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We report a new, inexpensive technique for creating a continuous curvilinear capsulorhexis (CCC) for intumescent total cataract. Peribulbar anesthesia is administered. A nick is created using a regular 26-gauge cystotome. Through a side port, the free capsule flap is vacuumed using the flat tip of a 25-gauge round cannula connected to a 5 mL syringe. Suction pressure is created by withdrawing the piston of the syringe in a controlled motion to create a curvilinear capsulorhexis without withdrawing the instrument from the anterior chamber. Next, liquefied cortex is aspirated with the same cannula. Complete vacuum was achieved with the cannula in 197 (98.5%) of 200 cases; 3 cases (1.5%) had capsulorhexis extension and vacuum was not achieved. The new cannula-vacuum CCC technique is safe and affordable and might be an alternative to conventional CCC performed using a 26-gauge cystotome or a Utrata or micro capsulorhexis forceps., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a manual prechop technique for splitting the nucleus of the lens using a recently developed reverse chopper., Methods: During the process, the reverse chopper and the Nagahara chopper are placed diagonally in the peripheral area of the nucleus of the lens after capsulorhexis. The reverse chopper and the Nagahara chopper then are pushed horizontally toward each other so they meet at the center of the lens to split the nucleus of lens into 2 parts., Results: In all cases, the reverse chopper was effective during the prechop procedure for hard nuclei, the nucleus of the lens remained in situ during the chopping process, and the reverse chopper did not retract the suspensory ligament in patients in whom the ligament was fragile. During the prechop procedure, no capsule breakage occurred, and the time and energy required for effective phacoemulsification were reduced significantly., Conclusions: The prechop technique using the reverse chopper can be applied for cases with grade III-V nuclei, overripe nuclei, and fragile suspensory ligaments. The procedure is simple, and the learning curve is not steep.

Purpose: To compare performance on the EyeSi surgical simulator in 3 training modules by users with different levels of experience in ophthalmology., Methods: We included 18 surgeons (6 residents with no cataract experience, 6 residents with little experience (1 to 10 cases) and 6 experienced cataract surgeons (over 500 cases). Three modules were selected (capsulorhexis, phacoemulsification-cracking and irrigation and aspiration). All subjects completed 12 levels of increasing difficulty twice, and the results of the second trial were analyzed according to the surgeon's experience., Results: For the capsulorhexis module, experienced surgeons achieved higher total scores than the other 2 groups in exercise 1 (P=0.0102). For the phaco-cracking module, experienced surgeons achieved higher total scores in exercise 8 (P=0.0495) and a tendency toward significance in exercises 3 (P=0.0934) and 5 (P=0.0938). Participants with greater experience had lower total task time in exercises 1 (P=0.0444), 4 (P=0.06) and 5 (P=0.0189)., Conclusion: Experienced surgeons outperformed residents with regard to overall score in 4 exercises of the capsulorhexis and phaco-cracking modules. Our results confirm previously demonstrated construct validity for these modules on the EyeSi simulator. These findings will help in the development of relevant training programs that could potentially be applied to the standard ophthalmological curriculum., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Purpose: To investigate the intraoperative performance and the ultrastructural features of anterior capsulotomy performed with the improved Zepto precision pulse capsulotomy (PPC) device., Setting: Launceston Eye Institute, Launceston, Tasmania, Australia., Design: Prospective, consecutive case series., Methods: Intraoperative observation of performance and complications were made on consecutive eyes having capsulotomies with the improved PPC device. The capsulotomy specimens were examined under scanning electron microscope and compared with manual continuous curvilinear capsulorhexis and femtosecond laser-assisted cataract surgery specimens., Results: The study comprised 52 eyes. Intended capsulotomy occurred in 50 eyes with 2 device failures. Complete free-floating capsulotomies were achieved in 48 eyes (96%). Anterior capsule tears occurred in 2 eyes (4%)., Conclusions: The ability of the PPC device to create complete free-floating capsulotomies improved; however, the radial tear rate remained high. The ultrastructural features in ex vivo human capsulotomy specimens still showed areas of irregular capsule margin with frayed edges., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Several techniques are used to make a capsulorhexis in white mature cataract cases as needle cystotome, Utrata capsulorhexis forceps, microincision capsulorhexis forceps, femtosecond Laser, etc. Zepto precision nano-pulse capsulotomy device (Mynosys Cellular Devices; Fremont, CA, USA) is Food and Drug Administration approved, a disposable capsulotomy device that uses low-energy pulses to create a precise central capsulorhexis, independent of pupil size, corneal clarity, or lens density. In this article, the authors report their experience of performing anterior circular curvilinear capsulorhexis with Zepto precision nano-pulse capsulotomy device in challenging cataract cases done at our center. The Zepto handpiece device was inserted through 2.8 mm clear corneal incision. Results of our study in 3 cataract cases (intumescent cataract, morgagnian cataract, and cataract with small pupil) revealed that the precision pulse capsulotomy technology mechanically and simultaneously cleaves all 360° of the apposed capsule of without cauterizing it, creating CCC of 5.2 mm size., Competing Interests: There are no conflicts of interest

