Cannula-vacuum continuous curvilinear capsulorhexis: Inexpensive technique for intumescent total cataract.

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.

[EyeSi surgical simulator: Construct validity of capsulorhexis, phacoemulsification and irrigation and aspiration modules]. / Simulateur de chirurgie de cataracte EyeSi : validité de construction des modules capsulorhexis, phacoémulsification et aspiration des masses cristalliniennes.

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.

A Prechop Technique Using a Reverse Chopper.

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.

Intraoperative performance and ultrastructural integrity of human capsulotomies created by the improved precision pulse capsulotomy device.

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.

Zepto-rhexis: A new surgical technique of capsulorhexis using precision nano-pulse technology in difficult cataract cases.

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.

Clinical results of the open ring PMMA guider assisted capsulorrhexis in cataract surgery.

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 mm2) than that of the free-hand group (20.34 ± 2.96 mm2, 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.

[Capsulorhexis Real-Life - Experienced Surgeon versus Femto Laser Assisted Cataract Surgery (FLACS) as Reported in Literature]. / Kapsulorhexis Real-Life ­ erfahrener Operateur versus Literaturdaten zur Femto Laser Assisted Cataract Surgery (FLACS).

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.

Ultrastructural Integrity of Human Capsulotomies Created by a Thermal Device.

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.

Zepto precision pulse capsulotomy: A new automated and disposable capsulotomy technology.

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.

Avaliação da eficácia de um novo marcador cirúrgico para capsulorrexe anterior / Effectiveness evaluation of a new surgical marker for anterior capsulorhexis

RESUMO Objetivo: Avaliar a eficácia de um novo marcador cirúrgico para ajudar na confecção da capsulorrexe anterior analisando o seu dimensionamento e formato, comparando com a capsulorrexe confeccionada manualmente de maneira livre. Métodos: Como experimento, 3 residentes (R3) de Oftalmologia do Hospital Universitário Onofre Lopes (HUOL) e 1 oftalmologista em treinamento, voluntários, realizaram (cada um) 10 capsulorrexes em olhos de porco enucleados. Em 5 olhos foi utilizado o marcador e em outros 5, não. Todos os olhos foram fotografados tendo ao lado uma régua para orientar e calibrar um aplicativo para a avaliação morfométrica do procedimento. O diâmetro alvo foi de 5 mm, cujo perímetro correspondente é 15,7 mm e a área 19,652 mm2. Foram avaliados em cada procedimento: os diâmetros máximo, mínimo e médio, o perímetro, a área e o desvio em relação ao diâmetro e quanto ao aspecto ideal. Resultados: No grupo utilizando o marcador o diâmetro médio foi 5,44mm (±0,89) contra 6,37mm (±0,67) (p=0,001), no grupo no qual não se utilizou o marcador; quanto ao perímetro, 17,52mm (±1,92) no grupo utilizando o marcador contra 20,14mm (±2,09) (p<0,001) sem o marcador e quanto a área, 24,73mm2 (±1,92) com o marcador, contra 32,62mm2 (±6,32) (p<0,001), sem o marcador. Em relação ao aspecto da capsulorrexe 1,26mm (±0,12), contra 1,21mm (±0,7) (p=0,09) e em relação ao desvio de curvatura: 0,87 (±0,05), contra 0,9 (±0,04), (p=0,06) respectivamente. Conclusão: O trabalho mostrou que o marcador avaliado é eficaz para auxiliar a confecção da capsulorrexe conduzindo a resultados melhores que o método a mão livre.

ABSTRACT Purpose: To evaluate the effectiveness of a surgical device that intented to help in the preparation of the anterior capsulorhexis analyzing the design and shape, comparing with capsulorhexis made by free hand. Methods: Three ophthalmology residents(R3) at the HUOL and one surgeon in training, participate in this research as volunteers. Each surgeon perform 5 capsulorhexis in porcine eyes using the device, and five others by free hand as a control. All capsulorhexis were photographed having a ruler as reference to guide and calibrate a computer application for morphometric evaluation (Cambuí Labs, Natal, Brazil). All surgeons aimed to produce a circular continuous capsulorhexis of 5 mm diameter that represents 15,7mm in perimeter and 19,652mm2 in area. Each wet-lab capsulorhexis was evaluated in regard to these criteria: diameter (mean, maximum and minimum), perimeter, area, deviation from the ideal diameter and ideal shape. Results: Compare to control groups, capsulorhexis with the aid of the surgical device showed: 5,44mm ±0,89 vs 6,37mm ±0,67, for capsulorhexis diameter (p=0,001); 17,52mm ±1,92 vs 20,14mm ±2,09 for capsulorhexis perimeter (<0.001); 24,73mm2 ±1,92 vs 32,62mm2 ±6,36 for capsulorhexis area (p<0,001). A tendency for better result with the aid of the surgical device was observed for deviation of an ideal diameter or ideal aspect were appreciated: 0,87mm ±0,05 vs 0,9 ±0,04 for deviation of a curve (p=0,06); 1,26mm ±0,12 vs 1,21mm ±0,7 for the capsulorhexis aspect (p=0,09). Conclusion: Capsulorhexis produced with the aid of the surgical device, significantly improved wet-lab capsulorhexis performance.

[Combined YAG-laser capsulotomy in pseudophakic patients with anterior capsular contraction syndrome]. / Tekhnologiia kombinirovannoi lazernoi kapsulotomii pri perednekapsuliarnom kontraktsionnom sindrome v artifakichnykh glazakh.

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.

Continuous Curvilinear Capsulorhexis Performed With the VERUS Ophthalmic Caliper.

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.].

Stabilizing the capsular bag and expanding the pupil with a pupil expansion device.

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.

Open ring-shaped guider for circular continuous curvilinear capsulorhexis during cataract surgery.

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.

Cystotome-assisted prechop technique.

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.

New device for creating a continuous curvilinear capsulorhexis.

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.

Bean-shaped ring segments for capsule stretching and centration of bag-in-the-lens cataract surgery.

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.