Bimanual technique for placement of footplates of phakic intraocular lens in eyes with intraoperative miosis.

We describe and assess the efficiency of a novel technique of placing implantable collamer lens (ICL) footplates in the sulcus in poorly dilated pupils utilizing perioptic holes and two instruments simultaneously (Sinskey hook and ICL manipulator). Twelve eyes of 10 patients underwent ICL implantation through this technique. The technique employs a bimanual approach engaging perioptic holes in the eyes with intraoperative miosis. Perioptic holes were engaged with a Sinskey hook and pulled slightly back, while the footplates were tucked under the iris by using an ICL manipulator. All patients had uneventful surgery. At 1 week follow-up, uncorrected distance visual acuity (UCDVA) was -0.01 ± 0.04 logMAR with a mean vault of 606.17 ± 108.33 microns. No complications were noted. However, too small a pupil is a limiting factor; this technique can be of use in up to mid-dilated pupils. Bimanual placement of haptics of ICL may represent a safe and effective technique in insufficient mydriasis or intraoperative pupillary miosis.

Aberrant regeneration of accommodation in pediatric inferior division oculomotor palsy.

Aberrant regeneration occurs in forms of oculomotor motor nerve palsy and frequently involves the pupil, but the incidence and functional impact of ciliary muscle involvement in pediatric patients is sparsely reported in the literature. A 4-year-old girl presented with inflammatory oculomotor motor nerve paresis affecting the inferior division. Initial treatment focused on her inability to accommodate through her physiologic +2.5 D hyperopia and the prevention and treatment of amblyopia. She subsequently developed aberrant regeneration of the pupil, with miosis on adduction. Following eye muscle surgery for residual exotropia and hypertropia, her dry refraction was noted to be more myopic in the affected eye on adduction, mirroring aberrant pupillary constriction. Recognition of pediatric aberrant regeneration of accommodation may influence surgical planning for oculomotor nerve palsy and/or management of amblyopia.

Pearls & Oy-sters: Ocular Myasthenia Gravis: Central Ocular Motor Signs and Unilateral Visual Loss Caused by the Great Neuro-Ophthalmologic Impersonator.

Myasthenia gravis (MG) has been described as a great mimicker of other neurologic and ocular motility disorders, including centrally mediated ophthalmoplegia. For example, ocular myasthenia gravis (ocular MG) may cause impaired binocular visual acuity for near vision due to reduced accommodation or for distance vision due to accommodative excess. Notably, accommodative excess due to ocular MG is rare, but may occur with exotropia, with or without diplopia. We report 2 cases of ocular MG: First, a 32-year-old man with exotropia, bilateral hypometric and slowed adducting saccades with dissociated abducting nystagmus, miosis, and decreased distance vision in his right eye; second, a 45-year-old man with similar ocular motor deficits, miosis, and myopia. Both patients showed ocular motor deficits which appeared to localize to the pons but were instead due to ocular MG. Ocular MG should be considered in patients who present with reduced visual acuities due to any disruption in accommodation. Any ocular motor deficit, even if appearing to be centrally mediated or occurring without ptosis, may be caused by ocular MG.

Surgical time and efficacy of illuminated chopper-assisted cataract surgery involving miosis after femtosecond laser pretreatment.

PURPOSE: To evaluate the efficacy of the illuminated chopper-assisted cataract surgery in terms of shortening the surgical time in eyes with miosis after femtosecond laser pretreatment. METHODS: As retrospective study, three hundred thirty-six eyes of 336 consecutive patients who underwent the femtosecond laser and illuminated chopper-assisted cataract surgery were included. Cases with pupil less than 6 mm after femtosecond laser pretreatment were included in the miosis group. Pupil diameter, surgical time, and improved efficacy (100/surgical time×pupil size) were compared between eyes with and without miosis. RESULTS: Of 336 eyes, 20 were included in the miosis group (6.0%). Pupil diameter was smaller in eyes with miosis than in those without miosis (5.23 ± 0.38 mm vs 7.35 ± 0.64 mm, p < 0.001); however, surgical time was not different (6.86 ± 0.73 min vs 6.60 ± 1.27 min, p = 0.071) between the two groups. Mechanical pupil dilations were not needed in any cases. As a result, improved efficacy was calculated to be higher in patients with miosis (2.83 vs 2.14, p < 0.001). CONCLUSION: In terms of surgical time and improved efficacy, using the illuminated chopper simplified cataract surgery involving miosis after femtosecond laser pretreatment. The use of an illuminated chopper is expected to be a good solution for femtosecond laser-assisted cataract surgeries.

