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Keeping control of the capsulorrhexis is key
 Uday Devgan |
The capsulorrhexis is one of the most difficult parts of cataract surgery to master because the anterior lens capsule is thin, clear and often seems to have a mind of its own. Tearing a consistently round, well-centered and continuous capsulorrhexis is key to success during phacoemulsification and is important to ensure long term stability of the IOL implant.
Etiology
The anterior lens capsule is rounded, particularly when the anterior chamber is shallow. The shallowness of the anterior chamber makes it more likely that the capsulorrhexis will roll downhill towards the zonules, and once the capsulorrhexis is radialized, it can be difficult to rescue. The primary culprit for beginning surgeons is an under-filled anterior chamber, often with a dispersive viscoelastic, and then inadvertent distortion of the wound, which allows leakage of the viscoelastic. This results in a shallow anterior chamber, a rounded anterior lens capsule and a capsulorrhexis that rolls downhill toward the zonules.
 With a shallow anterior chamber, the anterior lens capsule is curved and the capsulorrhexis radializes and tends to roll downhill towards the zonules. |
 By deeply filling the anterior chamber with viscoelastic, the anterior lens capsule is flattened and there is more control during the capsulorrhexis. |
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Controlling the capsulorrhexis
Experienced surgeons can use just about any viscoelastic, even the very dispersive ones, and still create a perfect capsulorrhexis. This is because their instruments float gently within the incisions, causing no distortion, and minimal leakage of the viscoelastic. By pivoting precisely in the incision, the anterior chamber depth is maintained at all times and the capsulorrhexis is kept under control. With the anterior chamber deep and the anterior capsule flat, further control can be achieved by tearing the capsulorrhexis centrally.
For the beginning surgeon, pivoting and floating within the incision, without causing leakage or distortion, can be difficult. Using a more cohesive viscoelastic allows for better maintenance of the anterior chamber depth and it is less likely to leak from the incision during the capsulorrhexis. Once the anterior chamber is deepened and pressurized with viscoelastic, the anterior lens capsule becomes flattened and tight, like the head of a drum. This flattened anterior capsule is ideal for creation of the capsulorrhexis because it is no longer rounded and the threat of the capsulorrhexis rolling downhill is reduced.
Refilling lost viscoelastic in the anterior chamber can help restore anterior chamber depth and control of the capsulorrhexis.
Controlled capsulorrhexis is key
For most IOLs, having a well-centered, round capsulorrhexis that is slightly smaller than the lens optic ensures long-term security and centration. With the edge of the capsulorrhexis overlapping the optic, the IOL position is secured and predictable, leading to increased refractive accuracy. And particularly for beginning surgeons, once the capsulorrhexis is successfully completed, it seems as if the rest of the case proceeds more smoothly.
- Uday Devgan, MD, FACS, is in private practice at Devgan Eye Surgery in Los Angeles, Beverly Hills, and Newport Beach, California. Dr. Devgan is Chief of Ophthalmology at Olive View UCLA Medical Center and an Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of Medicine. Dr. Devgan can be reached at 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax: 310-388-3028; e-mail: devgan@gmail.com; Web site: www.DevganEye.com. Dr.Devgan is a consultant to Abbott Medical Optics and Bausch & Lomb, and is a stockholder in Alcon Laboratories and formerly in Advanced Medical Optics.