Background: To compare the results of continuous curvilinear capsulorrhexis(CCC) after application of an open ring-shaped guider compared with a free-hand procedure in eyes with cataracts., Methods: This study comprised patients undergoing cataract surgery in Seoul St.Mary's Hospital, The Catholic University of Korea. Eyes were grouped depending on the capsulotomy method; CCC was performed by free-hand procedure on 94 eyes (free-hand group), and it was performed under the guidance after introduction of an open ring-shaped guider on consecutive 89 eyes (guided group). Horizontal and vertical diameter, area and circularity of capsulotomy were measured postoperatively at one day, two months and six months. Differences in parameters and the percentage of ideal capsulorrhexis were analyzed between the two groups., Results: On the first postoperative day, the vertical diameter in the guided group (5.24 ± 0.16 mm) was significantly longer than that of the free-hand group (5.01 ± 0.65 mm, P = 0.019). The area of capsulotomy was larger in the guided group (21.55 ± 0.87 mm 2 ) than that of the free-hand group (20.34 ± 2.96 mm 2 , P < 0.001). Circularity in the guided group (0.84 ± 0.03), was significantly greater than that of the free-hand group (0.69 ± 0.17, P = 0.036). Ideal capsulorrhexis was obtained in 60 eyes (67%) in the free-hand group and 81 eyes (86%) in the guided group., Conclusions: After introduction of an open ring-shaped guider, CCC became larger and more circular with less anterior capsular contracture. The rate of acquiring ideal capsulorrhexis was higher in the guided group than it was in the free-hand group for six months after surgery.

Background: Capsulorhexis is one of the most important steps in cataract surgery. Good centration, circular overlap in sufficient size and a circular edge without tears result in good centration of the intraocular lens (IOL). In this study, the capsulorhexis results of an experienced surgeon are compared with reported data in femtolaser assisted cataract surgery (FLACS)., Patients and Methods: 105 consecutive operations were photographically documented; in 81 cases size and overlap were analysed retrospectively. The surgeon's personal anterior capsular tear rate was taken from the EUREQUO database., Results: Average rhexis size was 5.03 ± 0.3 mm; the difference between the two measured diameters was 0.28 ± 0.18 mm. Circular overlap was found in 88.9% of cases. No radial tears were observed in 8000 operations in EUREQUO, resulting in a rate of less than 0.0125% in manual surgery., Conclusions: The overlap rate of manual surgery was comparable to FLACS; whether the slightly 'rounder' capsulotomy is clinically relevant remains unclear. The risk of an anterior capsular tear is very low in the hands of an experienced surgeon and even lower than with FLACS., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To investigate the ultrastructural features of anterior capsulotomy performed with a thermal device, the precision pulse capsulotomy (PPC)., Design: Prospective, multicenter case series., Participants: Consecutive patients undergoing capsulotomy with the PPC device., Methods: Prospective study of patients undergoing capsulotomy with the PPC by 2 surgeons, followed up by routine phacoemulsification cataract surgery, was undertaken. All capsulotomy specimens were collected for scanning electron microscopy (SEM). Observations were made regarding uniformity of the capsular edge and the presence of irregularities that may compromise integrity. Comparisons were made with manual continuous curvilinear capsulorrhexis., Main Outcome Measures: Ultrastructural features of PPC and presence of irregularities., Results: Frayed appearance of the anterior capsule edge was noted in postoperative visits under slit-lamp examination. Scanning electron microscopy sampling showed a generally uniform rolled capsular edge, but interspersed with areas of irregularity with frayed appearance at the capsule margin., Conclusions: The PPC device is capable of creating reproducible, central, and precise circular capsulotomy. The ultrastructural features in ex vivo human capsulotomy specimens generally show eversion of the capsulotomy edge, but in some cases, this was accompanied by areas of irregular capsule margin with frayed edges, likely caused by dissipated thermal energy. The postoperative appearance and SEM features warrant further assessment of the PPC integrity and clinical correlation., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Despite the appeal of an automated method of creating a perfectly circular anterior capsulotomy, global adoption of femtosecond laser capsulotomy (FSLC) has been limited by its high acquisition and per case cost. In addition, the femtosecond laser's large size and the need for eye docking create surgical efficiency and workflow challenges. The Zepto precision pulse capsulotomy (PPC) technology creates a circular anterior capsulotomy of a precise diameter using a disposable handpiece and tip that are used in the normal surgical sequence. Extensive preclinical and clinical testing has resulted in the US Food and Drug Administration (FDA) approval of the technology. Zepto PPC holds promise for complicated eyes such as those with intumescent or brunescent lenses, zonulopathy, or small pupils. This paper and the accompanying videos describe and demonstrate the technique and review the published studies.

