This patient has severe capsular phimosis which happens where there is weak zonular support and aggressive contraction and fibrosis of the anterior lens capsule. This made the 5 mm diameter capsulorhexis shrink down to about 1.5 mm in diameter. We have covered this topic of capsular phimosis extensively before and you should know that the conditions which lead this include pseudoexfoliation and retinitis pigmentosa. This capsule will be tough to tear due to the fibrosis, so an alternate method such as micro-scissors, anterior vitrector, Zepto capsulotomy, or femtosecond laser capsular opening should be used. And our surgeon uses this last method. Great job and definitely worthy of a careful watch.
This might be the ONLY situation where a femtosecond laser would provide some advantage in lens surgery. Fortunately extensive phimosis is a very rare situation and completely avoidable with LEC cleanup. The capsule opening can also be enlarged/ created with a curved 23g disposable vitreoretinal scissor. It is also important to keep in mind that zonular degradation/weakness is frequently associated with extensive capsulor fibrosis and phimosis.
Thanks Steve! This case is from 2016, and I agree, this and the occasional subluxated lens I still leave FLACS in my back pocket. I know the true masters will do a great job using small gauge scissors, but in my novice hands this produces a safer and “prettier” outcome! Let’s not forget YAG, that is a great first line!