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Purpose: To analyse the occurrence and potential causes of lens capsule-related complications during femtosecond laser-assisted cataract surgery (FLACS)., Methods: This prospective consecutive cohort study included the first 1600 eyes (from 1140 consecutive patients) who received FLACS performed by the same surgeon from May 2015 to December 2018. The potential causes and characteristic signs of capsulotomy-related complications, including incomplete capsulotomies and radial anterior capsule (AC) tears, were summarised based on the agreement of two ophthalmologists after they analysed the surgical videos. Subgroup analysis was conducted to characterise the capsulotomy learning curve., Results: Of the 1600 eyes, 52 (3.25%) had incomplete capsulotomies and 22 (1.38%) had radial AC tears. The most common causes of incomplete capsulotomies were eye tilt (16 eyes, 30.77%), air bubbles or ocular secretions at the interface (14 eyes, 26.92%) and white cataracts (7 eyes, 13.46%). Additionally, 54.55% (12/22) of AC tears were due to incomplete capsulotomy and secondary capsulorhexis. A significant difference was noted between the first 200 eyes and subsequent groups in terms of the incidence of incomplete capsulotomies. No difference was observed in the incidence of AC tears after the initial 100 procedures., Conclusion: The most common causes of incomplete capsulotomies were eye tilt and air bubbles or ocular secretions at the interface. Secondary capsulorhexis after incomplete capsulotomy is the main risk factor for AC tears. There was a steep learning curve for laser capsulotomy in the first 100 operated eyes, as evidenced by the higher complication rate, but this stabilised after 200 procedures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Anterior capsule contraction syndrome is a specific complication of continuous circular capsulorhexis in various phacoemulsification techniques. Surgical, laser and combined methods have been proposed for its treatment. All approaches in the treatment of anterior capsule contraction syndrome have some advantages, as well as certain problems and difficulties. This review presents the current state of this problem of cataract surgery and possible prospects for improving the treatment.

Purpose: To evaluate the efficacy of technique combining an anterior chamber maintainer (ACM) and spiral capsulorhexis under continuous fluid pressure in intumescent cataracts., Methods: One hundred thirty-one eyes of 128 patients who underwent phacoemulsification and IOL implantation for intumescent white cataracts without a red reflex were included in the study. Group 1 consisted of 67 eyes of 65 patients who underwent spiral capsulorhexis with an ACM under continuous fluid pressure. Group 2 consisted of 64 eyes of 63 patients who underwent capsulorhexis after injection of viscoelastic material into the anterior chamber. Both groups were compared in terms of endothelial cell loss, intraoperative and postoperative complications., Results: Progression to the periphery in the capsule not resulting in a radial tear was observed in 3 eyes in Group 1 and 11 eyes in Group 2 (P=0.019). While the type of radial tear known as the Argentinian flag sign was not observed in Group 1, it was observed in 8 eyes in Group 2 (P=0.003). Postoperative intraocular lens (IOL) decentration did not develop in any eye in group 1, but in 3 eyes in group 2 (P=0.11)., Conclusion: The combination technique of an anterior chamber maintainer and spiral capsulorhexis provides a controlled and safe capsulorhexis and reduces intraoperative and postoperative complications in intumescent cataracts., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

To explore the clinical efficacy of quadruple surgery (anterior segment pars plana vitrectomy + phacoemulsification + posterior capsulorhexis + intraocular lens (IOL) implantation + trabeculectomy) and dual surgery (phacoemulsification + IOL implantation + trabeculectomy) to treat medically uncontrolled acute primary angle-closure glaucoma (APACG). The clinical data of 44 patients (45 eyes) with APACG treated in the Department of Ophthalmology of Taihe Hospital were retrospectively analyzed. They were divided into 2 groups based on quadruple surgery and dual surgery. There were 20 patients (20 eyes) underwent quadruple surgery in group A. And there were 24 patients (25 eyes) dual surgery in group B. The changes in intraocular pressure (IOP), visual improvement, and complications were observed between the 2 groups preoperatively and 1 month, 3 months, and 6 months postoperatively. Preoperative best corrected visual acuity (BCVA) was the influencing factor of postoperative BCVA at 1 month, 3 months and 6 months. Before surgery, the mean IOP of group A was significantly higher than that of group B (P < .001), and no significant difference was found in the BCVA, age, gender, eyes, axial length (AL), anterior chamber depth (ACD) (PBCVA = 0.12, Page = 0.76, Peyes = 0.20, Pgender = 0.37, PAL = 0.94, PACD = 0.08). On comparison at postoperative 1week, there was no significant difference in the IOP and BCVA between the 2 groups (PIOP = 0.64, PBCVA = 0.66). The mean IOP of group A was significantly lower than that of group B 1 month, 3 months, and 6 months postoperatively (P1month = 0.002, P3months < 0.001, P6months < 0.001). The degree of visual acuity recovery was significantly higher in group A at 1 month, 3 months, and 6 months postoperatively (P1month = 0.03, P3months = 0.02, P6months = 0.02). During treatment, the incidence of complications in group B was significantly higher than that in group A (P < .01). The clinical efficacy of anterior segment pars plana vitrectomy combined with posterior capsulorhexis, phacoemulsification, and trabeculectomy elicits clinical safety in treating medically uncontrolled APACG. It has remarkable effects and leads to a significant decrease in the occurrence of complications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Zepto precision pulsed capsulotomy is an emerging technology aimed at providing a safer and more reproducible anterior capsulorhexis, with potential advantages in challenging cases. Initial reports suggest high safety, and thus far to our knowledge, no complications have been reported. Herein we report an unexpected complication. After the pulse delivery phase on a routine cataract case, a radial tear of the anterior capsule was observed. Upon careful review of the surgery video, an air bubble was noted, at the precise clock hour of the radial tear, trapped between the device wire and capsule. This air bubble presumably prevented the transfer of rapid phase transition at this site, interfering with capsule cleavage, and resulting in incomplete capsulotomy. Based on this observation, if a trapped air bubble is observed after the vacuum phase, we recommend applying more vacuum or disengaging and reattaching, before proceeding to the pulse delivery stage., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