Progressive metaplastic fibrosis of the anterior capsulorhexis opening is a frequent complication of the postoperative period. There is a widely practiced method of anterior capsular contraction syndrome (ACCS) correction through radial anterior laser capsulotomy. Despite many advantages, it can be complicated by unpredictable anterior capsule tearing and intraocular lens (IOL) dislocation into the vitreous Body, which justifies the search for new technical solutions., Aim: to develop a safe technique of combined laser anterior capsulotomy (LAC) in patients with ACCS., Material and Methods: The study included 19 patients (20 eyes) with ACCS. The suggested LAC technique involved two differently directed YAG-laser cuts that could be regarded as a combination of radial anterior capsulotomy and anterior peripheral linear capsulotomy. With the cuts located perpendicularly to each other, the distal end of each radial cut was connected to the middle of each longitudinal cut., Results: The suggested technique allows an increase in the anterior capsulorhexis diameter up to more than twice the pre-laser size. The difference between the average pre- and post-laser capsulorhexis diameters was statistically significant (р<0.0001). Neither case developed an unpredictable anterior capsule tear., Conclusion: The safety of the new technique is ensured by preliminary longitudinal cuts that create a barrier against unpredictable radial tears in the capsular bag during radial capsulotomy.

Purpose: To compare size, circularity, and centration outcomes of continuous curvilinear capsulorhexis (CCC) performed with or without assistance from the VERUS ophthalmic caliper (Mile High Ophthalmics, Denver, CO)., Methods: This was a multicenter retrospective consecutive case controlled series review., Results: Data from 40 consecutive cases using the VERUS device for CCC were compared to 40 consecutive cases with standard manual CCC. VERUS-assisted CCC size, circularity, and centration were closer to target compared to that of manual only procedures (P < .05). The average time from initiation to completion of the capsulotomy was shorter with manual (40 ± 11 seconds) compared to VERUS-assisted (71 ± 13 seconds) cases (P < .0001)., Conclusions: The VERUS ophthalmic caliper is effective at improving size, circularity, and centration of the CCC in a time-efficient manner when compared to manual procedures performed without VERUS guidance. [J Refract Surg. 2016;32(10):654-658.]., (Copyright 2016, SLACK Incorporated.)

Unlabelled: We describe a surgical technique for management of zonular instability and pupillary miosis using a pupil expansion device (Malyugin ring) in patients who need cataract surgery. In this technique, the pupil expansion device is first used in the usual fashion. After a capsulorhexis has been created, lateral scrolls of the pupil expansion device are released and repositioned to entrap both the anterior capsulorhexis and the pupil margin at the against-the-wound meridian (3 o'clock and 9 o'clock position) to fixate the unstable capsular bag to the iris. Phacoemulsification is performed, and the ring is removed after intraocular lens implantation. With this method, capsular stabilization and pupil expansion are achieved simultaneously with the same instrument., Financial Disclosure: No 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.)

Unlabelled: We describe a new type of open-loop caliper for capsulorhexis during cataract surgery. This tool, which is made of poly(methyl methacrylate), can optimize capsulorhexis shape, size, and centration. One of the strengths of this tool, which derives from the open-loop design, is its ease of insertion and removal via a small incision site compared with other calipers used for capsulorhexis. The caliper is positioned on the anterior capsule after the anterior chamber is filled with an ophthalmic viscosurgical device and removed after creation of the continuous curvilinear capsulorhexis. The caliper enables the surgeon to achieve an ideal capsulorhexis and promotes long-lasting circularity., Financial Disclosure: Dr. Joo is one of the inventors on the patent filed by the Catholic University of Korea covering details in this manuscript. Dr. Lee 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: We describe a manual prechop technique to divide the nucleus using a cystotome. In the cystotome-assisted prechop technique, after the capsulorhexis, the surgeon-bent cystotome is inserted into the lens while the Nagahara chopper is set around the lens equator. The cystotome and the chopper are then brought together in the center to create a bisecting crack in the nucleus, dividing it cleanly into 2 hemispheres., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015. Published by Elsevier Inc.)

