Making small capsulorhexis makes the cataract surgery more difficult because it limits access to the capsular bag and makes it tougher to bring nuclear pieces out of the capsular bag. When the capsular tissue opacifies with time, it can also restrict the effective pupil size and compromise night vision. And with an overly small capsulorhexis, the risk of complications can be higher as we explained in the video entitled The Curse of the Baby Rhexis.
There are some cases where a baby capsulorhexis is done at the beginning and then later enlarged prior to nucleus removal such as with intumescent white cataracts. We have explained that in detail here and here on CataractCoach where we called it the double rhexis technique.
In this routine case, there is no reason for a small capsulorhexis. You can see from the picture above that this is about a 4-mm capsulorhexis and that will make many parts of the surgery more challenging. Then at the end of the video, I show a solution to restore a normal capsulorhexis size.
Click below to learn about the perils of a baby capsulorhexis:
The enlargement cut seems a bit perpendicular here (you’ve mentioned it should be tangential in other videos). You enlarged the rhexis 360 degrees so it wasn’t a big deal but I wonder: suppose you were only able to enlarge the capsule about 180 degrees with that cut. Would you be worried about tearing out the rhexis during I/A with that new area of weakness?
I’ve been in this situation several times — staring at a baby rhexis at the end of an otherwise normal case and wondering what to do…honestly, in this case, I may have left it well enough alone. You know the patient will have great vision–the IOL is centered and super stable–and you can do a few relaxing cuts with a YAG later on if there’s concern for capsular contraction. I may be overemphasizing the “don’t let the perfect be the enemy of the good” mantra but I would love to hear your thoughts.
Thanks again for these videos! It’s whetting my appetite to get back into the OR. Hope you and your loved ones are doing well during these pandemic times. I’d love to get a video about your commentary about this whole situation (your “philosophical” posts are great!) and how to stay sharp in the OR during this extended time away.
Good points. If the enlargement is 180 degrees without an area of runout, then the risk during IA should be quite low. True about the saying of perfect is the enemy of good. All boils down to surgical judgment. And great idea about a video regarding the virus issue. I have one in process.