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.

Purpose: Comparison of lens capsule-related complications resulting from femtosecond laser-assisted capsulotomy and manual capsulorhexis in patients with white cataracts., Setting: Eye Center, Second Affiliated Hospital, Zhejiang Medical School, Hangzhou, China., Design: Prospective consecutive nonrandomized comparative cohort study., Methods: Selected patients were divided into a femtosecond laser-assisted cataract surgery group (FLACS group) and a conventional phacoemulsification cataract surgery group (CPCS group). Each case was recorded as either a type I or type II white cataract. Here, type I was characterized by the presence of a liquefied cortex, whereas type II had a solid cortex. Five experienced phacoemulsification surgeons conducted all surgeries. Lens capsule-related events, including anterior capsule tears, posterior capsule ruptures (PCRs), incomplete capsulotomies, and irregular capsulorhexes were recorded; surgical parameters, postoperative visual acuities, and intraocular lens (IOL) decentrations were evaluated., Results: The study comprised 132 eyes of 132 patients (66 in each group). Anterior capsule tears were significantly more common in the CPCS group than the FLACS group (12.1% versus 0%). All 8 cases of anterior capsule tears were type I cases. Six FLACS cases developed incomplete capsulotomies, four of which were type I cases. The incidences of PCRs and vitreous loss were the same. Capsulotomy produced better circularity index and diameter stability than capsulorhexis. IOLs were better centered in the FLACS group than the CPCS group. The mean ultrasound power, absolute phaco time, effective phaco time, and postoperative visual acuities were similar in both groups., Conclusions: Compared with CPCS, FLACS decreased the risk for anterior capsule tears in white cataracts, especially in type I cases. However, it did not reduce the incidence of PCR. Incomplete capsulotomy during FLACS could happen in white cataracts. Using FLACS on white cataracts enabled more precise capsulotomies and better-centered IOLs., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objective To investigate the long-term safety and efficacy of Nd:YAG laser anterior capsulotomy for the treatment of anterior capsular phimosis. Methods We retrospectively analyzed a consecutive case series of Nd:YAG laser anterior capsulotomy in patients with anterior capsular phimosis, who were treated between November 2012 and April 2014. Data collected included risk factors, interval between surgery and capsulotomy, best-corrected visual acuity (BCVA), and diameter of anterior capsule opening before and after Nd:YAG laser anterior capsulotomy. Results Eleven eyes of 11 patients were included in the study. The mean follow-up time was 30.1 ± 4.5 months (range: 26-42 months). At the last follow-up, the mean diameter of the anterior capsule opening was 5.1 ± 0.2 mm, which was significantly greater than the diameter before laser capsulotomy (2.2 ± 0.8 mm). BCVA remained stable or improved in nine eyes (81.8%) following capsulotomy. No patients experienced recurrence of phimosis. Conclusions In a long-term study of >2 years, we found that Nd:YAG laser anterior capsulotomy is safe and effective for the treatment of anterior capsule phimosis.