Purpose: To describe the evolution of a new device to facilitate continuous curvilinear capsulorhexis (CCC) creation., Setting: Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA., Design: Experimental study., Methods: Bench-side ex vivo testing of unique prototypes for guidance and assistance of CCC in bovine and human eyes was performed. Five designs were sequentially tested as follows: a flexible circular blade of nickel-titanium alloy (nitinol), a flexible nitinol guide wire, a flexible elastomeric suction device, a combination approach of a nitinol guide wire and flexible silicone ring, and a freestanding micropatterned silicone ring., Results: The first 3 designs were not amenable to insertion through a sub-2.4 mm corneal incision and failed to maintain adequate downward force to cut the capsule and/or prevent radial tears. The fourth design was successfully inserted through a 2.4 mm incision and maintained adequate downward pressure and contact to guide a manual CCC without radial tears. The final design was insertable through a 2.4 mm incision and exhibited self-adhesive characteristics after placement on the anterior capsule of an ophthalmic viscosurgical device-filled anterior chamber., Conclusions: Given the steep learning curve of manual capsulorhexis and the high cost of capsulotomy-assistive devices, such as the femtosecond laser, an alternative approach for creating a CCC is desirable. Performance of a highly precise manual CCC through a small incision using a medical-grade silicone device with an adhesive micropatterned design is a viable and cost-effective option for use in cataract surgery across a wide range of user experience., Financial Disclosure: All authors are named as the inventors in a patent filed by the University of Colorado covering the details in this report., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

The bag-in-the-lens (BIL) is a unique approach to IOL placement in cataract surgery. The BIL intraocular lens (IOL) is suspended centrally, supported by the anterior and posterior capsulorhexes. The placement confers a high degree of centration and stability; however, it is dependent on capsular and zonular integrity. In this report, we describe a patient with posttraumatic cataract featuring a sector of iris and suspensory zonule loss. The insertion of custom-designed bean-shaped segments provides capsular tension over the area of defect and a central aperture designed to support the BIL IOL., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

This study was done to compare the results of posterior continuous curvilinear capsulorhexis created using forceps with those created using vitrector in eyes suffering from congenital cataract. Vitrectorhexis term was first used by Wilson et al in 1999. [1] Fifty eyes with congenital and developmental cataract were included in this study. The posterior capsulorhexis was created using utrata forceps in 17 eyes or through a vitrector in 33 eyes. Forceps capsulorhexis was performed before IOL implantation, while vitrectorhexis was performed after IOL implantation in the bag. The results of both the surgery were compared using the following criteria: incidence of extension of rhexis, ability to achieve posterior rhexis of appropriate size, ability to implant the IOL in the bag, the surgical time, and learning curve. Vitrectorhexis after IOL implantation was an easy to learn alternative to manual posterior continuous curvilinear capsulorhexis in pediatric cataract surgery. It was more predictable and reproducible, with a short learning curve and lesser surgical time.

An adequately sized, intact capsulorhexis is a key to the outcome of any phacoemulsification procedure. Cystitome is widely used to create a continuous curvilinear capsulorhexis. A 'frozen' capsule (crumpled capsule) mixed with viscoelastic and cortex, however can result in loss of control while using a cystitome. The Sinskey's hook introduced through the side-port, can stabilize the globe as well as work in coordination with the cystitome to spread out the jumbled up anterior capsule allowing visualization of the tear edge in the Bimanual technique. The capsulorhexis is thereby completed comfortably obviating the need of capsulorhexis forceps or repeated injection of ophthalmic viscosurgical device., (Copyright © 2012 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Descemet-stripping automated endothelial keratoplasty has revolutionized the treatment of corneal endothelial disease. This procedure requires the removal of the Descemet membrane (DM) and the endothelium from the recipient cornea. We describe a simple technique to perform descemetorrhexis using an ophthalmic viscosurgical device to fill the anterior chamber and using capsulorrhexis forceps to create a controlled, continuous curvilinear DM tear in 19 cases. Avoidance of tearing the DM out to the periphery reduces endothelial cell loss, decreases migration of central endothelium to deficient areas, and minimizes the risk for chronic corneal edema and peripheral bullous keratopathy., (Copyright © 2012 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Context: Pediatric cataract surgery is traditionally done with the aid of high-molecular-weight viscoelastics which are expensive. It needs to be determined if low-cost substitutes are just as successful., Aims: The study aims to determine the success rates for anterior and posterior capsulorrhexis and intraocular lens (IOL) implantation in the bag for pediatric cataract surgery performed with the aid of a low-molecular-weight viscoelastic., Settings and Design: Nonrandomized observational study., Materials and Methods: Children less than 6 years of age who underwent cataract surgery with IOL implantation in the period May 2008-May 2009 were included. The surgeries were done by pediatric ophthalmology fellows. A standard procedure of anterior capsulorrhexis, lens aspiration with primary posterior capsulorrhexis, anterior vitrectomy, and IOL implantation was followed. Three parameters were studied: successful completion of anterior and posterior capsulorrhexis and IOL implantation in the bag., Results: 33 eyes of 28 children were studied. The success rate for completion was 66.7% and 88.2 % for anterior and posterior capsulorrhexis, respectively. IOL implantation in the bag was successful in 87.9%., Conclusions: 2% hydroxypropylmethylcellulose is a viable low-cost alternative to more expensive options similar to high-molecular-weight viscoelastics. This is of great relevance to hospitals in developing countries.

