Capsulotomy CCC
K.Nasrolahi MD1387
Anterior capulotomy a) Can – opener capsulotomy:
is performed by making a series of small connected tears in a circle to remove the central segment of anterior lens capsule
This method permits easy access to and
subluxation of the lens nucleus , but it
usually result in radial tears in the
anterior capsule extending from one or
more of the initial puncture sites out to
the periphery of the capsule
The radial tears can enlarge during
hydrodissection or nucleus manipulatin , and
they can affect IOL placement and stabilization
Placement of both IOL haptics in the bag may be difficult , and unequal postoperative contractile forces within the capsular bag may cause IOL dislocation
b) Continuous – tear circular capsulorrhexis
provides a more stable smooth edge to the anterior capsular opening
The surgeon begins an anterior capsulorrhexis
with a central linear cut in the anterior
capsule , using a cystotome needle
At the end of the linear cut, the
needle is either pushed or pulled in
the direction of the desired tear .
Allowing the anterior capsule to fold
over upon itself
The surgeon then engages the free edge of the anterior capsule with either forceps or the capsulotomy needle and the flap is carried around in a circular manner as the surgeon directs the tension toward the center of the lens
For maximum control , frequent regrasping of the flap near the tear is helpful
Radial extension of the capsulotomy
may occur in the setting of forward
displacement of the lens with
shallowing of the anterior chamber
or anterior traction on the capsular
flap
If the capsulorrhexis tear starts to extend too far peripherally , the flap can sometimes be salvaged and the tear brought more centrally
First the surgeon should check for positive vitrous pressure associated with forward displacement of the lens.
This may be caused by the capsulotomy instrument , the surgeons fingers , or the lid speculum pressing against the globe
It can be corrected.
Refilling the anterior chamber with
viscoelastic , and inserting a second
instrument ( such as an iris spatula )
through the paracentesis to press
posteriorly on the lens may help
reduce forward displacement of the
lens and allow for redirection of the
capsular tear.
Purpose and advantages of capsulorrhexis
1 )No tags or flaps anterior capsular remnants interfere with surgery , especially the aspiration of the
peripheral cortex
2 )The mechanical forces exerted
onto the zonules were minimal
with this technique.
3)The capsular bag is wide open during surgery especially with a closed system approach ;the posterior
capsule is ballooned posteriorly .
This gives the surgeon ample space to work in far away from the cornea and with greatly reduced risk of catching the posterior capsule as compared
with when it is flaccid.
4)With an intact capsulorrhexis , manipulations within the capsualr bag such as tilting or cracking the nucleus or implanting an IOL , no longer entail the risk of extending radial teras in the anterior capsulse
into the posterior capsule.
5)Even in the case of a posterior
capsule defect , regaedless of its size
an intact anterior capsulorrhexis
provide the possibility of implanting
an IOL safely into the ciliary sulcus
Complication and pitfalls
1 )Discontinuity of the anterior capsular rim.
2 )Capsulorhexis with too small a diameter.
3 )Viscoelastic incarcerations.
Discontinuity of the anterior capsular rimTo avoid this complication the capsulorhexis should never be completed inside out.Stellate bursts originating from initial puncturing attempts with a blunt needle may desroy an intact capsular margin.
In the course of surgery to form a discontinuity.The only effective remedy to repair discontinuity by transformation of the tear in to smooth edge.
Discontinuity of the anterior capsular rim
-In performing the capsulorhexis , the surgen may realize that the original arc is too small
_The capsulorhexis can be expanded by spiralling outward to the desired diameter and
then “closing the circle“
Capsulorhexis with too small a diameter
_If the anterior capsular rim adheres to the anterior IOL surface after implantation , viscoelastics residues may trapped behind the lens.
_If it does , mostly the lense blocks the passage for the viscoelastics in to the anterior chamber and at the same time allows the aqueous to invade the area behind the implant .
Viscoelastic incarcerations
Thus pushing the IOL in to the cornea.
_in such a situation an additional
puncture of the peripheral anterior or
in narrow pupils – posterior capsule is
required to provide for a release of
the viscoelastics in to the anterior
chamber or the vitreous.
Difficult cases
Small pupil: 1 )Removal of the pupillary membrane
2 )Removal of synechiae3 )Bimanual stretching
4 )Iris retractors5)Pupil dilator
Disadvantages of the CCC :Capsular shrinkage syndrom or capsularphimosis
_This complication is not known in any other capsulotomy technique and solely relates to the CCC.
_The genuine pathomechanism could not be clarified untile tody.
Disadvantages of the CCC :Capsular shrinkage syndrom or capsularphimosis
Clinically this problem can be observed especially in patients suffering from pseudoexfoliation syndrome (PEX) , uveitis , rtinopathy pigmentosa or subluxation in combination with PMMA or silicone IOL implantation.
_ All these diseases have a considerably reduced number of zonula fibers in common.
_This complicltion has not been described in patients suffering from these diseases in context with an acrylic IOL implantation.
Allows the conclusion that a certain mechanical intraction of acrylic lenes surface and capsule successfully prevents this problem so that the acrylic IOL is presently the lense of choise in such cases.
_This is not valid for low _ water acrylics.
_A potential remedy to avoid capsular phimosis is the insertion of a capsular tention ring .
Poor Zonular integrity
Zonular dialysis
Exfoliation syndrome ( pseudoexfoliation )
1) In exfoliation syndrome a basement membrane – like fibrillogranular white material is deposited on the lens , cornea , iris , anterior hyaloid face , ciliary processes , zonular fibers , and trabecular meshwork
Phaco in pseudoexfoliation syndrome
2) Associated with this condition are atrophy of the iris at the pupillary margin , deposition of pigment on the anterior surface of the iris , poorly dilating pupil , increased pigmentation of the trabecular meshwork , capsular fragility zonular weakness , and open –angle glaucoma
3) Patients with exfoliation syndrome may also experience weakness of the zonular fibers and spontanous lens subluxation and phacodonesis
4) Poor zonular integrity may affect cataract surgery technique and IOL implantation
5) The exfoliative material may be elaborated even after the crystalline lens is removed
Poorly dilating pupil ( small pupil)