We report a case of iatrogenic creation of an excessive anterior-to-posterior gradient in the setting of an open anterior capsule during capsulorhexis. This complication shows the inverse mechanism of that observed in the Argentinean flag sign. An excessive anterior-to-posterior gradient from an exuberant ophthalmic viscosurgical device fill of the anterior chamber caused radialization of the anterior capsule during creation of a continuous curvilinear capsulorhexis in a nonintumescent lens. We describe this complication as the reverse Argentinean flag sign., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Objective: To perform a meta-analysis on the precision and safety of femtosecond laser-assisted anterior capsulotomy versus conventional manual continuous curvilinear capsulorrhexis., Methods: This meta-analysis was conducted from February 2010 to November 2014. Literature search on PubMed, Google Scholar, ExcerptaMedica database and Cochrane Library was done to identify randomised controlled trials and case-control studies. SPSS 20 was used for data analysis., Results: Of the 10 articles included, there were 3(30%) randomised controlled trials and 7(70%) non-randomised controlled trials. The meta-analysis was based on a total of 2,882eyes. Of them, 1,498(51.97%) underwent femtosecond laser-assisted capsulotomy and 1,384(48.02%) underwent manual continuous curvilinear capsulorrhexis. The diameter of the capsulotomy and the rates of anterior capsule tear showed no statistical difference between the femtosecond laser group and the manual capsulorrhexis group (p=0.29 and p=0.68). In terms of circularity of capsulotomy, femtosecond laser group had a more significant advantage than the manual capsulorrhexis group (p<0.001)., Conclusions: Femtosecond laser performed capsulotomy with more precision and higher reliability than the manual continuous curvilinear capsulorrhexis.

We describe a unique complication during primary posterior continuous curvilinear capsulorhexis (PCCC) in a patient with megalocornea scheduled for phacoemulsification with toric multifocal intraocular lens (IOL) implantation. After nucleus emulsification and cortex removal, the capsular bag was filled with cohesive viscoelastic in preparation for PCCC to achieve reverse optic capture of the IOL, thus ensuring stability. However, as soon as the initial puncture was made using a 27-gauge needle to start the capsulotomy, the posterior capsule opening extended peripherally from 0º-180º. This capsule extension was similar to the Argentinean-flag sign in hypermature cataracts, and both are caused by excessive intracapsular pressure. Careful bimanual manipulation was performed to implant the IOL on the desired axis, which occurred uneventfully. At a postoperative visit, the patient exhibited excellent uncorrected visual acuity with a well-aligned IOL.

Objective: To assess the effect of femtosecond laser-assisted anterior capsulotomy in intumescent white cataract surgery. Methods: Retrospective case series study. One hundred and fifty cataract patients (150 eyes) from June 2014 to June 2015 in Wuhan Aier ophthalmology hospital were enrolled in this study. They were divided into three groups: 50 intumescent white cataract patients (50 eyes) in the study group were performed femtosecond laser-assisted capsulotomy (LenSx system) operation selectively. Fifty intumescent white cataract patients (50 eyes) underwent normal manual continuous circular capsulorhexis as the control group 1. Fifty other types cataract patients (50 eyes) underwent femtosecond laser-assisted capsulotomy as the control group 2. To observe the complications such as radial tear in anterior capsule, posterior capsule rupture and vitreous prolapse occurred during operations in each group respectively. The microscopic images of the free anterior capsule after dyeing were observed in the studygroup and the control group 2. Using the German company Oculus Pentacam three-dimensional anterior eye segment system to collect the Scheimplug images of each group at 1, 3, 6 months and 1 year after operation. The data were analyzed by SPSS19.0 software package. Complications during operations in all groups were compared with Fisher exact test. The eccentricity and tilt of IOL in each group were analyzed by single factor analysis of variance. The SNK-q test was used to compare the different follow-up time groups. Results: One hundred and fifty patients aged from 50 to 86 years old, including 72 male cases and 78 female cases. In study group, radial tear in anterior capsule occurred in 2 eyes (4%), adherent tongue-like capsule adhesion was found in 6 eyes (12%), incomplete capsulotomy button happened in 2 eyes (4%), and posterior capsule rupture and vitreous prolapse occurred in 1 eye (2%). In the control group 1, radial tear in anterior capsule occurred in 8 eyes (16%) and posterior capsule rupture and vitreous prolapse occurred in 3 eyes (6%). The cases number of radial tear in anterior capsule and posterior capsule rupture and vitreous prolapse in the study group was obviously lower than the control group 1. The difference was statistically significant ( P< 0.05). In the control group 2, all 50 eyes were successfully completed. The implantation was uneventful and the IOL was centered. And posterior capsular rupture and vitreous prolapse did not occur. The difference was statistically significant between the study group and the control group 2 ( P< 0.05). After 1 year follow-up, the study group and the control group 2 showed no significant IOL tilt and eccentricity. The eccentricity and tilt of IOL in horizontal and vertical direction in control group 1 were significantly higher than those in the study group ( F was 2.31, 1.10, 2.78 and 2.90 respectively) and control group 2 ( F was 2.50, 2.32, 2.56 and 2.18respectively). The difference was statistically significant ( P< 0.05). Conclusions: Femtosecond laser-assisted anterior capsulotomy is accurate circle and center to avoid IOL eccentricity and tilt caused by capsular bag contraction asymmetrically after implantation, so as to ensure the long-term stability of the visual quality postoperatively. (Chin J Ophthalmol, 2017, 53: 281-287) .

This is a review of the literature on capsule contraction syndrome (CCS) in pseudophakic patients that involves severe fibrosis along the margin of the anterior capsule's opening and progressive contraction of the capsular bag. Possible causes of CCS and principles of its prevention and treatment have been analyzed.