Purpose: To evaluate usefulness of a new semicircular capsulotomy marker in continuous curvilinear capsulorrhexis (CCC)., Methods: In 20 eyes of 20 patients who underwent cataract surgery, a newly designed semicircular marker with an internal diameter of 5.5 mm was used to place a circular mark directly on the lens capsule. The mark was then used as a guide to complete CCC of the set diameter. The resultant size of CCC in each case was confirmed by analysis of the video image., Results: The average CCC diameter size was 5.2 ± 0.3 mm. In all cases, the edge of the intraocular lens was completely covered by the anterior capsule., Conclusion: The semicircular capsulotomy diameter marker was useful in making a complete CCC of a set diameter.

We describe a T-shaped capsule stabilization hook (modified capsule expander [M-CE]) used for repositioning and scleral fixation of the lens capsule of subluxated lenses. The 5-0 polypropylene device is flexible and attached to a curved needle. The contact portion is bent at 1.25 mm, and the end bifurcates in a T configuration to form a 3.75 mm footpad from which the capsular bag can be suspended. Modified capsule expanders were implanted in 4 eyes of 4 patients with subluxated cataractous lenses and provided excellent support and centration of the intraocular lens (IOL)-capsular bag complex. The IOLs remained well centered and stable. The corrected distance visual acuity improved to at least 20/20 in all patients after surgery. Thus, M-CEs were effective in fixating the lens capsule to the sclera in patients with significant zonular weakness., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyse and quantitatively compare the outcomes of microincisional cataract surgery (CCMIC) with those of conventional phacoemulsification, evaluating the induced astigmatism, endothelial cell count, corneal thickness and foveal thickness in the pre- and postoperative period., Methods: Prospective and randomised study, including 74 eyes of 37 patients with a mean age of 72.97±7.55 years. All of them underwent conventional phacoemulsification in one eye and CCMIC in the other eye. The evaluated parameters were refractive and topographic astigmatism, endothelial cell count, corneal thickness and foveal thickness, which were measured preoperatively and at 1 day, 1 week, 1 month and 3 months after surgery., Results: The variations between pre- and postoperative parameters showed no statistically significant differences between the two surgical procedures (p>0.05)., Conclusions: CCMIC is an effective and safe technique that offers an excellent alternative for cataract surgery, with a smaller incision and postoperative outcomes comparable to the standard technique. Prospective studies with more patients and longer follow-ups are needed to establish if there really are statistically significant and clinically relevant differences between both techniques., (Copyright © 2010. Published by Elsevier Espana.)

Aim: To evaluate the safety and efficacy of dry pars plana posterior capsulotomy and anterior vitrectomy in paediatric cataract surgery using 25-gauge instruments., Methods: A consecutive series of 57 paediatric patients (80 eyes) who underwent dry pars plana posterior capsulotomy and anterior vitrectomy with 25-gauge devices after in-the-bag intraocular lens (IOL) implantation were retrospectively reviewed., Results: The mean follow-up period was 13.7 (SD 8.3) months. All IOL were well centred in the capsular bags. No intraoperative complications were noted to be attributable to the small-gauge instruments. Postoperative hypotony (intraocular pressure <8 mm Hg) was observed in two eyes (2.5%), which spontaneously recovered within 3 days. Eight eyes (10%) had light fibrin reactions and two eyes (2.5%) had mild posterior synechiae. No reopacification of the visual axis, IOL capture, vitreous prolapse, choroidal detachment or retinal detachment was found during the follow-up., Conclusions: Dry pars plana posterior capsulotomy with anterior vitrectomy using 25-gauge instruments is safe and effective for the management of posterior lens capsule and anterior vitreous in surgery for paediatric cataract.

