With an intumescent white cataract, we know that the capsular bag is filled with fluid — liquefied lens cortex material. This increases the pressure within the capsular bag and the danger during a normal capsulorhexis is that it can radialize and lead to complications such as posterior capsule rupture, retained lens material, and more.
To create an opening in the anterior lens capsule we have many options:
- depressurize the lens capsule by aspirating fluid using a needle or even the phaco probe
- use the double capsulorhexis technique to keep the anterior chamber pressure higher than the intra-lenticular pressure for the initial small capsulorhexis, then enlarging to the regular size capsulorhexis once the lens has been depressurized
- use a device like the Zepto capsulotomy system to instantly create the capsulotomy in the anterior capsule (full video of this device coming soon to CataractCoach)
- use a femtosecond laser to create the capsulotomy while the eye is closed, before the first incision is made. This works well, but is far more expensive than other methods
In our surgery center in Beverly Hills, we are fortunate to have access to multiple femtosecond lasers, so in this case I used it to create the anterior lens capsulotomy with a diameter of 5.3 mm. We must be very careful that there are no adherent capsule tags with these white cataracts because sometimes the capsule can be fibrotic. In addition, the opaque nature of the lens means that we cannot use the femtosecond laser to fragment the cataract.
We still use trypan blue dye to stain the capsule to aid in visualization and in this case, I place the central capsule remnant on the corneal surface to inspect it and ensure that it is round and without defects. A defect of the capsule remnant would imply that the corresponding part of the capsular bag would also have a defect. Fortunately, all is well here.
Click below to learn about using a femtosecond laser to assist in this white cataract case: