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Forceps capsulorhexis
CORRESPONDENCE
Figure 3. (Rao) Mobilizing the strip of cortex on the posterior capsule allows its easy removal by the I/A probe.
be effective in this situation. Pulling on the longer strip of cortex on the posterior capsule may allow easier removal of the shorter anterior segment, as in our case. Since the angulation of the anterior and posterior strips at the equator of the capsular bag is also different, we are not sure whether this plays a role in the phenomenon described. SRINIVAS K. RAO, MD PREMA PADMANABHAN, MD Chennai, India
References 1. Menapace R, Findl O, Georgopoulos M, et al. The capsular tension ring: designs, applications, and techniques. J Cataract Refract Surg 2000; 26:898 –912 2. Sudhir RR, Rao SK. Capsulorhexis phimosis in retinitis pigmentosa despite capsular tension ring implantation. J Cataract Refract Surg 2001; 27:1691–1694 3. Faschinger CW, Eckhardt M. Complete capsulorhexis opening occlusion despite capsular tension ring implanation. J Cataract Refract Surg 2000; 25:1013–1015
Forceps Capsulorhexis
C
ontinuous curvilinear capsulorhexis is routinely performed with a forceps. Most surgeons in the West use high-viscosity viscoelastic substances such as sodium hyaluronate, which significantly facilitates the capsulorhexis performed with a forceps. One bolus of sodium hyaluronate is retained in sufficient quantities to allow the entire capsulorhexis to be completed in 1 step. However, sodium hyaluronate is an expensive viscoelastic material and is thus not readily accessible to surgeons in developing countries. Alternatively, hydroxypropyl methylcellulose 2% (HPMC) is used for the capsulorhexis. The problem with using this dispersive viscoelastic material while making a capsulorhexis with a forceps is that it is not retained well in the anterior chamber. The viscoelastic
material continuously escapes from the 2.8 to 3.2 mm clear corneal incision, leading to shallowing of the anterior chamber and an increased risk of extension of the capsulorhexis. This is especially likely when capsulorhexis is done by trainee surgeons who take more time to maneuver the flap and complete the procedure. The continuous loss of viscoelastic material also creates a problem if the margin of the capsulorhexis has strayed to the periphery and one is trying to bring it to the center. To avoid this difficulty, the surgeon usually withdraws the forceps, reinflates the anterior chamber with HPMC, and proceeds with the capsulorhexis. This may have to be done 2 or 3 times before the capsulorhexis is completed. A simple way to overcome this problem is to continuously inject viscoelastic material through the side port with 1 hand while the other hand performs the capsulorhexis. The cannula of the viscoelastic syringe is put through the side port and viscoelastic material is continuously injected to maintain a deep anterior chamber and flatten the curvature of the anterior lens surface, while the forceps is being moved to perform the capsulorhexis. A balance must be kept between the amount of viscoelastic material being injected through the side port and the amount being lost via the main clear corneal incision to maintain a stable chamber and avoid excessive injection of viscoelastic material. The cannula put through the side port performs the additional function of stabilizing the globe while the capsulorhexis is performed. This simple technique helps the surgeon complete the forceps capsulorhexis in a single step, considerably decreasing the time spent on the procedure. It also helps to keep the anterior chamber well inflated throughout the procedure and thus decreases the chance of extension of the capsulorhexis. This will be a useful procedure for all trainee surgeons who are performing capsulorhexis with a forceps under HPMC. If the surgeon uses a bent 26-gauge needle mounted on a syringe instead of a forceps to perform the capsulorhexis, the syringe can be filled with HPMC. This is injected into the anterior chamber while the capsulorhexis is being performed without having to withdraw the needle and inject HPMC through the side port.
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002
TANUJ DADA, MD HARINDER SETHI, MD New Delhi, India 1491
Figure 3. (Rao) Mobilizing the strip of cortex on the posterior capsule allows its easy removal by the I/A probe.
be effective in this situation. Pulling on the longer strip of cortex on the posterior capsule may allow easier removal of the shorter anterior segment, as in our case. Since the angulation of the anterior and posterior strips at the equator of the capsular bag is also different, we are not sure whether this plays a role in the phenomenon described. SRINIVAS K. RAO, MD PREMA PADMANABHAN, MD Chennai, India
References 1. Menapace R, Findl O, Georgopoulos M, et al. The capsular tension ring: designs, applications, and techniques. J Cataract Refract Surg 2000; 26:898 –912 2. Sudhir RR, Rao SK. Capsulorhexis phimosis in retinitis pigmentosa despite capsular tension ring implantation. J Cataract Refract Surg 2001; 27:1691–1694 3. Faschinger CW, Eckhardt M. Complete capsulorhexis opening occlusion despite capsular tension ring implanation. J Cataract Refract Surg 2000; 25:1013–1015
Forceps Capsulorhexis
C
ontinuous curvilinear capsulorhexis is routinely performed with a forceps. Most surgeons in the West use high-viscosity viscoelastic substances such as sodium hyaluronate, which significantly facilitates the capsulorhexis performed with a forceps. One bolus of sodium hyaluronate is retained in sufficient quantities to allow the entire capsulorhexis to be completed in 1 step. However, sodium hyaluronate is an expensive viscoelastic material and is thus not readily accessible to surgeons in developing countries. Alternatively, hydroxypropyl methylcellulose 2% (HPMC) is used for the capsulorhexis. The problem with using this dispersive viscoelastic material while making a capsulorhexis with a forceps is that it is not retained well in the anterior chamber. The viscoelastic
material continuously escapes from the 2.8 to 3.2 mm clear corneal incision, leading to shallowing of the anterior chamber and an increased risk of extension of the capsulorhexis. This is especially likely when capsulorhexis is done by trainee surgeons who take more time to maneuver the flap and complete the procedure. The continuous loss of viscoelastic material also creates a problem if the margin of the capsulorhexis has strayed to the periphery and one is trying to bring it to the center. To avoid this difficulty, the surgeon usually withdraws the forceps, reinflates the anterior chamber with HPMC, and proceeds with the capsulorhexis. This may have to be done 2 or 3 times before the capsulorhexis is completed. A simple way to overcome this problem is to continuously inject viscoelastic material through the side port with 1 hand while the other hand performs the capsulorhexis. The cannula of the viscoelastic syringe is put through the side port and viscoelastic material is continuously injected to maintain a deep anterior chamber and flatten the curvature of the anterior lens surface, while the forceps is being moved to perform the capsulorhexis. A balance must be kept between the amount of viscoelastic material being injected through the side port and the amount being lost via the main clear corneal incision to maintain a stable chamber and avoid excessive injection of viscoelastic material. The cannula put through the side port performs the additional function of stabilizing the globe while the capsulorhexis is performed. This simple technique helps the surgeon complete the forceps capsulorhexis in a single step, considerably decreasing the time spent on the procedure. It also helps to keep the anterior chamber well inflated throughout the procedure and thus decreases the chance of extension of the capsulorhexis. This will be a useful procedure for all trainee surgeons who are performing capsulorhexis with a forceps under HPMC. If the surgeon uses a bent 26-gauge needle mounted on a syringe instead of a forceps to perform the capsulorhexis, the syringe can be filled with HPMC. This is injected into the anterior chamber while the capsulorhexis is being performed without having to withdraw the needle and inject HPMC through the side port.
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002
TANUJ DADA, MD HARINDER SETHI, MD New Delhi, India 1491