Background: Congenital cataract surgery can be performed using a pars plana/plicata approach if placement of an intraocular lens at the time of cataract removal is not a consideration. To prevent development of secondary cataract, we performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy via pars plana or pars plicata approach. Lentectomy in babies should be performed using a minimally invasive technique to prevent complications. Immediately after surgery, insertion of a contact lens should be possible., Method: The series consisted of 11 eyes of 8 consecutive children who suffered from congenital cataract and underwent pars plana/plicata lentectomy between April 2007 and September 2008. Age at operation ranged from 6 weeks to 13 months (median age 4 months). The inclusion criterion was congenital cataract affecting the visual axis. Lentectomy was performed via a pars plana or pars plicata approach using a special 23-gauge aspiration and irrigation system and a 23-gauge cutter. We performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy., Results: Postoperatively the eyes showed only mild signs of inflammatory reaction. At the end of the operation, all eyes were provided with contact lenses. For all eyes, the surgical technique provided a clear visual axis during the follow-up period of 2-18 months. One eye developed secondary cataract., Conclusion: The use of 23-gauge instruments has advantages over standard 20-gauge equipment. Pars plana/plicata lentectomy using 23-gauge instruments is a safe, effective, and minimally invasive method for treating cataract in babies.

Purpose: To evaluate a new pulsed-electron avalanche knife design for creating a continuous curvilinear capsulotomy (CCC) and compare the CCC with a mechanical capsulorhexis., Setting: Department of Ophthalmology, Stanford University, Stanford, California, USA., Methods: In this study, CCCs were created in freshly enucleated bovine eyes and in rabbit eyes in vivo. The cutting velocity was adjusted by controlling the burst repetition rate, voltage amplitude, and burst duration. Tissue samples were fixed and processed for histology and scanning electron microscopy (SEM) immediately after surgery., Results: The study included 50 bovine eyes and 10 rabbit eyes. By adjusting the electrosurgical waveforms, gas-bubble formation was minimized to permit good surgical visualization. The optimum voltage level was determined to be +/-410 V with a burst duration of 20 mus. Burst repetition rate, continuously adjustable from 20 to 200 Hz with footpedal control, allowed the surgeon to vary linear cutting velocity up to 2.0 mm/s. Histology and SEM showed that the pulsed-electron avalanche knife produced sharp-edged capsule cutting without radial nicks or tears., Conclusions: The probe of the pulsed-electron avalanche knife duplicated the surgical feel of a 25-gauge cystotome and created a histologically smooth capsule cut. It may improve precision and reproducibility of creating a CCC, as well as improve its proper sizing and centration, especially in the face of surgical risk factors, such as weak zonules or poor visibility., Financial Disclosures: Drs. Palanker and Vankov hold patents to the pulsed electron avalanche knife technology, which are licensed to PEAK Surgical by Stanford University. Drs. Palanker and Chang are consultants to PEAK Surgical. Dr. Vankov is an employee of PEAK Surgical. Neither of the other authors has a financial or proprietary interest in any material or method mentioned., (Copyright 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the results of anterior and posterior continuous curvilinear capsulorhexis created using forceps with those created using vitrector in eyes suffering from congenital cataract., Methods: Twenty-eight eyes with congenital cataract were included in the study. The anterior and posterior continuous curvilinear capsulorhexes were created using microforceps in 17 eyes or through a vitrector in 11 eyes., Results: Corneal edema (P = .56) and anterior chamber flare (P = 1.0) were comparable in both groups. In addition, the time for optical axis clarity was also similar between the groups (P = .98)., Conclusion: The current results suggest that the use of both techniques appears to be equally safe and effective for the achievement of anterior and posterior capsulorhexis.