This paper reviews studies on biomechanical properties of the anterior lens capsule. Early experiments in this field were more fundamental. Later studies were aimed mainly at assessing the mechanical stability of the capsule edge after manual or femtosecond laser capsulorhexis (capsulotomy) - an important step in modern minimally invasive phaco surgery. For biomechanical tests, ex vivo samples of human and animal anterior capsules were used. The results of the studies presented here are quite heterogeneous, which suggests the necessity of gaining further insight into the issue.

Purpose: To describe the tearing pattern during continuous curvilinear capsulorhexis in a patient with anterior lenticonus due to Alport syndrome., Methods: A patient with bilateral anterior lenticonus underwent successful bilateral phacoemulsification and implantation of a single-piece intraocular lens., Results: The capsule tore in an atypical cogwheel-like tearing pattern during capsulorhexis. This tearing pattern likely correlates to the known ultrastructural characteristics of thinning and periodic dehiscence and breaks in the anterior capsule., Conclusions: Knowing this tearing pattern preoperatively can help to prevent capsule runoff and capsule rupture.

Unlabelled: An anterior zonulotomy technique to rescue a capsulorhexis tear-out is described. The technique uses microsurgical instruments that are capable of performing microprocedures within the confines of the anterior chamber. The anterior zonulotomy releases the tractional impediment caused by the anterior zonular fibers, enabling the surgeon to use conventional rescue methods to redirect the CCC centrally. The technique demonstrates how microsurgical instruments can be used to safely perform an anterior zonulotomy for radial tear-outs that have become lodged in the zonular fibers., Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Capsule tear-out in hypermature cataracts (Argentinean flag sign) is a common and frustrating complication during the creation of a capsulorhexis. Completing the capsulorhexis through a small side-port incision, filling the anterior chamber with a highly viscous ophthalmic viscosurgical device such as a viscoadaptive agent, and using a 23- or 25-gauge microcapsulorhexis forceps to fill the side-port incision can reliably prevent this complication., Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Posterior capsule opacification (PCO) is a vision impairing condition that arises in some patients following cataract surgery. The fibrotic form of PCO is caused by myofibroblasts that may emerge in the lens years after surgery. In the chick embryo lens, myofibroblasts are derived from Myo/Nog cells that are identified by their expression of the skeletal muscle specific transcription factor MyoD, the bone morphogenetic protein inhibitor Noggin, and the epitope recognized by the G8 monoclonal antibody. The goal of this study was to test the hypothesis that depletion of Myo/Nog cells will prevent the accumulation of myofibroblasts in human lens tissue. Myo/Nog cells were present in anterior, equatorial and bow regions of the human lens, cornea and ciliary processes. In anterior lens tissue removed by capsulorhexis, Myo/Nog cells had synthesized myofibroblast and skeletal muscle proteins, including vimentin, MyoD and sarcomeric myosin. Alpha smooth muscle actin (α-SMA) was detected in a subpopulation of Myo/Nog cells. Areas of the capsule denuded of epithelial cells were surrounded by Myo/Nog cells. Some of these cell free areas contained a wrinkle in the capsule. Depletion of Myo/Nog cells eliminated cells expressing skeletal muscle proteins in 5-day cultures but did not affect cells immunoreactive for beaded filament proteins that accumulate in differentiating lens epithelial cells. Transforming growth factor-betas 1 and 2 that mediate an epithelial-mesenchymal transition, did not induce the expression of skeletal muscle proteins in lens cells following Myo/Nog cell depletion. This study demonstrates that Myo/Nog cells in anterior lens tissue removed from cataract patients have undergone a partial differentiation to skeletal muscle. Myo/Nog cells appear to be the source of skeletal muscle-like cells in explants of human lens tissue. Targeting Myo/Nog cells with the G8 antibody during cataract surgery may reduce the incidence of PCO.

Purpose: To evaluate and compare the effects of femtosecond laser-assisted anterior capsulotomy and manual anterior capsulorhexis on posterior capsule opacification (PCO) development., Methods: Femtosecond laser-assisted anterior capsulotomy was performed in 40 eyes of 40 patients (FS group) and manual anterior capsulorhexis was performed in 39 eyes of 39 patients (CCC group). An AcrySof one-piece hydrophobic acrylic intraocular lens (Alcon Laboratories, Inc., Fort Worth, TX) was implanted in all eyes. The PCO level was measured using Open-Access Systematic Capsule Assessment (OSCA) software 18 to 26 months after surgery. Postoperative intraocular lens position (ie, tilt and decentration) was measured using Scheimpflug images (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany)., Results: There was no statistically significant difference in age, axial length, and follow-up time between the two groups (P > .05). Vertical tilt, horizontal and total decentration of intraocular lenses, and PCO proved to be significantly higher in the CCC group (P = .03, .04, .03, and .01, respectively). After adjusting for axial length and follow-up time, manual anterior capsulorhexis was found to be a significant predictor of higher PCO scores in the multivariable regression model (β: 0.33; 95% CI: 0.01 to 0.65; P = .04). Vertical tilt affected PCO scores after adjusting for axial length and follow-up time (β: 0.07; 95% CI: 0.01 to 0.12; P = .02). No capsulotomies were performed during follow-up in either group., Conclusions: Femtosecond laser-assisted anterior capsulotomy proved to be a safe procedure for postoperative PCO rates. Due to better intraocular lens position, femtosecond laser-assisted anterior capsulotomy resulted in slightly decreased PCO scores; however, evaluating its clinical significance requires further studies., (Copyright 2014, SLACK Incorporated.)

