**5.4 The challenge of small pupil and flabby suspensory ligament**

A disease that often causes difficulty with capsulorhexis is exfoliation syndrome, because of two clinical aspects. Firstly, the pupils cannot be dilated past 5 mm,

#### **Figure 24.**

*Decompression of intumescen lens. To pierce the intumescent AC with the tip of capsulorhexis forceps (A). The liquefied cortex spills out (red arrows in B). Discission needle was applied to clear the liquefied cortex beneath AC (C). AC collapse appeared as larger annular reflections (D).*

#### **Figure 25.**

*The pupil is too small to expose the trajectory of the capsulorhexis. Skilled surgeons could perform a blind capsulorhexis.*

#### **Figure 26.**

*Suspensory ligament of exfoliation syndrome is extremely flabby which could appear as the radial and wrinkled reflections during capsulorhexis (red arrow).*

generating an insufficient red reflex for the operator to perform the procedure comfortably. The Malyugin ring, as mentioned in the section on the surgical field of vision**,** can be used in such situations. However, skilled surgeons often perform a blind capsulorhexis. The trajectory of the capsulorhexis is covered by the iris, as shown in **Figure 25**.

The other difficulty is extreme relaxation or even rupture of the suspensory ligament, which can be difficult to detect, even with UBM (Ultrasound Biomicroscopy). As the pupil cannot be dilated large enough and therefore the condition of suspensory ligaments around the capsule is not clear. However, the extent of the suspensory ligament relaxation can be judged by the folds caused by the tip of the capsular tweezers when touching the surface of the AC during capsulorhexis as showed in **Figure 26**.

When such a situation occurs, the surgeon should be careful, and the number of capsulorhexis should be appropriately increased to improve controllability. This method is also suitable for small pupils in diabetic patients and patients with prostatitis treated with Finasteride. Beginners should be aware of this disease and refer the cases to experienced surgeons.

**17**

**7. Conclusion**

capsulorhexis**.**

**Conflict of interest**

*Continuous Curvilinear Capsulorhexis DOI: http://dx.doi.org/10.5772/intechopen.96556*

following recommendations:

**Figure 27.**

1.The patient needs to be able to cooperate.

*conducted. Lens plane was also displayed by anterior OCT (yellow arrow).*

3.The pupil must be dilated to at least 5 mm.

The authors declare no conflict of interest.

**6. Capsulorhexis assisted by femtosecond laser**

Femtosecond laser capsulorhexisis superior in accuracy and precision compared with manual capsulorhexis, as well as the tensile strength of the capsule opening. An accurate circular, continuous and centered capsulorhexis as achieved by a femtosecond system cannot be achieved manually [21] (**Figure 27**). Because of these advantages, capsulorhexis assisted by a femtosecond laser is even more critical for premium IOLs. Presently, femtosecond laser surgery is also used in mature, traumatic, and for

This system greatly reduces the risk of capsulorhexis with due attention to the

*The display interface of femtosecond laser during capsulorhexis. A perfect AC opening (red arrow) was* 

2.The patient's head and eye position should remain absolutely horizontal, as shown in **Figure 5**. Excessive upturn and downturn can lead to failure of capsulorhexis. Therefore, patients with head tremor and uncooperative eye position should be cautious. We can refer to the surface of the lens shown in

As cataract surgery enters the refractive age, the criteria "continuous, circular, and centered" have become the basic requirement of the capsulorhexis technique. Therefore, it is extremely important for the surgeon to master the technique of

anterior OCT of this system as yellow arrow in **Figure 27**.

other cataract patients with suspensory ligament abnormalities [22–26].

*Current Cataract Surgical Techniques*

**16**

**Figure 26.**

**Figure 25.**

*capsulorhexis.*

shown in **Figure 25**.

*wrinkled reflections during capsulorhexis (red arrow).*

refer the cases to experienced surgeons.

*Suspensory ligament of exfoliation syndrome is extremely flabby which could appear as the radial and* 

*The pupil is too small to expose the trajectory of the capsulorhexis. Skilled surgeons could perform a blind* 

generating an insufficient red reflex for the operator to perform the procedure comfortably. The Malyugin ring, as mentioned in the section on the surgical field of vision**,** can be used in such situations. However, skilled surgeons often perform a blind capsulorhexis. The trajectory of the capsulorhexis is covered by the iris, as

The other difficulty is extreme relaxation or even rupture of the suspensory ligament, which can be difficult to detect, even with UBM (Ultrasound Biomicroscopy). As the pupil cannot be dilated large enough and therefore the condition of suspensory ligaments around the capsule is not clear. However, the extent of the suspensory ligament relaxation can be judged by the folds caused by the tip of the capsular tweezers when touching the surface of the AC during capsulorhexis as showed in **Figure 26**. When such a situation occurs, the surgeon should be careful, and the number of capsulorhexis should be appropriately increased to improve controllability. This method is also suitable for small pupils in diabetic patients and patients with prostatitis treated with Finasteride. Beginners should be aware of this disease and