Purpose: To evaluate the deviation of the continuous curvilinear capsulorhexis (CCC) from the target size and shape when a data-injection ring is used., Setting: University Eye Clinic, Bochum, Germany., Methods: In a randomized clinical trial, the horizontal and vertical intraoperative and postoperative CCC diameters in 96 eyes having cataract surgery were measured and compared with a 5.1 mm target size. The eyes were randomly assigned to 1 of 2 groups: (1) data-injection ring system, in which a reference ring was projected through the light source of the operating microscope to the anterior capsule surface to guide the CCC procedure, and (2) no data-injection system. The primary clinical endpoint was the identification of a statistically significant difference in CCC diameter and in the scatter around the target diameter between Group 1 and Group 2., Results: No statistically significant between-group differences were found in mean CCC diameter or horizontal and vertical diameter deviation from the target size. Significant differences were found in the scatter around the target CCC diameter. Intraoperatively, the horizontal CCC diameter was within the normal reference range (4.9 to 5.3 mm) in 92% of eyes in Group 1 and 27% of eyes in Group 2 (P<.001). The vertical diameter was within the normal range in 83% and 21%, respectively. Postoperatively, the same tendency persisted (P

We describe a new type of caliper to optimize the size, shape, and centration of the capsulorhexis during intraocular lens (IOL) surgery. This flexible, ring-shaped tool is positioned on the anterior capsule surface, where it is kept in place by an ophthalmic viscosurgical device. When in place, the caliper provides an ideal guide for the surgeon to follow and facilitates optimal capsulorhexis shape and centration.

We describe a new capsular stabilization device for suspending a lens with weak zonular support. It is flexible, 10.0 mm in length, and fashioned from 5-0 nylon. The contact portion is bent at 1.25 mm with an end bifurcating to form a T-shape to minimize stress on the capsular equator. After a continuous curvilinear capsulorhexis is created, the capsular stabilization devices to hook the capsulotomy margin are inserted. The T-shaped end is passed around the anterior capsular flap to fit the curvature of the equator. Phacoemulsification and aspiration using this device was performed in 12 eyes of 9 patients, and the usefulness and complications were analyzed. The capsular stabilization devices suspended the capsule and facilitated safe phacoemulsification in all eyes. Posterior capsule rupture occurred in 2 eyes. None of the cases had notable postoperative complications. This device ensures a stable capsule-iris complex and reduces surgical risks.

The authors have developed a new method for removal of congenital cataract in children, by taking into account its clinical forms, namely, combined laser instrumental extraction including YAG-laser anterior capsular rhexis, followed by removal of lens debris by the aspiration-irrigation technique. A differential technology of YAG-laser anterior capsular rhexis has been developed, by taking into account of age-specific features of the lens and eyes in children. The optimum energy modes and techniques have been defined for different clinical forms of congenital forms of congenital cataracts. An analysis of the outcomes and complications of extraction of congenital cataracts has indicated that the authors' combined laser instrumental extract procedure (75 operations) assures the better quality of anterior capsular excision, improves optical and functional effects, and reduces the frequency of some complications as compared to the routine instrumental procedure (107 operations) (p < 0.05-0.001). Clinicofunctional and immunological studies have provided evidence for that the YAG-laser technique has no significant effect on the child's eye. Combined laser instrumental extraction is indicated for the treatment of any forms of congenital cataracts in children.

This study was performed to evaluate the efficacy and safety of the capsular tension ring on posterior capsular opacity in comparison with cases undergoing intraocular lens (IOL) implantation alone. We analyzed 127 eyes which had undergone cataract surgery, including capsular tension ring insertion, along with 127 eyes which had undergone IOL implantation alone by the same surgeon from September 1998 to March 2003. In the insertion group, 41 eyes (group A) had been followed up for more than one year after silicone IOL implantation, as had 40 eyes (group B) in the control group. We compared the incidence, type, and degree of capsular opacity between A and B groups and also endothelial cell loss after surgery between the two groups. For insertion group A, the frequency of posterior capsular opacity was lower(7.3%), the duration to development was longer, and the energy required for Nd-Yag capsulotomy of PCO was less than for control group B (25%) (p=0.037). The endothelial cell count loss rate was not significantly different between the two groups (p=0.522). The capsular tension ring is associated with a significantly reduced incidence of posterior capsular opacity and is a safe procedure.

The continuous curvilinear capsulorhexis (CCC) has paved the way for advancements in phacoemulsification by providing a tear-resistant opening in the anterior capsule. This article presents the advantages of the (CCC) and the management of challenging situations related to the (CCC).

