Initial and Definitive Capsulorhexes: An Extended Application

At our training center, we found that instructing the beginning phaco surgeon to perform a small continuous curvilinear capsulorhexis (CCC) initially was a good way to circumvent the problems of peripheral extension of the advancing CCC margin. The consultant surgeon would enlarge this “initial” small CCC at the end of the procedure to achieve a larger “definitive” CCC. In these cases, the consultant surgeon was able to achieve an endocapsular plane of phacoemulsification more often than in cases in which a moderate-to-large CCC was made initially. In addition, enlarging the initial trainee-made small CCC to achieve a definitive large CCC resulted in less anterior capsule rim in apposition to the IOL optic, ensuring less fibrosis and fewer attendant complications. With further experience, we became convinced that what began as a training strategy, in uncomplicated routine cases, had too many merits to be ignored. Secondary enlargement of the CCC has been reported for difficult cataracts.1,2 But by incorporating this protocol of initial and definitive CCCs into our standard phaco cases, we can train upcoming surgeons (our “fellows”) to perform a proper CCC while ensuring an endocapsular plane phaco and a significantly reduced incidence and area of anterior capsule fibrosis. In this part of the world, in which hard cataracts are more the rule than the exception, we need a strategy to ensure an endocapsular plane of phaco consistently. Not only the increased amount of dissipated energy, but also the proximity of hard lens fragments, rubbing against the corneal endothelium, can be extremely detrimental to the long-term outcome in these eyes. Hence, we believe that fashioning an initial small (about 4.0 mm) CCC and using a nucleus division technique that allows all surgical maneuvers to be performed within the central space, without undue stress on the bag/zonules (e.g., step by step, chop in situ and lateral separation3), will ensure endocapsular phaco. Contrary to what many might think, the CCC enlargement technique4 is extremely easy to incorporate into one's repertoire and does not require additional instrumentation. Also, the enlargement does not necessarily involve a 360 degree widening of the initial CCC. More often, only the excessive anterior capsule in any particular quadrant has to be removed. Occasionally, when the CCC enlargement is attempted after IOL implantation, one must remove only the excessive rim in a particular quadrant (if the initial CCC was eccentric) to achieve a symmetry of the capsular rim over the IOL optic. With this policy, for the past 2 years we have been enjoying the best of both worlds—endocapsular phaco and markedly reduced anterior capsule opacification—while ensuring proper training of our fellows. We highly recommend this practice, especially at phacoemulsification training centers. Abhay R.