EyeWorld Asia-Pacific September 2012 Issue

29 EWAP CAtArACt/IOL September 2012 immobilize a capsular bag that is partially subluxated due to a severe zonular dialysis. Finally, they restrain the peripheral anterior and equatorial capsule from being aspirated and dehisced by the phaco or I/A tip. As a single strategy for severe zonular deficiency, capsule retractors are significantly more effective than capsular tension rings at preventing posterior capsule rupture. Because CTRs can only redistribute instrument and mechanical forces to the remaining intact zonules, the greater the zonular defect or deficiency, the less effective a CTR is at stabilizing the bag. However, a CTR can be used in conjunction with capsule retractors, particularly if there is a sizable zonular dialysis. If after first inserting retractors the unsupported equatorial regions of the capsular bag tend to collapse inward toward the phaco tip, a CTR can be inserted to distend the equator of the bag to its proper anatomic configuration. Although the tip of the capsule retractor is dull, it is possible for the hooks to tear the capsulorhexis margin during surgery. There is a tendency to over tighten the capsular retractors because the tension is initially adjusted with a soft eye. Inserting the phaco tip with irrigation suddenly displaces the nucleus and capsular bag posteriorly, which effectively further tightens the retractors (Figure 3). After inserting the phaco tip, it is therefore important to momentarily assess whether the capsule retractors have become so taut that they tent the capsulorhexis edge. If so, they should be loosened slightly so that the capsular rim does not tear during phacoemulsification. This is particularly important if the capsulorhexis diameter is on the small side. EWAP references 1. Chang DF. Strategies for the difficult capsulorrhexis. In: Chang DF, ed. Phaco Chop. Chapter 12. Thorofare, NJ: Slack; 2004. 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg. 2006;32: 1420-1422. MST capsule retractors have a looped tip that reduces the risk of puncturing the equatorial capsule and are inserted through paracentesis sites. They are packaged in sets of three and are inserted after capsulorhexis completion. Hydrodissection is delayed until after insertion of capsule retractors to reduce the risk of extending the traumatic zonular dialysis with nuclear rotation. Initiation of irrigation propels the nucleus posteriorly, resulting in over tightening of one of the capsule retractors. Seeing this, the surgeon should loosen the tight retractor before resuming phaco. Compared to a CTR, capsule retractors do not impede cortical aspiration. The capsule retractors stabilize the capsular bag against the decentering force of CTR implantation. The latter is delayed until after cortical cleanup has been completed. Source: David F. Chang, MD “Everything has to be sized, the anterior capsulorhexis must be done in a proper way, centered, done in a certain size, and you also have to do a posterior capsulorhexis, which quite a lot of older generation ophthalmologists are a bit reluctant to do,” she explained. However, the younger generation of ophthalmologists is quite optimistic, and there are now several young ophthalmologists in France who have adopted the technique and this lens, she said. Certainly, as with every new technique, there is a learning curve, Dr. Tassignon said. However, she said it is not a difficult technique to learn. Most surgeons who learn the technique at her surgery center are surprised at how quickly it can be done, she said. “They always think that it is a technique that is done here and there. As it is our routine Bag-in-the-lens - from page 24 Phaco - from page 27 technique, we do up to 10-12 cases in one day, and you can’t do it in that rhythm if it is very difficult,” she said. Abhay R. Vasavada, FRCS, Iladevi Cataract & IOL Research Center, Raghudeep Eye Clinic, Ahmedabad, India, who has implanted about 20-30 BIL IOLs with a 2-year follow-up, but is not doing them routinely, said that his results have been excellent. However, he has found the procedure to be technically demanding and has not been able to consistently put the bag in the lens successfully. EWAP Editors’ note: Dr. Tassignon is the developer of the Tassignon lens (Morcher, Stuttgart, Germany) and receives royalties. Dr. Vasavada has no financial interests related to this article. Contact information tassignon: +32 3 821 33 77, marie-jose.tassignon@uza.be Vasavada: icirc@abhayvasavada.com Tel: +65 64936953 Fax: +65 64936955