The fibrotic bands can impede the production of the capsulorrhexis (also known as continuous curvilinear capsulorrhexis (CCC), is a technique pioneered by the famous eye surgeon and ophthalmologist, Howard Gimbel which is till now used to remove the capsule of the lens from the eye during cataract surgery by shear and stretch forces using surgery tools). Opening up the lens capsule usually by producing a capsulorrhexis, is one of the most important steps in cataract surgical procedure. Our objective is to eliminate the lens content while preserving the capsular bag so that it can support the intra Ocular Lens (IOL). In unusual or rare cases, the anterior lens capsule can become fibrotic and also old and wrinkly, which will certainly hamper the formation of the capsulorrhexis, creating a problem for our cataract eye surgery. Using customized techniques, we can overcome these challenges and effectively develop the capsular opening and finish the cataract surgical treatment.
This patient has an intumescent white cataract, which implies that the capsular bag is loaded with dissolved lens cortex. This makes the pressure within the capsular bag greater than normal and also puts us in danger for the Argentinian flag sign, when the anterior capsule rips frantically out to the zonular attachments. Due to the fact that the capsule is stained with trypan blue colour, this mix of white cataract with a ripped capsule appears like the blue-white-blue red stripes of the Argentinian flag and therefore the unusual name.
To minimize this risk, we need to decompress the lens and also release the pressure gradient. This enables us to have more control, as well as it decreases the threat for capsular complications. Using a 27-gauge needle on an empty 3 cc syringe, the anterior lens capsule is penetrated while the anterior chamber is pressurized with viscoelastic. With mild pulling of the plunger, the liquefied cortex is aspirated right into the syringe, and also the capsular bag is decompressed (Figure 1).
The fibrotic bands are viewed as wrinkles, particularly after staining the capsule with trypan blue colour. These are usually due to chronic inflammation within the eye but may additionally exist in instances of damaged zonular support such as after injury or with pseudoexfoliation disorder. In our case, the zonular frameworks are undamaged, and also the anterior lens capsule is taut. To specifically begin the capsulorrhexis, we make use of sharp Vannas scissors to penetrate and then incise the anterior lens capsule (Figure 2). The scissors are angled to ensure that the cut forms one margin of the designated capsulorrhexis margin.
Forceps can now be used to tear the capsulorrhexis, which ought to continue usually until a coarse band is reached. Now, there will certainly be resistance to capsulorrhexis creation, and if excessive pressure is used, the capsule can tear obdurately. Rather, we can make use of the cystotome by means of a 2nd laceration to meticulously cut through this fibrotic band. We have actually also positioned an extra paracentesis incision to facilitate this process (Figure 3).
Forceps are made use of for countertraction to draw the capsule flap in the right path as the cystotome is made use of in the other hand to explore through the coarse bands (Figure 4). This technique will permit us to develop a total anterior capsulotomy, but it may not be as sstrong as an intact continuous capsulorrhexis. The areas of dissection making use of sharp tools such as the cystotome may have weakness that might enable the anterior capsular edge to radialize as well as rip toward the lens equator and posterior capsule.
To remove the nucleus, we wish to lessen the forces on the capsular bag that come mainly during manoeuvres to separate nuclear halves and quadrants. Executing horizontal chop rather than divide-and-conquer may be a better option in this regard. As soon as the lens nucleus is removed, we should likewise be cautious during cortex removal. We wish to keep the aspiration tip well within the capsular bag to ensure that we do not inadvertently grab the capsule rim. If the capsule has actually stood up well throughout the cataract removal, placement of a single-piece IOL in the bag is an excellent option. If there is any type of uncertainty as to the structural integrity of the capsular bag, then a three-piece IOL might be a better option. The three-piece IOL can be put in the capsular bag or in the sulcus, with or without optic capture, depending on the level of tissue support.
With these specialized methods, we can efficiently deal with a fibrotic lens capsule and also an intumescent white cataract. This patient started with such limited vision, hardly able to see a hand in front of his face, and after that attained outstanding vision with this surgery.