Pharmacological management of intra-operative miosis during cataract surgery.

Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.

Pharmacological Accommodative Changes of the Anterior Segment and Its Impact on the Vault in Implantable Collamer Lens Implantation.

PURPOSE: To estimate the accommodative changes of the anterior segment and its impact on the central and peripheral vaults after Visian Implantable Collamer Lens (ICL) (STAAR Surgical) implantation. METHODS: Eighty eyes of 40 consecutive patients (mean age: 28.05 years; range: 19 to 42 years) were examined 3 months after ICL implantation. Eyes were randomly divided into a mydriasis group and a miosis group. Anterior chamber depth (ACD) to crystalline lens (ACD-L), anterior chamber depth to ICL (ACD-ICL), central distance from endothelium to sulcus to sulcus (ASL), central distance from sulcus to sulcus to crystalline lens (STS-L), central distance from ICL to sulcus to sulcus (STS-ICL), and central (cICL-L), midperipheral (mICL-L), and peripheral (pICL-L) vaults were measured by ultrasound biomicroscopy at baseline and after induction with tropicamide or pilocarpine. RESULTS: After tropicamide treatment, cICL-L, mICL-L, and pICL-L decreased from 0.531 ± 0.200, 0.419 ± 0.173, and 0.362 ± 0.150 mm to 0.488 ± 0.171, 0.373 ± 0.153, and 0.311 ± 0.131 mm, respectively. The values decreased from 0.540 ± 0.185, 0.445 ± 0.172, and 0.388 ± 0.149 mm to 0.464 ± 0.199, 0.378 ± 0.156, and 0.324 ± 0.137 mm after pilocarpine administration, respectively. The ASL and STS showed a significant increase in the mydriasis group (all P ≤ .038), but a decrease in the miosis group (all P < .001). The ACD-L increased and STS-L decreased in the mydriasis group (all P < .001), indicating the backward shift of the crystalline lens, whereas crystalline lens forward shift was observed in the miosis group. Additionally, the STS-ICL decreased in both groups (all P ≤ .021), suggesting the ICL backward shift. CONCLUSIONS: Both central and peripheral vaults decreased during the pharmacological accommodation process, and the ciliaris-iris-lens complex contributed to the changes. [J Refract Surg. 2023;39(6):414-420.].

A new intraocular lens marker to guide the implantation of toric intraocular lenses in small and mid-dilating pupils.

Insufficient pupillary dilatation is a significant challenge during cataract surgery, as it increases the risk of various intraoperative complications. Implantation of toric intraocular lenses (TIOL) is particularly difficult in eyes with small pupils, as the toric marks are provided in the periphery of the IOL optic, making the visualization of the same difficult for proper alignment. Attempts at visualizing these marks using a second instrument such as a dialler or iris retractor lead to additional manipulations in the anterior chamber resulting in increased chances of postoperative inflammation and intraocular pressure rise. A new intraocular lens (IOL) marker to guide the implantation of TIOLs in eyes with small pupils is described, which can potentially be beneficial in achieving accurate alignment of toric IOLs in small pupils, without the need for additional manipulations, thus improving safety, efficacy, and success rates of TIOL implantation in these eyes.

A novel Y-shaper and chopper for small pupil management in cataract surgery: The initial experience.

Small pupil is a well-known risk factor for causing cataract surgery complications such as vitreous loss, anterior capsular tear, increased inflammation, and an irregular pupil shape. Because all currently available pharmacological approaches of dilating the pupil before or during cataract surgery cannot guarantee the result, the surgeon sometimes resorts to the use of mechanical pupil-expanding devices. However, these devices can increase the overall surgical cost and operative time. Very frequently, a combination of the two is needed; thus, we present the Y-shaped chopper designed by the authors, which serves the purpose of managing the intra-operative miosis and allows simultaneous nuclear emulsification.

