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Midway tangential capsular flap can help rescue extending capsulorrhexis
Can J Ophthalmol. 2010;45(3):256-258.
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Creation of a midway tangential capsular flap assisted in the rescue of an extending capsulorrhexis, resulting in uneventful cataract removal, a study showed.
"The technique was successfully performed in all cases, leading to an uneventful phacoemulsification," the study authors said.
The consecutive case series included 22 eyes of 22 patients who had extending capsulorrhexis and were treated at one center in Iran.
The first step of the surgical procedure involved the creation of a tangential capsular opening on the border of the presumed continuous curvilinear capsulorrhexis, between the capsulorrhexis and the edge of the extending capsulorrhexis. This was designed to make a tangential flap of the anterior capsule.
The second step involved grasping the center of the new flap and pulling it centripetally until the edges of the new flap joined the edges of the extending flap to complete the capsulorrhexis, the authors said.
Dr. Mohammadpour has presented another good idea for rescuing an errant capsulorrhexis, building upon an already extensive literature. Fercho first proposed the use of continuous curvilinear capsulorrhexis (C. Fercho, MD, ‘‘Continuous Circular Tear Anterior Capsulotomy,’’ presented at the Welsh Cataract Congress, Houston, Texas, September 1986), which was followed by its popularization by Gimbel and Neuhann. Subsequently, I described the physics of how capsulorrhexis works, and how to deal with an errant tear. Since then, many techniques to deal with errant tears have been described as is evident from a cursory search of “capsulorrhexis” on the Journal of Cataract & Refractive Surgery website, which yields over 1,500 references in that journal alone. The most popular current technique is the “Little capsulorrhexis tear out rescue” method.
Every successful technique described to date relies upon:
1. Stabilizing the errant capsulorrhexis by filling the anterior chamber completely with preferably a highly viscous and elastic OVD, thus directing the spontaneous tearing tendency of a tear on the convex anterior lenticular surface inwards rather than outwards by depressing the central lens surface, making it concave instead of convex.
2. Applying gentle directed force to the capsulorrhexis flap to pull the tear inwards rather than outwards, preserving the shearing nature of the force and avoiding stretching.
The paper of Mohammadpour neglects step 1, but presents a viable alternative for step 2 above. If the OVD step 1 is added to the technique, it works, and study of the technique in the illustrations of the paper shows how this maneuver will, once the eye is pressurized with OVD, fulfill the physical requirements to achieve a redirected tear. With this modification, I recommend the technique.
– Steve A. Arshinoff, MD, FRCSC
OSN
Cataract Surgery Board Member
References:
- Arshinoff S. Mechanics of capsulorrhexis. J Cataract Refract Surg. 1992;18:623-628.
- Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorrhexis technique. J Cataract Refract Surg. 1990;16:31–37.
- Little BC, Smith JH, Packer M. Little tear out rescue. J Cataract Refract Surg. 2006; 32:1420-1422.
- Neuhann T. Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd 1987; 190:542–545.
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