Issue: June 25, 2020
Source/Disclosures
Disclosures: Devgan reports he owns CataractCoach.com, which is a free teaching website.
June 19, 2020
3 min read
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Specialized techniques can deal with fibrotic lens capsule in cataract surgery

The fibrotic bands can impede the creation of the capsulorrhexis.

Issue: June 25, 2020
Source/Disclosures
Disclosures: Devgan reports he owns CataractCoach.com, which is a free teaching website.
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Opening the lens capsule, typically by creating a capsulorrhexis, is one of the most critical steps in cataract surgery. Our goal is to remove the lens contents while preserving the capsular bag so that it can support the IOL. In rare cases, the anterior lens capsule can become fibrotic and wrinkled, and that will impede the creation of the capsulorrhexis. Using specialized techniques, we can overcome these challenges and successfully create the capsular opening and complete the cataract surgery.

This patient has an intumescent white cataract, which means that the capsular bag is filled with liquefied lens cortex. This makes the pressure within the capsular bag higher than normal and puts us at risk for the Argentinian flag sign, when the anterior capsule rips uncontrollably out to the zonular attachments. Because the capsule is stained with trypan blue dye, this combination of white cataract with a ripped capsule resembles the blue-white-blue stripes of the Argentinian flag.

Uday Devgan
Uday Devgan

To minimize this risk, we need to decompress the lens and release the pressure gradient. This allows us to have more control, and it minimizes the risk for capsular complications. Using a 27-gauge needle on an empty 3 cc syringe, the anterior lens capsule is punctured while the anterior chamber is pressurized with viscoelastic. With gentle pulling of the plunger, the liquefied cortex is aspirated into the syringe, and the capsular bag is decompressed (Figure 1).

anterior lens capsule is punctured
Using a 27-gauge needle on an empty 3 cc syringe, the anterior lens capsule is punctured while the anterior chamber is pressurized with viscoelastic. With gentle pulling of the plunger, the liquefied cortex is aspirated into the syringe, and the capsular bag is decompressed.

Source: Uday Devgan, MD
cut the fibrotic anterior lens capsule
Sharp Vannas scissors are used to cut the fibrotic anterior lens capsule in a controlled manner before attempting a capsulorrhexis with forceps.

The fibrotic bands are seen as wrinkles, particularly after staining the capsule with trypan blue dye. These are often due to chronic inflammation within the eye but may also be present in cases of weakened zonular support such as after trauma or with pseudoexfoliation syndrome. In our case, the zonular structures are intact, and the anterior lens capsule is taut. To precisely start the capsulorrhexis, we use sharp Vannas scissors to puncture and then incise the anterior lens capsule (Figure 2). The scissors are angled so that the cut forms one margin of the intended capsulorrhexis margin.

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Forceps can now be used to tear the capsulorrhexis, which should proceed normally until a fibrous band is reached. At this point, there will be resistance to capsulorrhexis creation, and if excessive force is applied, the capsule can rip uncontrollably. Instead, we can use the cystotome via a second incision to carefully cut through this fibrotic band. We have even placed an additional paracentesis incision to facilitate this process (Figure 3).

cut through this tissue
The tearing of the capsulorrhexis is blocked by a fibrous band, so a sharp cystotome is used in the other hand to carefully cut through this tissue. Note the placement of an additional paracentesis incision to facilitate this technique.

Forceps are used for countertraction to pull the capsule flap in the correct direction as the cystotome is used in the other hand to dissect through the fibrous bands (Figure 4). This technique will allow us to create a complete anterior capsulotomy, but it may not be as strong as an intact continuous capsulorrhexis. The areas of dissection using sharp instruments such as the cystotome may have weakness that could allow the anterior capsular rim to radialize and rip toward the lens equator and posterior capsule.

forceps place countertraction
The forceps place countertraction on the capsulorrhexis flap while the cystotome makes additional cuts to dissect through the fibrous bands.

To remove the nucleus, we want to minimize the forces on the capsular bag that come primarily during maneuvers to separate nuclear halves and quadrants. Performing horizontal chop instead of divide-and-conquer may be a better option in this regard. Once the lens nucleus is removed, we must also be cautious during cortex removal. We want to keep the aspiration tip well within the capsular bag so that we do not inadvertently grab the capsule rim. If the capsule has held up well during the cataract removal, placement of a single-piece IOL in the bag is a good option. If there is any doubt as to the structural integrity of the capsular bag, then a three-piece IOL may be a better choice. The three-piece IOL can be placed in the capsular bag or in the sulcus, with or without optic capture, depending on the level of tissue support.

With these specialized techniques, we can successfully deal with a fibrotic lens capsule and an intumescent white cataract. This patient started with such limited vision, barely able to see a hand in front of his face, and then achieved excellent vision with this surgery.

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Surgical video of this case is available at CataractCoach.com.