Light- and drug-induced pupillary dynamics in eyes with a retropupillary iris-claw intraocular lens.

PURPOSE: We evaluated the pupillary characteristics and response to light and drugs in eyes with posterior chamber (PC) placement of iris-claw intraocular lens (IC-IOL). METHODS: In this cross-sectional, comparative study, we included adults with an IC-IOL implanted in the PC of a single eye. We excluded patients with ocular trauma, postoperative IC-IOL displacement or complications, and extended iris atrophy. We used anterior segment optical coherence tomography to perform light-controlled pupillography, measure the pupil diameter (PD), and estimated the pupil circularity under mesopic conditions. PD was also assessed under photopic, scotopic, pharmacological mydriasis, and miosis conditions. The results were compared to those of the fellow eye, phakic, or regular pseudophakic. RESULTS: The IC-IOL and control groups included 30 eyes each. The most frequent reasons for IC-IOL implantation were complicated cataract (37%) and dislocated/luxated prior IOL (33%). Compared to the control group, the IC-IOL group had lower visual acuity, a smaller PD under scotopic conditions (p = 0.0010) and after pharmacological mydriasis (p < 0.0001), and a larger PD after pharmacological miosis (p < 0.0001). Mesopic pupil circularity was comparable between the groups. We also considered ongoing extraocular treatments with possible effects on iris motility. CONCLUSIONS: The pupillary size and profile were similar between the groups in mesopic light. Reduced mydriasis was noted in response to light and drugs, while the degree of miosis was reduced in response to inducing drugs in the IC-IOL compared to the control group. This study complements previous results concerning the PC placement of IC-IOLs by adding original observations on drug-induced pupil motility.

Coma, Severe Hypotension, and Pinpoint Pupils After Olanzapine Intoxication in the Intensive Care Unit with Symptom Reversal After Administration of Flumazenil.

BACKGROUND Olanzapine is an antipsychotic drug and is used in critical care to treat delirium. There is no known antidote to olanzapine intoxication. Overdosing olanzapine can cause, tremor, bradykinesia, hypotension somnolence, coma, and miosis. CASE REPORT We present the case of a previously healthy 69-year-old man who after routine mitral valve surgery developed pneumonia and severe sepsis requiring several weeks on a ventilator in the Intensive Care Unit. He developed delirium and paranoia and was prescribed olanzapine. After 4 doses, he became hypotensive and nonresponsive and developed pinpoint pupils. The symptoms were reversed minutes after administration of flumazenil. The clinical picture in this case corresponds well with an olanzapine intoxication. No other drugs, such as benzodiazepines or opioids, had been administered that could explain the reaction. Olanzapine intoxication is known to present with hypotension, coma, and miosis. The doses given were normal starting doses for olanzapine in the outpatient setting but much higher than recommended doses in the intensive care setting. CONCLUSIONS This case illustrates a risk for severe adverse effects, even within normal prescription range, when olanzapine is used in the intensive care setting. Finally, it is intriguing that the symptoms were reversed after administration of flumazenil, a selective competitive antagonist of the GABA receptor. Olanzapine mainly effects dopamine, serotonin, a1-adrenergic, histamine, and muscarinic receptors, but a low affinity to GABA and benzodiazepine sites can perhaps explain the observed effect.

Tunnel-floor entry continuous curvilinear capsulorhexis technique: Rhexis in a controlled and stable anterior chamber always.

Continuous circular capsulorhexis (CCC) was demonstrated independently by Thomas Neuhann, Kimiya Shimizu, and Howard Gimbel in the 1980s and it finds mention in the landmark paper by Gimbel and Neuhann. The authors describe a technique of achieving the rhexis in a stable, viscoelastic-filled anterior chamber using the tunnel floor as the entry. This gets covered by the roof of the tunnel postoperatively and, therefore, does not leak. There is no oar-locking or striae even when cystitome goes beyond the edge of the tunnel. As there is no escape of the viscoelastic substance, there is no change in the pressure or shallowing of the anterior chamber. It is a useful technique for beginners. It is of great help in difficult cases like intumescent cataracts, shallow anterior chambers, hyperopes, nanophthalmos, pseudoexfoliation, small non-dilating pupils, intraoperative floppy iris syndrome (IFIS), and phacomorphic glaucoma.

