Spiral capsulorhexis technique with anterior chamber maintainer under continuous fluid pressure in intumescent cataracts and its clinical outcomes

When the phacoemulsification method was used for cataract extraction, the popularity of a continuous, circular capsulorhexis (CCC) rapidly grew [1]. The most challenging step in intumescent cataracts is to create a well-sized, central, continuous curvilinear capsulorhexis. In such intumescent and white cataracts, the capsule tends to be thin and fragile, and the absence of red reflex makes it difficult to see the capsular rim along the capsulorhexis [2]. In addition, when the pressurized and swollen lens capsule is punctured, there may be a tendency for the tear in the anterior capsule to expand towards the equator with the exit of liquefied cortical material and the milky material may cause a sudden decrease in capsule visibility [2], [3], [4], [5]. The increased intralenticular pressure is the reason why a capsulorhexis tear turns into a radial tear called the Argentinean flag sign [6], [7]. Thus, complications such as zonular rupture or posterior capsule tear, nucleus drop, vitreous loss, and intraocular lens (IOL) decentration may occur [6], [7], [8].

A clear view of the rims of the anterior capsular flap might reduce these complications. This can be achieved by using capsule dyes [8] like trypan blue [9] and indocyanine green [10], which create a contrast between the anterior capsule and the cortex, or using devices such as a surgical slit illuminant [11] or an endoilluminator [3]. However, in intumescent white cataracts, even if the visualization of the capsule is increased with dyes, capsular complications cannot be completely eliminated. Therefore, various methods have been described so far to minimize the risk profile of an uncontrolled opening of the anterior lens capsule and improve surgical outcomes. Nevertheless, the risk of complications in intumescent cataracts remains frequent and a major concern for surgeons.

The capsulorhexis technique with anterior chamber maintainer (ACM) was previously reported in senile cataracts [12]. However, to our knowledge, the efficacy of capsulorhexis in intumescent cataracts with ACM, which increases anterior chamber pressure by infusion and counteracts increased intralenticular pressure, has not been evaluated before. In this study, we intended to evaluate the effectiveness of the combination technique of ACM and spiral capsulorhexis under continuous fluid pressure, which might be an effective, safe, low-cost, and easily applicable method in intumescent cataracts with high intralenticular pressure.

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