Phaco capsulotomy in intumescent cataract

Abstract

Dear Editor, Intumescent cataracts are challenging cases even for experienced phaco surgeons (Bhattacharjee et al, 1999;Ermiss et al, 2003). In these eyes, during capsulorhexis, there are very high chances of anterior capsule tears with peripheral extension due to the high pressure of the hydrated cataractous lens. Following this, the continuation of phacoemulsification is extremely difficult and is associated with complications such as posterior capsule tear, vitreous loss and posterior migration of the lens matter. Different methods have been tried to prevent this uncontrolled extension of capsulorhexis. These include direct aspiration of lens fluid using a 26 G needle mounted onto a syringe. Alternatively, using high-cohesive viscoelastics is also helpful in maintaining the pressure on the anterior chamber and creating a complete capsulorhexis. Use of high-frequency diathermy and preoperative Nd:YAG laser anterior capsulotomy has also been reported as an optional technique (Pham et al, 1998;Coelho et al, 2009). Phaco capsulotomy is a technique where the anterior capsule is punctured using a phacoemulsification probe and then the probe is used to debulk the lens matter by aspirating the intralenticular fluid. Once intralenticular pressure is relieved, the capsule is grasped with a capsulorhexis forceps and the rhexis is completed. The initial surgical steps of cataract removal are the creation of the paracentesis and the main wound, capsular staining using trypan blue and maintenance of the anterior chamber using viscoelastics. Using the main wound, the phacoemulsification probe is introduced into the anterior chamber and the tip of the bevel of the phaco hand piece is directed upwards, centered over the center of the anterior capsule. The settings used during phaco capsulotomy are a power 40 %, a vacuum of 200 mm Hg and an aspiration flow rate of 28 cc/min. The foot pedal is pressed to position three and the anterior capsule is punctured with the phaco tip (Figure). This creates the initial anterior capsule puncture with the release of intra-lenticular fluid which is aspirated. The phaco hand piece is then removed from the eye and the viscoelastics are injected into the anterior chamber to pressurize the anterior surface of the capsule. The anterior capsular tear is visualized and grasped with a capsulorhexis forceps. The continuous curvilinear capsulorhexis is then fashioned with the forceps keeping the force of the pull of the rhexis margin to the centre. Following this, the nucleus is removed by phacoemulsification (Song et al, 1998). In conclusion, phacocapsulotomy is a safe and effective technique which prevents sudden extension of capsulorhexis by depressurizing the intralenticular pressure and debulking the lens. This technique prevents the spontaneous peripheral migration of the capsulorhexis edge, thus reducing the concurrent complications. A large series of cases will be required to prove the efficacy and safety of this novel technique.

Achieving successful capsulorhexis in intumescent white mature cataracts to prevent Argentinian flag sign - A new multifaceted approach to meet the challenge

“…In the ‘Brazilian technique’ described by Figuerado et al , they made use of the irrigation aspiration cannula for lens matter decompression and completed the rhexis in two stages. [ 13 ] Another technique ‘phacocapsulotomy’ described by Mahalingam& Sambhav,[ 19 ] in which they use the phaco tip to puncture the anterior capsule and debulk the lens matter. However, in the above-mentioned techniques, it might be difficult to immediately catch hold of the rhexis edge or redirect it if a sudden runaway of the rhexis occurs.…”

Nghiên Cứu Đặc Điểm Lâm Sàng Và Đánh Giá Kết Quả Phẫu Thuật Phaco Trên Mắt Đục Thể Thủy Tinh Chín Trắng Căng Phồng Với Phương Pháp Xé Bao Trước Kết Hợp Kim 30g Tại Bệnh Viện Đa Khoa Xuyên Á Vĩnh Long Năm 2022 – 2023

“…Một kỹ thuật khác là 'phacocapsulotomy' được mô tả bởi Mahalingam & Sambhav [6] trong đó sử dụng đầu phaco để chọc thủng bao trước và bóc tách thủy tinh thể. Tuy nhiên, với kỹ thuật này có thể khó nắm bắt ngay lập tức mép xé bao hoặc kiểm soát hướng xé nếu mép bao đột ngột đi ra chu biên.…”

An alternative endocapsular approach for the management of Argentinean flag capsular tear during cataract surgery

“…Achieving a CCC for a mature, white cataract is difficult and many techniques have been suggested. These include decompressing the pressure within the capsular bag through aspiration of cortical material on perforating the anterior capsule, [6] using phacocapsulotomy technique, [7] using the two-stage capsular bag by creating two symmetric semicircles. Our technique was applied successfully in four cases.…”