"Show me the way" - Endoilluminator-assisted manual small-incision cataract surgery in a case of corneal scar with a small pupil.

Cataracts with coexisting corneal opacities due to various causes present a daunting challenge to surgeons. Adding to the plight could be factors like shallow anterior chamber, small pupil and mono-ocular patient. A manual small-incision cataract surgery (MSICS) could be a saviour in such situations. We demonstrate a case of post perforation corneal scar secondary to Hansen's disease with complicated cataract with non-dilating pupil in a bilaterally blind patient. Due to poor visualisation, there could have been difficulties in capsulorrhexsis, cortex aspiration & many other intraoperative manoeuvres, but use of an endo illuminator providing oblique illumination was very useful, resulting in uneventful surgery with good visual outcome. MSCICS, a surgery with minimal instrumentation, short learning curve and comparable results to phacoemulsification is perhaps the preferred procedure, in India, for complicated cataracts with multiple pre-existing pathologies.

The Effects of High Energy Capsulotomy on Aqueous Cytokine Profiles and Pupil Size During Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To assess whether aqueous cytokine profiles and pupil size are altered when high capsulotomy energy is used in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS), and if preoperative use of a topical non-steroidal anti-inflammatory drug (NSAID) has an effect on this. METHODS: This prospective study recruited 83 eyes (63 patients) that were allocated to four treatment groups: conventional phacoemulsification (n = 20 eyes); FLACS with 90% capsulotomy energy without NSAID pretreatment (n = 20 eyes); FLACS with 90% capsulotomy energy with NSAID pre-treatment (n = 21 eyes); and FLACS with 150% capsulotomy energy with NSAID pretreatment (n = 22 eyes). Aqueous humor was collected before and after phacoemulsification to assess cytokine profiles. Pupil size was measured before and after laser capsulotomy. RESULTS: FLACS increased aqueous concentrations of pros-taglandin E2 (PGE2), interferon γ (IFN-γ), and interleukin 6 (IL-6) compared to conventional phacoemulsification. However, when increasing capsulotomy energy from 90% to 150% (with topical NSAID pretreatment), there was no significant increase in aqueous concentrations of PGE2 (37.7 ± 21.7 vs 33.6 ± 27.6 pg/mL, P = .99), IFN-γ (3.6 ± 1.1 vs 3.6 ± 0.8 pg/mL, P = .99), or IL-6 (7.1 ± 2.9 vs 6.3 ± 2.4 pg/mL, P = .99). For 90% and 150% capsulotomy energy, there was significant miosis following laser capsulotomy. Increased PGE2 concentration was significantly correlated with a reduction in pupil area (r = -0.58, P < .001) and pupil diameter (r = -0.57, P < .001). However, when a topical NSAID was given preoperatively, there was no difference in the degree of miosis between the 90% and 150% capsulotomy energy groups. CONCLUSIONS: Pretreatment with a topical NSAID prevented a rise in PGE2, IFN-γ, and IL-6 levels and excessive miosis when a higher capsulotomy energy was used. When a topical NSAID is used preoperatively, it is safe to use higher capsulotomy energy settings (with a low pulse energy femtosecond laser system) to achieve a satisfactory capsulotomy. [J Refract Surg. 2022;38(9):587-594.].

Case Report: Novel STIM1 Gain-of-Function Mutation in a Patient With TAM/STRMK and Immunological Involvement.

Gain-of-function (GOF) mutations in STIM1 are responsible for tubular aggregate myopathy and Stormorken syndrome (TAM/STRMK), a clinically overlapping multisystemic disease characterised by muscle weakness, miosis, thrombocytopaenia, hyposplenism, ichthyosis, dyslexia, and short stature. Several mutations have been reported as responsible for the disease. Herein, we describe a patient with TAM/STRMK due to a novel L303P STIM1 mutation, who not only presented clinical manifestations characteristic of TAM/STRMK but also manifested immunological involvement with respiratory infections since childhood, with chronic cough and chronic bronchiectasis. Despite the seemingly normal main immunological parameters, immune cells revealed GOF in calcium signalling compared with healthy donors. The calcium flux dysregulation in the immune cells could be responsible for our patient's immune involvement. The patient's mother carried the mutation but did not exhibit TAM/STRMK, manifesting an incomplete penetrance of the mutation. More cases and evidence are necessary to clarify the dual role of STIM1 in immune system dysregulation and myopathy.

