Irrigating cystitome enabled capsulorhexis in hypermature Morgagnian cataract and white intumescent cataract: A novel technique

INTRODUCTION

Hypermature Morgagnian cataract and white intumescent cataract are known to cause difficulty in achieving continuous curvilinear capsulorhexis (CCC). In an intumescent white cataract, the lens is swollen and the capsule is stretched due to high intralenticular pressure (ILP). In a hypermature Morgagnian cataract, ILP, though normal, the cortex is liquified and ceases to provide support for CCC. Formation of CCC in such cases is usually difficult owing to the absence of red reflex, fragile capsule and poor visibility caused by egress of milky liquified cortex when the capsule is punctured.^[1] Often, the capsulorhexis extends to the periphery giving rise to the Argentinian flag sign. This renders the next steps in phacoemulsification very dangerous and may lead to rupture of the posterior capsule.^[2] Incidence of incomplete capsulorhexis in white mature cataracts ranges from 3.85% to 28.3%.^[3]

Different techniques have been described to manage capsulorhexis in white cataract. It includes two-stage capsulorhexis,^[4] 30G needle-assisted aspiration of lens cortex,^[3] microrhexis forceps-assisted CCC through 0.8 mm side port,^[5] femto-second laser-assisted capsulorhexis,^[6] closed chamber capsulorhexis under air tamponade,^[2] vacuum capsulorhexis^[7] and modified phaco capsulotomy.^[8]

We describe a novel method of achieving CCC in hypermature Morgagnian cataract and white intumescent cataract by attaching the cystitome to the infusion line connected to the irrigating fluid, balanced salt solution (BSS).

INNOVATION

This innovative technique of capsulorhexis was employed in 44 eyes of patients with white intumescent cataract [Video 1] and 30 eyes of patients with hypermature Morgagnian [Video 2]. The study period was from November 2022 to December 2023. Inclusion criteria included all patients with white intumescent cataract and hypermature Morgagnian cataract who needed phacoemulsification. Exclusion criteria included patients with retinal diseases, corneal opacity, uveitis, glaucoma and subluxated cataract. Mean anterior chamber (AC) depth in patients with white intumescent cataract was 2.52 ± 0.30 mm and in patients with hypermature Morgagnian cataract was 3.14 ± 0.26 mm. All patients received 250 mg of acetazolamide orally on the day of surgery. Pupillary dilatation was achieved with a combination of topical 5% phenylephrine and 0.8% tropicamide eye drops. 0.1% nepafenac eye drop was instilled to maintain pupillary mydriasis and avoid intraoperative miosis. All surgeries were performed by the same surgeon under peribulbar anaesthesia.

Surgical technique

The surgeon sits at the superior location (patient’s head end). Two side port incisions 1.2 mm in size are made with a sideport knife. Trypan blue solution 0.06% is injected into the AC to stain the anterior lens capsule. Trypan blue stain is washed out with BSS after 30 s. The pictorial representation of the innovation is given in Figure 1. A bent cystitome (26 G needle) attached to the infusion line connected to the irrigating fluid, hence the name irrigating cystitome, is inserted through the right-sided side port incision. The controller of the irrigating fluid drip set is open fully. Bottle height used for the irrigating cystitome ranged from 90 to 110 cm, depending upon whether the cataract was intemuscent (110 cm) or hypermature (90–100 cm). The flow of fluid is a uniform stream while entering the AC through the paracentesis stab wound (side port). It is used to make a small puncture in the anterior capsule [Figure 2a]. After the initial puncture, the continuous irrigation washes out the milky liquefied cortical matter while also maintaining the AC [Figure 2b]. The irrigating cystitome is inserted into the capsular bag and a gentle to and fro motion is done, so that more liquified cortex gets washed away. This manoeuvre allows the ILP to come down. Once the liquefied cortex is fully irrigated out, capsulorhexis is continued with the irrigating cystitome and completed [Figure 2c-e]. If there was any tendency of the capsule to run away or extend to the periphery, viscoelastic material (2% hydroxypropyl methylcellulose) was injected through the second side port. 4 eyes of patients with white intumescent cataract had a tendency to run away and viscoelastic was used in those cases. We always try to keep the everted capsular flap flat over the anterior lens surface. Continuous irrigation keeps a positive pressure on the capsule, which counteracts the high ILP.

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Figure 1:

Pictorial representation of the steps of irrigating cystitome enabled capsulorhexis; (a) Fluid coming out of the cystitome, (b) Initial nick is made; fluid washes out the liquified cortex, (c) Once the liquefied cortex is fully irrigated out, capsulorhexis is continued, (d) Capsulorhexis is continued, (e) Optimum-sized capsulorhexis is achieved.

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Figure 2:

(a) Irrigating cystitome makes a small puncture in the anterior capsule. (b) Continuous irrigation washes out the milky liquefied cortical matter. (c) Once the liquefied cortex is fully irrigated out, capsulorhexis is continued. (d) Capsulorhexis is continued taking care that the everted flap is placed flat on the anterior lens surface. (e) Optimum-sized capsulorhexis is achieved.

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After completing CCC, a clear corneal incision of 2.2 mm is made in the 10 o’clock position, followed by standard phacoemulsification surgery.

DISCUSSION

Over the years, a multitude of techniques have been tried and evaluated to create a predictable and reproducible CCC in hypermature Morgagnian cataract and white intumescent cataract.

Gimbel and Willerscheidt and Vasavada et al. described the two-stage technique of capsulorhexis in white cataract, wherein a small capsulorhexis is done initially.^[4,9] This is followed by endophacoemulsification. The CCC is enlarged before the insertion of the intraocular lens.^[4,9] Kara-Junior et al. found that two-stage capsulorhexis was successful in creating CCC in 89.9% of cases. It also helps to prevent radial tears in the initial capsulotomy.^[1]

Balyan et al. reported a multifaceted approach to deal with white mature cataracts.^[3] They used a 30G needle of an insulin syringe inserted through a limbal stab incision to decompress the lens capsule. CCC was later performed with a microcapsulorhexis forceps inserted through the main port.^[3] Alsmman et al. reported closed chamber anterior capsulorhexis under air tamponade in white cataracts.^[2] Needle capsulorhexis was done under large air bubble tamponade without the use of staining dye.^[2]

In the present study, irrigating cystitome enabled capsulorhexis was successfully performed in all 74 eyes. Herein, single-stage capsulorhexis was done without the use of any extra devices. The irrigating cystitome performs a triple action of washing out the liquified cortex, acts as an AC maintainer and performs the capsulorhexis. Thus, it does away with the requirement of first decompressing the lens capsule and then performing CCC with rhexis forceps or cystitome. Furthermore, not all surgeons are familiar with or have access to microscissors and microrhexis forceps. This technique can be a convenient tool for those who serve in remote hospitals or cater to patients belonging to a low socioeconomic profile.

CONCLUSION

Irrigating cystitome-enabled capsulorhexis is a safe and effective method to achieve capsulorhexis in hypermature Morgagnian cataract and white intumescent cataract. The learning curve for this technique is shallow, as it does not involve any new instrumentation. Instead of fitting the 26G cystitome into a visco-filled syringe, it is connected to the infusion line of the irrigating fluid. It can prevent the Argentinian flag sign at no extra cost.