Benefit-risk profile of prophylactic capsular tension ring implantation in routine cataract surgery: a systematic review and meta-analysis

Background The benefit-risk profile of prophylactic capsular tension ring (CTR) implantation during routine cataract surgery in eyes without documented or suspected zonulopathy remains uncertain. This review evaluated its effects in this population. Methods PubMed, EMBASE, CENTRAL, and Web of Science were searched for randomized controlled trials (RCTs) and prospective comparative studies of phacoemulsification with in-the-bag intraocular lens (IOL) implantation with or without a nonsutured CTR. Primary outcomes were postoperative IOL decentration, tilt, and anterior chamber depth (ACD). Secondary outcomes included visual acuity, ocular aberrations, refractive outcomes, and complications. Random-effects meta-analyses were performed, and certainty of evidence was assessed using the GRADE framework. Results Eighteen studies (1887 eyes) were included. CTR implantation did not significantly affect IOL decentration (MD 0.00 mm; 95% CI, − 0.09 to 0.10; P = .923), tilt (MD 0.28°; 95% CI, − 0.75 to 1.31; P = .597), or anterior chamber depth (MD 0.10 mm; 95% CI, − 0.01 to 0.21; P = .065). Substantial between-study heterogeneity was observed for decentration and tilt. Visual acuity outcomes did not differ significantly between groups. CTR implantation was associated with a small hyperopic difference in postoperative spherical equivalent (MD 0.10 D; 95% CI, 0.06 to 0.14; P < .001) and lower intraocular coma in three studies (230 eyes; SMD − 0.35; 95% CI, − 0.61 to − 0.09; P = .009). Exploratory analyses based on two informative studies suggested lower 12-month Nd: YAG capsulotomy (RR 0.11; 95% CI, 0.01 to 0.88; P = .037) and posterior capsule fold rates (RR 0.03; 95% CI, 0.00 to 0.20; P < .001). Conclusions In eyes without documented or suspected zonulopathy, prophylactic CTR implantation did not demonstrate a consistent improvement in IOL positional stability or visual acuity. CTR implantation was associated with a small, likely clinically negligible hyperopic shift and with lower intraocular coma and selected capsular complications; however, these findings were based on limited, generally low-certainty evidence and are insufficient to support routine CTR use. Trial registration PROSPERO CRD420250630595.