STIM1 and ORAI1 mutations leading to tubular aggregate myopathies are sensitive to the Store-operated Ca2+-entry modulators CIC-37 and CIC-39.

Gain-of-function mutations on STIM1 and ORAI1 genes are responsible for an increased store-operated calcium entry, and underlie the characteristic symptoms of three overlapping ultra-rare genetic disorders (i.e tubular aggregate myopathy, Stormorken syndrome, York platelet syndrome) that can be grouped as tubular aggregate myopathies. These mutations lead to a wide spectrum of defects, which usually include muscle weakness and cramps. Negative modulators of store-operated Ca2+-entry targeting wild-type STIM1 and ORAI1 have entered clinical trials for a different array of disorders, including pancreatitis, COVID-19, cancer, and autoimmune disorders and, while efficacy data is awaited, safety data indicates tolerability of this STIM1/ORAI1 mutations are amenable to pharmacological intervention. If this were so, given that there are no approved treatments or clinical trials ongoing for these rare disorders, it could be envisaged that these agents could also rehabilitate tubular aggregate myopathy patients. In the present contribution we characterized the Ca2+-entry patterns induced by eleven STIM1 and three ORAI1 mutations in heterologous systems or in patient-derived cells, i.e. fibroblasts and myotubes, and evaluated the effect of CIC-37 and CIC-39, two novel store-operated calcium entry modulators. Our data show that all STIM1 and ORAI1 gain-of-function mutations tested, with the possible exception of the R304Q STIM1 mutation, are amenable to inhibition, albeit with slightly different sensitivities, paving the way to the development of SOCE modulators in tubular aggregate myopathies.

Comparison of different pupil dilatation methods for phacoemulsification in eyes with a small pupil.

PURPOSE: To compare 6 methods for intraoperative pupil dilatation in eyes with insufficient pupil size during phacoemulsification. METHODS: This was a prospective case-control study. 99 microcoria cataract patients (120 eyes) were collected and were divided into 6 groups(20 eyes each group), and their pupils were dilated by bimanual stretching pupil (group I), pupil radial cut open(group II), mechanical pupil dilatation with iris-retractor hooks (group III), OASIS iris expander (group IV), and Malyguin-ring (Microsurgical company, America) (group V), B-HEX Pupil Expander (Med Invent Devics, India)(group VI),respectively. 3.0 mm clear corneal incision were used in phacoemulsification. All cases were followed up at 1 week and 1, 3, 6 months after the surgery. The best corrected visual acuity (BCVA), intraocular pressure(IOP), corneal endothelium cell density(ECD), pupil diameter(PD) of before and after surgery were compared. RESULTS: One same doctor finished all cataract surgeries successfully. The eyes' condition before surgery and at 6 months after surgery were compared. There were no significant statistical differences for the conditions of the eyes before surgery among six groups. The ECDs were better at 6 months postoperatively in group III and V, median values: 2114/mm2, 1961/mm2. PD was largest in group II (median value: 5.5 mm), which was significantly larger than other groups (Padjusted < 0.05). CONCLUSIONS: All 6 methods used in this study were effective for the mechanical dilatation of small pupils and didn't affect the postoperative visual acuity and intraocular pressure in microcoria cataract phacoemulsification. Iris-retractor hooks and the Malyugin Ring can reduce intraoperative corneal endothelium cell loss. Postoperative PD is larger when the iris was cut open radially.

Femtosecond laser-assisted cataract surgery in small pupils using non-aligned iris expansion ring without viscoelastic and corneal suture.