Capsular bag distension syndrome is a very rare complication of cataract surgery. Most cases occur after uneventful phacoemulsification with continuous curvilinear capsulorhexis and implantation of an intraocular lens in the capsular bag. The entity presents with reduction of visual acuity and myopic shift in the early-to-late postoperative period. Characteristic findings include the distension of the capsular bag due to the accumulation of milky material and the forward displacement of the intraocular lens. We present two cases with an unusually delayed presentation of 6 and 8 years respectively following phacoemulsification, and describe their successful management with Nd:YAG laser posterior capsulotomy.

We describe a new approach to treat late-onset capsular distension syndrome in which the fluid in the capsular bag is cloudy and prevents a posterior neodymium:YAG (Nd:YAG) laser capsulotomy. A peripheral laser iridotomy is created through which the anterior lens capsule peripheral to the IOL optic is accessed. This opening in the iris provides an access point through which an anterior Nd:YAG laser capsulotomy can be performed. Following disruption of the anterior lens capsule, the capsular fluid is released into the anterior chamber and absorbed through the inherent drainage system of the eye. This approach avoids the need for a more invasive surgical intervention., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

We report a unique case of spontaneous per-operative idiopathic development of true exfoliation of the anterior lens capsule during capsulorhexis. A 45 year old female who underwent phacoemulsification for a cataract in the left eye, developed a partial split (the double ring sign) and eventual complete separation of the superficial lamina of the lens capsule during capsulorhexis. Radial tears developed in the remaining lamina making the capsular bag unstable. The surgery was converted to manual nucleus expression. An intra ocular lens was implanted via scleral fixation. The final best corrected visual acuity in the left eye was 6/6. The patient is comfortable with the vision. Though a rare event, the surgeon must always be alert to the development of spontaneous idiopathic per operative true exfoliation of the lens capsule.

Negative dysphotopsia is a relatively common photic phenomenon that may occur after implantation of an intraocular lens. The etiology of negative dysphotopsia is not fully understood. In this investigation, optical modeling was developed using nonsequential-component Zemax ray-tracing technology to simulate photic phenomena experienced by the human eye. The simulation investigated the effects of pupil size, capsulorrhexis size, and bag diffusiveness. Results demonstrated the optical basis of negative dysphotopsia. We found that photic structures were mainly influenced by critical factors such as the capsulorrhexis size and the optical diffusiveness of the capsular bag. The simulations suggested the hypothesis that the anterior capsulorrhexis interacting with intraocular lens could induce negative dysphotopsia.

Background: The aim of this study was to evaluate the impact of capsulorhexis diameter, localization and shape on posterior capsule opacification (PCO) development after cataract extraction with phacoemulsification., Material/methods: We retrospectively analyzed of 297 patients who underwent phacoemulsification and AcrySof SA60AT implantation. In a first group of 97 patients, 53 received small capsulorhexis (3.9 to 4.9 mm in diameter) and 44 patients received large capsulorhexis (5.0 to 5.9 mm in diameter). Another group of 99 patients was split into subgroups--66 patients whose capsulorhexis were centrally located and 33 patients whose capsulorhexis were paracentral. A third group of 101 patients was split into subgroups--a subgroup of 59 patients were classified as having a regularly rimmed capsulorhexis and a subgroup of 42 patients as having an irregularly rimmed capsulorhexis. At 6 months follow-up, PCO was classified as none, mild, moderate, or severe, depending on the number of quadrants involved., Results: 86.79% of the patients with a small capsulorhexis had no or mild PCO (p<0.001), whereas, 68.18% of the patients with a large capsulorhexis experienced moderate or severe PCO; 89.4% of the patients with a central capsulorhexis had no or mild PCO (p<0.001), whereas, 75.75% of the patients with a paracentral capsulorhexis had moderate or severe PCO; 86.44% of the patients with a regularly rimmed anterior capsulorhexis had no or mild PCO (p<0.001); and 69.04% of the patients with an irregular capsulorhexis rim had moderate or severe PCO., Conclusions: A small capsulorhexis diameter, its central localization and regular shape result in less PCO following phacoemulsification.

