Lost Capsulorhexis – here is the Solution

lost rhexis title

This patient is having cataract surgery but during capsulorhexis creation, the flap edge seems to get lost. And due to the poor view from multiple cortical spokes, the visualization is poor. How do we proceed at this point? Can we will still achieve an intact capsulorhexis without radialization? Or must we resort to a “can-opener” approach?

One solution is to re-start the rhexis by cutting or nicking the existing capsular opening edge and then continuing with the capsulorhexis. Care must be taken to avoid the issue of having an area of weakness or radialization which could zip around to the posterior capsule and cause significant complications.

The “can-opener” approach will work and by creating many points of anterior capsular weakness, it spreads any forces around thereby decreasing the risk of a posterior extension of one of these capsular tears.

Our solution is to create a new capsulorhexis which is larger than the initial capsular opening so that any irregularity is fully encompassed and any irregular edges are eliminated.

rhexis lost fix

Click below to see the video of this technique in action:

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    1. Yes, indeed, that would be a good option. In this case, the resident had already injected dispersive viscoelastic into the eye. And with the anterior lens capsule coated with OVD, it makes it hard for the trypan blue dye to stain the lens capsule. For future cases like this I recommended to the young doctor that trypan blue dye would make life easier.

      1. I love your coaching series.

        I would suggest that at the time of poor visualization that you stop and stain. Remove the OVD with the IA through the main incision being careful not to touch the flap. Then add air through paracentesis. Then add trypan blue stain also being careful not to touch the capsule. You cannot use the usual technique of rubbing the anterior capsule with stain as you may extend existing tear. Then wash out residual stain and bubble with BSS. Then reintroduce the OVD. You should now be able to see the capsule despite poor reflex from the cortical cataract.

        Thank you again for all of your hard work for ophthalmology!

      2. Great idea — I usually avoid trying to stain the anterior capsule because the dispersive viscoelastic makes it tough for the blue dye to stain the capsule. Removing the OVD with I/A is a solution for that. I appreciate the tip and will keep it in mind for next time! This CataractCoach project is also a learning experience for me 🙂

  1. Which is the side port blade being used to nick the capsule ? Can we use the routine disposable side port blades?

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