What is the secret to a perfect capsulorhexis?

capsulorhexis perfect title

When I examine an eye that had previous cataract surgery years ago, I see two things: the incision and the capsulorhexis. And based on those, we sometimes make a judgment as to the skills of the previous surgeon. We have no idea as to the prior post-op inflammation, corneal edema, or even macular swelling — all of which have resolved with the healing process. How can we make the ideal incisions and the perfect capsulorhexis in order to produce a beautiful result and more importantly, to provide the best visual results for our patients?

The incision must have a good architecture that seals well, induces little astigmatism, and heals quickly. The capsulorhexis should ideally overlap the optic a full 360° and securely hold the IOL in position for decades to come. If we start the cataract surgery with a great incision an a precise capsulrhexis, the rest of the case will unfold nicely with a lower risk of complications and better visual results for our patients.

A good incision is critical because it plays an important part in the fluidics of the surgery, the flow of cataract material to the phaco probe, and the stability of the anterior chamber. The capsulorhexis stays intact during intra-capsular maneuvers such as nucleus division and cortex removal and it holds the IOL optic securely in position and keeps it planar for optimal refractive results.

The secret to the perfect capsulorhexis is multi-factorial:

  • have great incisions which help retain viscoleastic to keep the anterior chamber formed during capsulorhexis creation
  • float within the incisions and pivot so that the anterior chamber is stable
  • use markings on the forceps to measure the capsulorhexis as it is created
  • have the tip of the forceps trace the perfect circle and the capsulorhexis will follow
capsulorhexis measurement
These forceps have a mark that is 2.5 mm from the tip (radius of the capsulorhexis) shown in green and another that is 5.0 mm from the tip (diameter of the capsulorhexis) shown in yellow.

 

The following video is shown in slow motion (about 50% of normal speed) in order to emphasize these important techniques during cataract surgery:

video is here:

 

©2018 Uday Devgan MD. All rights reserved.

 

5 Comments

  1. Dear Mr. Devgan,
    How do you deal with very elastic ant. capsule in a young patient. Had a case like this. The flap continuously was running out… I have used a lot of viscoelastic, however it was still misbehaving.
    Thanks!
    Kind regards,
    Cezara

    1. you can stain it with Trypan blue to make it less elastic, then keep the AC highly pressurized with a good viscoelastic. Then bring the rhexis inwards as you tear it in order to counteract the elastic pulling force.

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