Purpose: To evaluate the frequency of capsule wrinkling and associated factors during capsulorhexis in patients with primary angle-closure glaucoma (PACG) undergoing cataract surgery., Methods: This prospective study enrolled 91 eyes of 91 patients (26 eyes with PACG, 65 control eyes) who underwent cataract surgery. Capsule wrinkling during capsulorhexis was determined intraoperatively. The PACG group was evaluated for factors associated with capsule wrinkling such as intraocular pressure (IOP) on presentation, history of acute attacks, previous laser or trabeculectomy surgery, iris atrophy, peripheral anterior synechiae, and posterior synechiae., Results: The frequency of capsule wrinkling was higher in the PACG group (7/26, 26.9%) than in the control group (0/65, 0%) (P < 0.0001). Among the PACG patients, capsule wrinkling was associated with a higher IOP on presentation (54.71 ± 16.15 mmHg) than in patients without capsule wrinkling (32.95 ± 11.21 mmHg) (P = 0.001). Iris atrophy was significantly related to capsule wrinkling (P = 0.028), and the location of iris atrophy correlated with that of capsule wrinkling in 80% of cases (4/5)., Conclusions: Capsule wrinkling during capsulorhexis was a significant finding in some patients with cataract and PACG, especially when the IOP on presentation was high and iris atrophy was present.

This case report retrospectively reviews the outcome of a 43-year-old man with retinitis pigmentosa who suffered rapid anterior capsular phimosis in each eye within 3 weeks following uncomplicated phacoemulsification with continuous curvilinear capsulorrhexis and single-piece acrylic intraocular lens (IOL) implantation. Anterior YAG capsulotomy was successfully performed in both eyes. It has been previously documented in the literature that capsular phimosis is more common in patients with retinitis pigmentosa. However, in the cases that were reviewed, capsular contracture progressed much less rapidly than in this patient. It is proposed that zonular dehiscence or increased lens epithelial cell fibrosis accompanying retinitis pigmentosa may be responsible for phimosis following phacoemulsification; in this case, the single-piece IOL may have offered less resistance to capsular contraction. Using a three-piece IOL, capsular tension ring, or making radial relaxing incisions in the anterior lens capsule may be useful approaches to minimize the aforementioned complications in patients with retinitis pigmentosa and cataracts., (Copyright 2010, SLACK Incorporated.)

A 35-year-old woman with zonular weakness in the left eye had phacoemulsification with inthe- bag implantation of an acrylic intraocular lens (IOL) and a capsular tension ring. 6 months postoperatively, the patient developed significant visual loss secondary to capsule shrinkage and contraction of the capsulorhexis opening, associated to a slight IOL decentration. Neodymium: YAG laser radial anterior capsulotomy and anterior capsulectomy were performed leading to visual acuity restoration.

Purpose: The combination of anterior capsule opacification (ACO) with capsulorrhexis phimosis and intraocular lens (IOL) decentration characterises the capsule contraction syndrome (CCS). Eight cases of ACO complicated with capsule phimosis are described., Methods: In this study, 231 patients who underwent cataract extraction using phacoemulsification from September 2005 to May 2006 were included. An acrylic one-piece IOL was implanted with the use of the injector supplied by the manufacturer through a 2.75 mm incision. A thorough pre- and post-operative examination (visual acuity measurement, corneal curvature measurement, applanation tonometry, fundus examination) was performed for each patient., Results: In eight of 243 eyes of 231 patients, anterior capsule opacification with capsulorrhexis phimosis and IOL decentration was observed two to four months post-operatively. In all eight cases, the haptic implanted inferiorly was observed to be mounted on the IOL optic., Conclusions: The combination of IOL memory loss in addition to ACO, capsulorrhexis phimosis and decentration can be a cause of the CCS, an observation that has not been reported previously.

I describe a technique of slitlamp needle revision in eyes with capsular block syndrome (CBS) with distention of the capsular bag and forward displacement of the intraocular lens (IOL) in the capsular bag. After topical anesthesia and povidone-iodine are applied to the eye, a 30-gauge needle is introduced in a beveled fashion across the peripheral cornea into the anterior chamber and used to gently push the IOL posteriorly into the capsular bag, reversing CBS. In 8 patients, the technique instantly resolved the CBS and the induced myopic shift. No patient experienced complications or had a recurrence of CBS.