Purpose: To compare the quality of the edges of anterior capsulotomies performed in porcine eyes using 3 different techniques., Setting: David J. Apple, MD Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA., Methods: Four porcine eyes were submitted to the center in 10% neutral buffered formalin. The cornea of the eyes had been removed, and a continuous capsulotomy had been performed in each eye using the Fugo plasma blade. To provide morphologic correlation, 4 additional porcine eyes were used in the study. In 2, a manual continuous curvilinear capsulorhexis (CCC) was performed after the cornea or cornea/iris was removed and in the other 2, a can-opener capsulotomy (COC) was performed. The eyes were then placed in 10% neutral buffered formalin. Gross (macroscopic) and microscopic analysis of each eye was performed, and photographs were taken. One eye in each group was also prepared and analyzed under scanning electron microscopy (SEM)., Results: The capsulotomy margin in the Fugo blade group presented some regularly spaced tags directed centrally with smooth edges at the base. Such a configuration would not interfere with the dynamics of the capsulorhexis sphincter and would generally not lead to radial tears. The smooth and regular nature of the capsulotomy margin in the CCC group was confirmed by gross and microscopic examinations of the eyes. The capsulotomy margin in the COC group presented some sharp notches directed outward, irregularly spaced, and irregular in shape. These are known to have a tendency to extend and form radial tears., Conclusion: Although performance of an anterior capsulotomy with the Fugo blade was associated with some margin irregularities, the geometry of the centrally directed tags prevented them from becoming the site of radial tear formation. The base of the capsulotomy performed with the Fugo blade appeared to be almost as smooth and regular as in the CCC under SEM evaluation.

In cataract surgery, the most commonly-used procedure for incision of the anterior capsule is continuous curvilinear capsulorrhexis (CCC), developed by Gimbel and Neuhann. As Gimbel has reported, CCC is a safe technique for phacoemulsification and aspiration (PEA) and intraocular lens (IOL) implantation. The optimum incision method for CCC is thought to be that of using anterior capsulotomy forceps. Recently, I have developed the side-port 23 gauge anterior capsulotomy forceps (23G forceps), manufactured by Asico, which can be manipulated via a small incision, as well as the side-port 25 gauge anterior capsulotomy forceps (25G forceps) and 25/23 gauge tapered anterior capsulotomy forceps (tapered forceps), manufactured by Inami, which are thought to provide even better ease of handling. In view of the fact that the visibility, ease of handling, bending, adverse effect on the wound, and effect on the cornea of these various forceps are important, the present comparison study among these forceps was conducted on pig lenses by means of 0.1 % trypan blue staining of the anterior capsule. It was found that capsulorrhexis was difficult with the 25G forceps because of the strong bend of the shaft. However, the tapered forceps has little bend, and like the 23G forceps, it showed outstanding handling and visibility and had little adverse effect on the wound.

Cataract surgery was performed in a 63-year-old man with bilateral coloboma of the lens. There was no traumatic history, but the patient had lower zonule deficiency and zonular weakness in both eyes, leading us to suspect congenital coloboma of the lens. In the first eye having cataract surgery, it was impossible to rotate the cataractous lens and place the intraocular lens (IOL) centrally in the capsular bag because the lens capsule was not round. The second eye had similar problems, and capsular tension ring implantation improved cataract lens rotation and phacodonesis, enabling central IOL implantation in the capsular bag. The visual acuity recovered to 20/20 in both eyes. Capsular tension ring implantation can facilitate cataract surgery in coloboma of the lens, even in long-term and continuous lens capsule deformity.

Purpose: To evaluate the extent of capsular bag shrinkage after cataract surgery with intraocular lens (IOL) implantation and develop a regression formula to predict postoperative capsular bag size., Setting: Eye Hospital, Johannes Gutenberg-University, Mainz, Germany., Methods: The axial length (AL), anterior chamber depth, and corneal radius in 58 eyes were measured preoperatively. Cataract surgery was by phacoemulsification followed by implantation of a 3-piece, acrylic, posterior chamber IOL. The capsular bag diameter and anterior capsulorhexis were measured intraoperatively and 1 day and 1, 3, and 6 months postoperatively using a Koch capsule measuring ring (HumanOptics)., Results: The mean capsular bag size was 10.53 mm intraoperatively, 10.31 mm at 1 day, 9.62 mm at 1 month, 9.07 mm at 3 months, and 9.01 mm at 6 months. The mean capsular bag shrinkage over the entire postoperative period was 14.8% (P<.001). Of the parameters studied, only AL had a positive correlation with capsule shrinkage. The correlation was moderate but statistically significant (P =.001)., Conclusions: A correlation was found between capsular bag shrinkage and AL. Using preoperative biometric data, a regression formula of moderate validity was determined to predict capsular bag shrinkage.

Recent improvements in intraocular lens (IOL) design and material delay posterior capsule opacification (PCO) after cataract surgery. However, studies have shown that without anterior capsule coverage of the IOL, PCO rates tend to increase. Surgeons have traditionally sized anterior capsulotomies without using a reference. The capsulotomy diameter mark is a convenient and inexpensive method to more consistently perform an anterior capsulorhexis that will allow anterior capsule overlap of the IOL optic.