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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 3  |  Page : 322-325

Phacocapsulectomy: A novel technique to deal with extensive capsular fibrosis

1 Department of Cornea and Cataract Services, Cornea and Cataract Services, Chandraprabha Eye Hospital, Jorhat, Assam, India
2 Department of Cornea and Cataract Services, Cornea and Cataract Services, Chandraprabha Eye Hospital, Jorhat, Assam; Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry, India

Date of Submission01-May-2021
Date of Acceptance22-May-2021
Date of Web Publication08-Dec-2021

Correspondence Address:
Dr. Sandip Sarkar
Department of Ophthalmology, Jawaharlal Institute Postgraduate Medical Education and Research, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_101_21

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To describe a new technique of performing capsulotomy with phacoemulsification probe in cataracts with extensive capsular fibrosis. After making two side ports and a 2.2-mm temporal limbal incision, the phaco probe is inserted into the eye. An initial cut is made on the fibrosed anterior capsule with the phacotip. Subsequent cuts are made in the same plane to create a central opening which is of 5–5.5 mm size. This opening is quite stable as it is surrounded by fibrous tissue. Phacoemulsification and intra-ocular lens implantation can be safely done through this opening without damaging the integrity of the capsular opening. We have performed phacocapsulectomy in four such cases. All of them gained best-corrected visual acquity better than 20/40 at 3 months of follow-up. Creating a capsular opening in a cataract with extensive anterior capsular fibrosis is always challenging. Phacocapsulectomy can be a very useful method in dealing such cases.

Keywords: Anterior capsular fibrosis, phacocapsulectomy, phacoemulsification

How to cite this article:
Bardoloi N, Sarkar S. Phacocapsulectomy: A novel technique to deal with extensive capsular fibrosis. Kerala J Ophthalmol 2021;33:322-5

How to cite this URL:
Bardoloi N, Sarkar S. Phacocapsulectomy: A novel technique to deal with extensive capsular fibrosis. Kerala J Ophthalmol [serial online] 2021 [cited 2022 Jan 19];33:322-5. Available from: http://www.kjophthal.com/text.asp?2021/33/3/322/331909

  Introduction Top

Fibrosis is a pathological condition characterized by excessive production and accumulation of collagen, loss of tissue architecture, and organ failure in response to uncontrolled wound healing.[1] Fibrosis on the anterior capsule of the human crystalline lens though rare in occurrence, but can be found in traumatic, hypermature, and long-standing cataracts. Capsulorhexis in the presence of anterior capsular fibrosis is always challenging. Any pull on the fibrosed area by capsulotomy needle or forceps may result in stress on the zonules as well as increased the propensity of the rhexis margin to run into the periphery. In these situations, the most commonly applied tool is a micro-scissors which cuts the fibrosed portion and helps in completion of the capsular opening with the help of forceps. Radio-frequency diathermy and Fugo blade are also capable of producing capsulorhexis in these challenging situations.[2],[3] We are describing a technique where phacoemulsification probe has been used effectively to produce decent capsular opening in cases of extensive anterior capsular fibrosis.

  Surgical Technique Top

We hereby describe a case series of four patients where extensive anterior capsular fibrosis was noted and we applied our technique “phacocapsulectomy” to perform the anterior capsulotomy. A single experienced surgeon (NB) performed all the cases under peribulbar anesthesia. After making the two-side port incision, the trypan blue dye was injected to stain the anterior capsule [Video File 1]. A temporal limbal 2.2 mm main incision was created with a dual bevel keratome. The phacoemulsification probe (Centurion Vision System, Alcon laboratories, USA) with parameters set as: Power 70% OZIL, vacuum 80 mm Hg, flow rate 30 and IOP 50 mm Hg, with bevel up was introduced inside the eye. With continuous irrigation on, we press the food pedal to third position to puncture the anterior capsule [Figure 1]a. The initial puncture gives an idea of the thickness of the anterior capsule, and subsequent cuts are made exactly on the thickened, fibrosed capsule in a very controlled manner [Figure 1]b. Special care was taken to involve just the anterior capsule only, not the nucleus. Short burst of phaco energy was delivered in bevel up position, with moderate vacuum, taking care not to pool the nucleus with the phaco probe [Figure 1]c and [Figure 1]d. A 5–5.5 mm capsulorhexis was created by taking subsequent cuts exactly on the anterior capsule with the phaco probe [Figure 1]e and [Figure 1]f. Though the opening is not as smooth and stretchable as in conventional capsulorhexis, but the margins are quite strong and they did not give away during the subsequent steps. After finishing the capsulotomy, without doing any hydro procedure we started the nucleus management. First, we chopped the nucleus into different small pieces using chop in situ technique [Figure 2]a and [Figure 2]b,[4] and the pieces were emulsified subsequently with the parameters of power: OZIL 70%, vacuum 400 mmHg, aspiration flow rate 20, IOP 50 mmHg [Figure 2]c and [Figure 2]d. A foldable hydrophobic intra-ocular lens (IOL) was implanted into the capsular bag [Figure 2]e and [Figure 2]f using hydroimplantation technique.[5] Although the areas around the capsular opening are quite opaque, no attempt is made to remove those opaque areas. Preservative free 0.1 ml moxifloxacin (Vigamox, Alcon laboratories, Inc.) was injected into the anterior chamber to prevent the postoperative endophthalmitis. The main and side port incisions were sealed with stromal hydration. Postoperatively, the patients were prescribed 1% prednisolone acetate (Predforte, Allergan India,) eye drops for 6 weeks in a tapering dose and 0.5% moxifloxacin (Vigamox, Alcon laboratories, Inc.) eye drops 4 times/day for 4 weeks.
Figure 1: (a an b) Anterior capsule punctured with the phaco probe in bevel up position, (c and d) Subsequent cuts are make exactly on the anterior capsule taking care not to involve the nucleus, (e and f) Enlarging the capsular opening solely by the phaco probe