Purpose: To evaluate possible changes in macular morphology after cataract surgery with combined primary posterior capsulorhexis and posterior optic buttonholing in comparison to conventional in-the-bag intraocular lens (IOL) implantation., Design: Prospective randomized study., Methods: Fifty consecutive age-related cataract patients with normal macular morphology and function waiting for bilateral cataract surgery were enrolled. Cataract surgery with combined primary posterior capsulorhexis and posterior optic buttonholing was performed in one eye; in the fellow eye cataract surgery was performed with in-the-bag IOL implantation, leaving the posterior lens capsule untouched. Optical coherence tomography measurements were performed one week and one month postoperatively., Results: During follow-up, no statistically significant changes of macular morphology could be observed in any of the tested patients. Mean central retinal thickness, minimum and maximum retinal thickness, and central retinal volume were all statistically comparable between the eyes with combined primary posterior capsulorhexis and posterior optic buttonholing and the control eyes (P > .05). Best-corrected visual acuity was full in all patients (Snellen 20/25 and better). No cases of subclinical macular edema were observed., Conclusion: Cataract surgery with combined primary posterior capsulorhexis and posterior optic buttonholing apparently does not increase the risk for postoperative macular edema in patients with a normal macula, since no cases of biomicroscopically noticeable macular edema with visual loss were observed in the first 1,000 eyes with primary posterior capsulorhexis/posterior optic buttonholing cataract surgery and no case of subclinical macular edema was found in this prospective randomized study.

A case of severe capsular phimosis following implantation of an acrylic intraocular lens (hydrophobic acrylic with polymethylmethacrylate haptics) in a patient with pseudoexfoliation is described.

In 4 patients with congenital cataract, subtle signs of anterior vitreous face (AVF) disturbance were documented during posterior continuous curvilinear capsulorhexis. The signs were vitreous strands in the anterior chamber, vitreous strands attached to the capsule flap, and distortion of the anterior and posterior capsulorhexis margins; the latter is considered a pathognomonic sign of AVF disturbance. As a result of the early recognition, modifications to the cataract surgery technique were made.

Purpose: To compare the functional outcome of epilenticular intraocular lens (IOL) implantation vs the technique of anterior continuous curvilinear capsulorhexis (ACCC), posterior continuous curvilinear capsulorhexis (PCCC) with vitrectomy and in-the-bag IOL implantation in paediatric cataract surgery., Methods: Forty eyes of 33 children with developmental or traumatic cataract, whose mean age was 2-12 years, were randomly divided into two groups A and B. Group A patients underwent epilenticular IOL implantation while in group B patients, ACCC, PCCC with anterior vitrectomy with in-the-bag IOL implantation was performed. Equal number of eyes (10 each) with developmental cataracts (subgroups A1 and B1) and traumatic cataracts (subgroups A2 and B2) were allotted to both the groups. Postoperative visual acuity, opacification of the visual axis, and possible complications were observed and analysed., Results: Four eyes in subgroup B2 had fibrous or ruptured capsules, and were managed by epilenticular IOL implantation technique. One eye in subgroup B2 developed central posterior capsular opacification and hence required a secondary capsulotomy. All cases in group A maintained a clear visual axis at the last follow-up. Minimal postoperative inflammation was noticed in all groups, which subsided with anti-inflammatory medication. At the last follow-up, all eyes in group A gained visual acuity >/=6/18. Whereas in group B, visual acuity >/=6/18 was obtained in 85.7% cases with the epilenticular IOL implantation technique and in 83.3% cases with ACCC and PCCC with anterior vitrectomy technique., Conclusion: Epilenticular IOL implantation offers a safe and effective alternative for management of paediatric cataract. In selected cases of traumatic cataract, it is the preferred treatment modality.

Aim: Combining primary posterior capsulorhexis (PPC) and posterior optic buttonholing (POBH) in cataract surgery is an innovative approach to prevent after-cataract formation effectively and to increase postoperative stability of the intraocular lens (IOL). The present study was designed to compare the postoperative intraocular flare after cataract surgery with combined PPC and POBH to conventional in-the-bag implantation of the IOL., Methods: Fifty consecutive age-related cataract patients with cataract surgery under topical anaesthesia in both eyes were enrolled prospectively into a prospective, randomised clinical trial. In randomised order, cataract surgery with combined PPC and POBH was performed in one eye; in the other eye cataract surgery was performed conventionally with in-the-bag IOL implantation keeping the posterior lens capsule intact. Intraocular flare was measured 1, 2, 4, 6, 12 and 24 h postoperatively, as well as 1 week and 1 month postoperatively, using a KOWA FC-1000 laser flare cell meter., Results: The peak of intraocular flare was observed in POBH eyes and eyes with in-the-bag IOL implantation 1 h postoperatively. In both groups, the response was steadily decreasing thereafter. During measurements at day 1, small though statistically significant higher flare measurements were observed in eyes with in-the-bag IOL implantation (p<0.05). At 1 week and 1 month postoperatively, intraocular flare measurements were comparable again (p>0.05)., Conclusion: Cataract surgery with combined PPC/POBH showed slightly lower postoperative anterior chamber reaction compared to conventional in-the-bag implantation during 4-week follow-up, indicating that POBH might trigger somewhat less inflammatory response. This could be explained by the posterior capsule sandwiching between the optic and the anterior capsule, preventing direct contact-mediated myofibroblastic trans-differentiation of anterior lens epithelial cells with consecutive cytokine depletion.

