was less when cataract surgery was performed using PPC than when performed using CCC. Circularity was better and had a more predictable size with PPC than with CCC.
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Affiliation(s)
- Seung Pil Bang
- Department of Ophthalmology, Keimyung University School of Medicine, Dongsan Medical Centre, Daegu, Republic of Korea
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
| | - Jong Hwa Jun
- Department of Ophthalmology, Keimyung University School of Medicine, Dongsan Medical Centre, Daegu, Republic of Korea
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Park MJ, Bang CW, Han SY. Precision pulse capsulotomy in challenging cataract surgery cases. Clin Ophthalmol 2019; 13:1361-1368. [PMID: 31440024 PMCID: PMC6664258 DOI: 10.2147/opth.s217919] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/02/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the use of the precision pulse capsulotomy (PPC) device for challenging cataract surgery cases. Patients and methods This 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. Results No 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. Conclusion The 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.
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Affiliation(s)
- Min Ji Park
- Department of Cornea and Refractive Surgery, Busan Sungmo Eye Hospital, Busan, Republic of Korea
| | - Chan Woo Bang
- Department of Cornea and Refractive Surgery, Busan Sungmo Eye Hospital, Busan, Republic of Korea
| | - Sang Youp Han
- Department of Cornea and Refractive Surgery, Busan Sungmo Eye Hospital, Busan, Republic of Korea
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Chougule P, Warkad V, Badakere A, Kekunnaya R. Precision pulse capsulotomy: an automated alternative to manual capsulorhexis in paediatric cataract. BMJ Open Ophthalmol 2019; 4:e000255. [PMID: 31245610 PMCID: PMC6557080 DOI: 10.1136/bmjophth-2018-000255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 03/28/2019] [Accepted: 04/21/2019] [Indexed: 11/30/2022] Open
Abstract
Objective To report our operative experience with precision pulse capsulotomy (PPC) for anterior capsulotomy in a paediatric cataract series. Methods and analysis This study is a retrospective interventional, descriptive series of consecutive paediatric eyes (≤16 years) undergoing cataract surgery using PPC. Surgical time and the time required to perform PPC was recorded. Any intraoperative and postoperative adverse events were noted. Postoperatively, visual acuity, anterior segment examination and intraocular pressure (IOP) were recorded for all children at day 1, 1 week and 1 month. Results 21 eyes of 14 patients were included in the study, with the median age at surgery of 6.0 years (IQR; 5-7.75, range=1–16 years). Male to female ratio was 11:3. 13 eyes had lamellar cataract, 3 eyes had total cataract, 2 had posterior subcapsular cataract, 2 had traumatic cataract, while 1 eye had sutural cataract. Median surgical time was 26 min (IQR 21-32) and median PPC time was 75.0 secs (IQR 56-86.5). The anterior capsulotomy was round and complete in most cases, except in one case due to faulty suction. All patients underwent a successful in the bag implantation of intraocular lens with capsulotomy margins overlapping the optic edges in 19 eyes (90%). Median PPC size was 5.54 mm (n=9, IQR 5.39 -5.75) which was slightly larger than expected. None of the cases had any intraoperative or postoperative adverse events with no radial tears of capsulotomy. Postoperatively, the mean final follow-up was 5.71+3.20 weeks. Conclusion To conclude PPC can be used as an alternative to manual continuous curvilinear capsulorhexis in paediatric cataract surgery producing round well- centred and strong capsulotomy with an easier learning curve.
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Affiliation(s)
- Pratik Chougule
- Jasti V Ramanamma Children's Eye Care Center, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Vivekanand Warkad
- Myriam Hyman Children's Eye Care Center, Child Sight Institute, LV Prasad Eye Institute, Bhubaneshwar, Odissa, India
| | - Akshay Badakere
- Jasti V Ramanamma Children's Eye Care Center, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Ramesh Kekunnaya
- Jasti V Ramanamma Children's Eye Care Center, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, Telangana, India
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Abstract
PURPOSE OF REVIEW Continuous curvilinear manual capsulorhexis is currently the standard of cataract surgery. In the past several years, new technologies have been developed to improve the consistency and safety of capsulorhexis creation. This article reviews the most recent technologies in capsulotomy formation and their advantages and disadvantages. RECENT FINDINGS Guidance devices, femtosecond laser capsulotomy and precision pulse capsulotomy improve the centration, circularity and precision of anterior capsulorhexis and capsulotomy. These developments show particular promise for complex cataract surgeries, though clinical data on the refractive outcomes and complication rates of these technologies are currently limited and warrant additional investigation. SUMMARY New technological advances in capsulorhexis help surgeons achieve a more ideal capsulotomy geometry. Whether this translates into more predictable refractive outcomes and safer surgeries remains an area of future study.
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Becker MD, Michels S, Lortz S, Kaminski S. [Precision pulse capsulotomy : The new capsulorhexis?]. Ophthalmologe 2018; 116:288-290. [PMID: 30367232 DOI: 10.1007/s00347-018-0807-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The manual capsulorhexis created by Neuhann is still the standard procedure for opening the anterior capsule for cataract surgery. A limitation is the inaccuracy in the size and placement of the opening due to manual execution. In addition to the femtosecond laser a possible improvement in the standardization of capsulorhexis is provided by the Zepto procedure (precision pulse capsulotomy, PPC). In this case a 5.25 mm rhexis is created in a standardized fashion with a flexible suction adapter in which a nitinol ring is located. Whether the strength of PPC is comparable or better than that of the manual technique and how it behaves in terms of capsule shrinkage has not yet been finally clarified.
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Affiliation(s)
- M D Becker
- Augenklinik Stadtspital Triemli, Birmensdorferstr. 497, 8063, Zürich, Schweiz.
| | - S Michels
- Augenklinik Stadtspital Triemli, Birmensdorferstr. 497, 8063, Zürich, Schweiz
| | - S Lortz
- Augenklinik Stadtspital Triemli, Birmensdorferstr. 497, 8063, Zürich, Schweiz
| | - S Kaminski
- Augenklinik Stadtspital Triemli, Birmensdorferstr. 497, 8063, Zürich, Schweiz
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Dudeja L. Commentary: Precision pulse capsulotomy: New technology for capsulorhexis. Indian J Ophthalmol 2018; 66:1276-1277. [PMID: 30127139 PMCID: PMC6113801 DOI: 10.4103/ijo.ijo_890_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Lakshey Dudeja
- Medical Officer, Cornea and Refractive Surgery, Aravind Eye Hospital, Salem, Tamil Nadu, India
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