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Arch Ophthalmol ; The capsular tension ring: Designs, applications, and techniques. J Cataract Refract Surg ; Use of capsular tension ring in phacoemulsification. Indications and technique. Indian J Ophthalmol ; Endocapsular ring approach to the subluxed cataractous lens.
Management of zonular dialysis in phacoemulsification and IOL implantation using the capsular tension ring. Ophthalmic Surg Lasers ; Gimbel HV, Sun R. Clinical applications of capsular tension rings in cataract surgery. Fine, who inserted CTRs during the early clinical studies alone.
Fine has a long list of indications for CTRs: all cases of trauma, any metabolic or endocrine disease, all cataract patients with previous glaucoma filtering surgery, all cases of radial keratotomy RK where there are more than eight incisions, and progressive zonular disease. Fine said. When there are more than eight incisions, the surgeon was trying to achieve maximal effect, and the zonules are now weak in many of those eyes.
So we use CTRs in all cases just to be sure.
Capsular Tension Rings Warrant Caution
We also use CTRs in all eyes longer than 27 mm, where there is a tendency to weaken the zonules with cataract surgery. In contrast, Dr. Otherwise we would have implanted thousands of rings for naught. He recalled cases where a ring was accidentally placed into the anterior chamber, another ring fractured, and another went through the capsular bag. Osher did stress that while not every case of weak zonules requires a CTR, having the CTR available is imperative when performing any phaco procedure because one never knows when a zonular problem will be encountered.
Surgeons should always hold off until you have to put it in. Kenneth J. However, Dr. Rosenthal has developed a technique that obviates the risk of cortex entrapment.
A retentive viscoelastic is then placed within the capsular bag, which displaces the nucleus and any leftover cortical fibers posteriorly. Fine, on the other hand, maintains that a ring should be placed right away, before doing phacoemulsification and as soon as hydrodissection is completed. We use a Lester hook and a second hook 90 degrees away, which allows us to neutralize the forces on the capsule during implantation of the ring.
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We can then inject the ring toward the zonular weakness. While contention swirls around CTRs, all of these surgeons stressed the value of having this device available in their practice. Said Dr. Fine, who cited statistics in which 17 percent of patients with compromised zonular integrity who underwent surgery without a ring required reintervention.
This is not easy to do and results are not always consistent. It also can take a lot longer than typical cortical removal in the routine case. Attempt tangential cortical stripping.
Rather than pulling toward the center of the capsule, pull along its equator. Slide it back and forth, trying to move the cortex sideways along the ring. Often that is just enough to loosen it. Another choice is to remove it along the posterior capsule. While we typically remove cortex anteriorly, often you need to go posteriorly and remove cortex.
If necessary, one may need to pull the CTR centrally to free up cortex. Iatrogenic Zonular Damage Patient choice and technique are equally important in avoiding this particular complication. When you have a dense, thick cataract, you have very little room in the capsular bag in which to work with the CTR. Any forces placed within the bag are easily transmitted to the zonules because there is no space in which those forces can be absorbed. This is of concern because the zonules are already damaged. Any additional force or tension could cause further loss and might be enough to actually cause the capsular bag to dislocate, or at least become partially dehisced.
Ophtec’s Preloaded Capsular Tension Ring Ringject Receives Approval in China – Eyewire News
While this is an area of some controversy, I believe in avoiding "early" implantation of the CTR in a very dense lens. With weak zonules and a dense cataract, remove the cataract first and then implant the ring. I have shown in my Miyaki-Apple video analysis of CTR insertion that, in these cases, you can create more damage to the zonules by implanting a CTR early in the case.
To support the zonules during phaco, some surgeons use multiple iris hooks at the capsulorhexis edge to act as synthetic zonules. Since a very small area of the hook holds the capsulorhexis edge, many surgeons will use the force of several hooks. There is still risk of capsular tears and dislodgment from the force applied with the hooks, so the surgeon using this method should be on his guard.
In general, I find that hooks and retractors often cause more problems than they solve. That's why I designed the capsular tension segment, a degree PMMA partial ring segment that has a 4. The CTS eliminates the problems with tears and dislodgment related to use of hooks for support. Inadequate Capsular Centration Unfortunately, it's too easy to transform someone with only three clock hours of zonular weakness into someone with six clock hours if you create further zonular damage. This may happen by implanting the ring "early" in a dense lens case, or by torquing the bag as you implant the CTR.
You may succeed with a CTR or a CTS at reforming the capsular bag, but if the zonules themselves are so weak that they can't support the bag, it will be out of position. Centration does require at least some zonular support to provide the tension to hold the bag in the proper place. Capsular Tension Segment Dr. Ahmed's capsular tension segment is a further modification to the capsular tension ring developed by Robert J. After capsulorhexis and before phacoemulsification, the surgeon may implant up to three in severe cases capsular tension segments to support the capsule over weakened zonules.
An iris retractor, placed through the fixation eyelet on the CTS, can further increase stability during lens removal. Once used, the CTS may be removed, or may be sutured over an area of zonular weakness for continuing support. Visit morcher. Another concern is that a CTR may not prevent progressive zonulysis conditions and late postoperative IOL decentration.
You can use either a modified Cionni ring or a capsular tension segment, either is ideally suited for these cases. However, since neither of these devices is available in the United States as of this writing, the best you can do is wisely select patients according to zonular risk, and modify your technique in ways that I recommend below.