Would you implant a CTR: Capsular Tension Ring?

This challenging cataract case has loose zonular architecture globally, not focally. There is no prior trauma and there is not a focal area of confined zonular loss or weakness. All of the zonular attachments seem lax and the anterior capsule wrinkles when we attempt to puncture it. There is no other ocular disease such as pseudo-exfoliation syndrome. The patient is 90 years old and is in reasonable health, but of course there are challenges in surgery for nonagenarians.

We are still able to create a round and well-centered capsulorhexis and we can remove the nucleus without issues. Even cortex removal is straightforward and no evidence of zonular loss or breakage appears during that critical step. When we implant the single-piece toric IOL into the capsular bag, we note that the formerly round capsulorhexis is now oval shaped, corresponding to the position of the haptics. The IOL appears stable and there is no pseudo-phakodonesis. We want to use a toric IOL given the high degree of corneal astigmatism. Note that there is no sulcus-based toric IOL in the US, so that is not an option.

Would you implant a CTR or leave it as is? Please leave a comment below

Click below to see this video and decide if you would place a CTR:


  1. yes, I will not hesitate to put in a CTR before single-piece IOL insertion because this will make the IOL more stable in the bag especially the toric IOL

  2. Had a very similar case 5 years ago. Very proud that I could complete case despite overall laxity. Pt fine until this year. IOL hangng down in the vitreous. I should have put in a CTR but not dial it in but open the incision a bit and place it with forcepts by holding it with the ends crossed

  3. I too feel the case ist best left as is – not much benefit in a CTR now as long as the toric IOL is well positioned. Capsular shrinking will lock the IOl in place eventually – probabbly even a little fast if the bag isn’t strechted out to the max.
    If, however positioning the toric where you want had become a problem a CTR might have helped – this defenitely is not a case where you want to go back in and try to rotate the IOL in a few weeks.

    1. this was my thinking as well. I left the patient as-is and everything looks good now. Time will tell, though the patient is already 90 years old.

  4. Dear Uday, nice video and beautiful case.
    I would implant a CTR, as you said it in the video, during cortical clean up you could notice a floating rhexis. With the wrinkles during capsulorhexis you can predict some kind of zonular weakness. During toric implantation you certainly want the IOL be on axis, so no doubt about a CTR. Even this 90 year old patient deserves a well centered toric lens and the best possible result.
    My moment for implantation of the CTR would be before lens implantation after filling up the bag with OVD.

    Keep up the good work with your videos!

  5. Dear Uday:
    Multiple surgery should be avoided in a 90 yo.
    Minimal manipulation, here. Well done.

    1. Had a similar case 5 years ago. Now the lens in half way into the vitreous and the patient is looking at a much bigger procedure than putting in a capsular tension ring. You can’t always count on Father Time to help you out.

      1. Good point. Do you think that a CTR would have prevented these issues for your patient?

      2. Hindsight’s 20/20 and it’s possible CTR insertion could have made everything worse. Could have gone from loose zonules to everything going south right then. on the other hand maybe it would have given him a couple more years of a centered IOL. probably a couple gortex sutured segments and he could live longer than me with a centered IOL. Where is the crystal ball when u need it😊

      1. actually if we take decision to put CTR we have to put in our mind more stress on capsular bag , in my opinion capsular segment will do better because it will be sutured on sclera

Leave a Reply