PURPOSE: To describe a technique for cataract surgery in eyes with small pupils that combines the use of the femtosecond laser and an iris expansion device, but without the use of corneal sutures and an ophthalmic viscosurgical device (OVD) at the time of laser application. METHODS: A retrospective case series of three eyes with small pupils were operated by the same surgeon without a corneal suture and with removal of anterior chamber OVD prior to laser application. RESULTS: Corrected distance visual acuity (CDVA) for 1 eye in a 70 year-old patient was 20/70 preoperatively and 20/20 thirty days postoperatively. CDVA for a second patient was 20/50 and 20/200 in the two eyes, which improved to 20/25 two months postoperatively in both eyes. There were no complications observed and the intraocular lens were well-centered. CONCLUSION: The use of mechanical pupil expander rings is safe and practical in setting small pupils during femtosecond laser-assisted cataract surgery.

Evaluation of a uniplanar pupil expansion ring in small-pupil cataract surgery: a feasibility study.

PURPOSE: The aim of this study was to evaluate the effectiveness of a disposable uniplanar pupil expansion device in small-pupil cataract surgery. METHODS: This is a feasibility study carried out at the Rothschild Foundation, Paris, France. Patients undergoing routine cataract surgery with a dilated pupil size < 6 mm, and who agreed to participate in the study were included. The trial enrolled 25 patients, of whom 21 proceeded to cataract surgery using the pupil expansion device to be evaluated. The pupil diameter was measured at defined stages during the cataract surgery, which was performed by a single surgeon, in a single center setting. The 1st generation Bhattacharjee pupil expansion ring was used if the preoperative pupil size was < 6 mm. Intraoperative and postoperative adverse events were recorded. RESULTS: Pupil size immediately after the Bhattacharjee ring implantation was ≥ 6 mm for 15 eyes (71.4%). The mean dilated pupil size before ring insertion was 4.5 ± 0.8 mm (range 2.5-5.8 mm), and the mean pupil size after ring insertion was 6.1 ± 0.3 mm (range 5.9-6.8 mm). Mean pupil size following removal of the ring was 4.2 ± 0.8 mm (range 2.5-5.4 mm). Two adverse events occurred during the surgeries: 1 Bhattacharjee ring broke prior to implantation, and 1 implanted Bhattacharjee ring was unstable and removed before the end of the surgery. No postoperative adverse event was recorded. CONCLUSIONS: The Bhattacharjee ring is an effective pupil expansion device, which facilitates stable pupil expansion during cataract surgery. This study was registered as a clinical trial at clinicaltrials.gov under the number NCT02434588.

[Surgical treatment of hypermature cataract in patients with lens subluxation and small pupil]. / Khirurgicheskoe lechenie perezreloi katarakty pri uzkom zrachke i podvyvikhe khrustalika.

Studying the possibilities of hybrid (femtosecond laser-assisted) phacoemulsification in complicated situations is a relevant problem in cataract surgery. PURPOSE: To develop a technique for hybrid (femtosecond laser-assisted) phacoemulsification in patients with a combination of hypermature cataract, small pupil and lens subluxation. MATERIAL AND METHODS: Hybrid (femtosecond laser-assisted) phacoemulsification of hypermature cataracts was performed in 36 patients (36 eyes) aged 63 to 78 years with grade I-II lens subluxation in combination with small pupil. The initial circular femtolaser capsulotomy was performed within the small pupil using the VICTUS system (Technolas Perfect Vision, Germany). After dilating the pupil with retractor hooks, the capsulorhexis was manually expanded to the required diameter. RESULTS: In all cases, the resulting capsulorhexis had a regular round shape with a smooth edge, without radial ruptures. This made it possible to apply modern methods of fixation and centration of the capsular bag in case of lens subluxation and to perform intracapsular implantation of an intraocular lens (IOL). Complete intracapsular fixation of the IOL with optics edge fully covered by the edge of the capsulorhexis in the postoperative period was achieved in 34 (94.4%) cases. In 2 (5.6%) cases in the postoperative period, the edge of the capsulorhexis exceeded the edge of the IOL optics. The loss of corneal endothelial cells 3 months after surgery was 8.8±1.9%. CONCLUSION: The use of the proposed combined technique of capsulorhexis made it possible to perform the most physiologically appropriate intracapsular IOL implantation in all patients with hypermature cataract, small pupil and lens subluxation.