Introduction: Anterior capsule contraction syndrome after phacoemulsification is rare and can compromise visual acuity. Nd:Yag laser capsulotomy is a good alternative in limited forms of contraction., Observations: We report four cases of anterior capsule contraction syndrome developed after a mean follow-up of 8 months after phacoemulsification and acrylic intraocular lens implantation. Nd:Yag laser capsulotomy was performed to help resolve the contraction and its symptoms. No relapses occurred during the follow-up., Conclusion: Nd:Yag laser capsulotomy is effective and safe in managing limited forms of anterior capsule contraction syndrome after phacoemulsification. Surgery is an alternative to Nd:Yag capsulotomy in severe cases.

Purpose: To report peripheral iridectomy using a 25-gauge vitreous cutter in a 42-year-old man with pupillary block due to adhesion of the internal iris surface to the continuous circular capsulorhexis., Methods: A corneal opening was made at 10 o'clock during vitrectomy. A 25-gauge vitreous cutter was inserted into the anterior chamber with the port facing downward, and peripheral iridectomy at the 12 o'clock position was performed. The vitreous cutter was set at a cutting speed of 2500 cpm and the aspiration pressure at 600 mmHg., Results: A 25-gauge vitreous cutter with a fine shaft could easily be inserted into the peripheral anterior chamber, and there was no contact with the corneal endothelium even when the anterior chamber became shallow in association with iridectomy. In this patient, pupillary block resolved with peripheral iridectomy, and ocular pressure was also controlled., Conclusions: 25-gauge peripheral iridectomy is a simple technique that permits iridectomy of appropriate size at any desirable location.

Purpose: Phacoemulsification cataract surgery is the gold standard for lens removal and continuous curvilinear capsulorhexis is one of the important first steps during the procedure. It is also one of the most difficult steps to master and so has a learning curve and capsulorhexis breach is therefore common among trainees. Once there is capsulorhexis breach, the surgeon could continue with the procedure or convert to extracapsular extraction, with each having its advantages and disadvantages. In our unit, the phacoemulsification procedure is usually continued with some modifications, and the results over a specified period are presented. To report the incidence of breach rhexis during phacoemulsification over a specific period, deduce reasons for the breach, as well as the surgical outcome including other intraoperative and postoperative complications directly resulting from the capsular tear. Interventional case series., Methods: All patients who developed breach rhexis during routine phacoemulsification had all information regarding the procedure entered into a predesigned ProForma. These ranged from the instruments used for the capsulorhexis to subsequent surgical modification to reduce risk of further complications to the final surgical outcome., Results: In the study period March 12, 2004, to March 30, 2005, the team carried out 358 phacoemulsifications, of which 20 (0.56%) had breach rhexis. The end of the breach was visible in 70% of cases and equatorial in the rest. None extended to the posterior capsule and so there was no vitreous loss in any of these cases. In most of the cases, the cause of the breach was attributed to inexperience or error of judgment (60%). However, modification of the surgery including the transfer of the procedure to a more experienced surgeon helped to reduce the rate of further complications. Eighty-five percent of the patients achieved a corrected visual acuity of 6/12 or better and those with worse vision had comorbidity., Conclusions: In this study, the authors showed that, when properly managed, capsular breach during phacoemulsification has little or no effect on the final surgical outcome.

Via meta-analysis, we assessed the effect of pediatric cataract surgery with posterior continuous curvilinear capsulorhexis (PCCC) with or without anterior vitrectomy (AV) on the incidence of after cataract. Group 1 consisted of pediatric cataract surgery with or without PCCC. Group 2 consisted of pediatric cataract surgery with PCCC with or without AV. The pooled odds ratio of after cataract in Group 1 was 0.21; in Group 2 it was 0.13. Pediatric cataract surgery with PCCC is superior to single cataract surgery in preventing the incidence of after cataract.

Introduction: The aim of this study was to determine if racial differences exist in the rate of posterior capsule rupture (PCR) during cataract surgery in Singapore., Materials and Methods: All intraoperative complications during cataract surgery were prospectively reported as part of a clinical audit programme. A retrospective review of all patients who sustained a PCR during cataract surgery between July 1995 and December 1998 was performed., Results: Of 8230 consecutive eyes which underwent cataract surgery, 6951 (84.5%) were Chinese, 597 (7.3%) were Malay, 524 (6.4%) were Indian, and 158 (1.9%) were of other races. The overall incidence of PCR was 1.9%. The PCR rates were 1.8% [125 of 6951; 95% confidence interval (CI), 1.49 to 2.11] in Chinese, 2.0% (12 of 597; 95% CI, 1.01 to 3.57) in Malay, 2.7% (14 of 524; 95% CI, 1.13 to 3.56) in Indian, and 2.5% (4 of 158; 95% CI, 0.00 to 4.98) in other races. There was no statistical difference between the PCR rates (P = 0.62, chi-square test)., Conclusion: Racial differences in Singapore do not have an effect on the rates of PCR during cataract surgery.