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Figure 2: (a and b) The nucleus is chopped into different small pieces using chop in situ technique, (c and d) the nuclear fragments are being emulsified, (e and f) A foldable, hydrophobic, acrylic intraocular lens implanted in the capsular bag

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We have been able to complete the capsulorhexis in all four cases without any complications and the phacoemulsification with IOL implantation was also uneventful. At 3-month postoperative follow-up, all patients gained best-corrected visual acquity of more than 20/40 without any significant postoperative complications [Table 1].
Table 1: Summary of all cases

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  Discussion Top

Fibrosis is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process. Fibrosis of the anterior capsule in traumatic cataract is a typical example of reparative type of fibrosis.[1] This fibrosis may involve a part or the entire area of anterior capsule and the area under fibrosis may become thick and wrinkled. In sclerotic type of hyper mature cataract, the cortex becomes disintegrated and the lens becomes shrunken due to leakage of water, the anterior capsule becomes thickened and fibrosed.[6] Creating a capsulorhexis in these kinds of fibrosed capsule is a challenging job even for an experienced surgeon. If the fibrosis is at the center and occupies <5 mm of circumference, capsulorhexis can be performed by avoiding the fibrosed area. The situation is not so favorable in those cases where the fibrosis involves the whole or some parts of the capsulorhexis track. Forceps, scissors, and micro-rhexis forceps are useful tools in cutting and creating central opening in the presence of extensive anterior capsular fibrosis. However, this needs very controlled exercise, and in many a times, the capsular opening may not be a sufficient enough to complete the surgery. Radiofrequency capsulotomy and Fugo blade have been tried to overcome this issue with variable success.[2],[3]

In this report, we are describing a new technique where a phacoprobe has been used to create a capsulorhexis in cases of extensive fibrosis involving the 360 degree of the anterior capsule. There are published reports, where phacoemulsification probe has been used to perform a capsulorhexis in intumescent white cataract.[7],[8] In this technique, puncturing the anterior capsule and subsequent aspiration of the cortical material with the phaco probe brings down the intra-lenticular pressure, followed by completion of capsulorhexis with a rhexis forceps. This does not apply in our cases where the major challenge is the thick anterior capsule, not the high intra-lenticular pressure. The main modification in our technique that we have completed the full 360° rhexis with phaco probe only, we did not use any forceps or needle. In every case, initially we tried to puncture the capsule with the cystotome, but as soon as we feel the resistance, we immediately shift to phaco probe to perform the capsulorhexis. By targeting the anterior capsule with short burst of phaco energy, we have minimized the zonular stress. However, the theoretical risk of zonular dehiscence will be present, if excessive energy with high vacuum is given during phaco capsulectomy.

To best our knowledge, this is the first time, a phacoemulsification probe has been used to create a capsular opening in cataracts having extensive anterior capsular fibrosis. This is a safe, easy, controlled does not require any other instruments to produce these central openings.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Birbrair A, Zhang T, Files DC, Mannava S, Smith T, Wang ZM, et al. Type-1 pericytes accumulate after tissue injury and produce collagen in an organ-dependent manner. Stem Cell Res Ther 2014;5:122.  Back to cited text no. 1
Findl O, Amon M. Anterior capsulotomy created by radiofrequency endodiathermy and continuous curvilinear posterior capsulorhexis in a patient with intumescent cataract and primary capsular fibrosis. J Cataract Refractive Surg 1998;24:870-1.  Back to cited text no. 2
Izak AM, Werner L, Pandey SK, Apple DJ, Izak MG. Analysis of the capsule edge after Fugo plasma blade capsulotomy, continuous curvilinear capsulorhexis, and can-opener capsulotomy. J Cataract Refract Surg 2004;30:2606-11.  Back to cited text no. 3
Vasavada A, Singh R. Step-by-step chop in situ and separation of very dense cataracts. J Cataract Refract Surg 1998;24:156-9.  Back to cited text no. 4
Bardoloi N, Sarkar S, Pilania A, Das H. Pure phaco: Phacoemulsification without ophthalmic viscosurgical devices. J Cataract Refract Surg 2020;46:174-8.  Back to cited text no. 5
Khurana A, Khurana B. Comprehensive Ophthalmology: With Supplementary Book-Review of Ophthalmology. London, UK: JP Medical Ltd; 2015.  Back to cited text no. 6
Genç S, Güler E, Çakır H, Özertürk Y. Intraoperative complications in intumescent cataract surgery using a phaco capsulotomy technique. J Cataract Refract Surg 2016;42:1141-5.  Back to cited text no. 7
Mahalingam P, Sambhav K. Phaco capsulotomy in intumescent cataract. Nep J Ophthalmol 2014;6:242-3.  Back to cited text no. 8


  [Figure 1], [Figure 2]

  [Table 1]


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