Continuous Curvilinear Capsulorhexis

*Liu Qian*

### **Abstract**

Continuous curvilinear capsulorhexis (CCC) is an important step in of modern phacoemulsification, which has crucial influence on the surgical process and prognosis. In this chapter, we mainly discuss following aspects: Preoperative preparation, Effects of incision on capsulorhexis, Capsulorhexis, Special cases of capsulorhexis and Capsulorhexis assisted by femtosecond laser. The problem need to pay attention and the solution way in above aspects will be elaborated.

**Keywords:** continuous, circular, centered, capsulorhexis, cataract

#### **1. Introduction**

Thomas Neuhann and Howard Gimbel, considered as pioneers in the development of the centered continuous curvilinear capsulorhexis (CCC) technique, first published their paper on the technique in 1990 [1]. The use of CCC technique makes the rim of the anterior capsule (AC) much stronger and decreases the risk of tearing, thus providing a solid foundation for applying the "chip and flip," "divide and conquer," "phaco chop," and "phaco pre-chop" techniques. What is more, the IOL could be more correctly positioned and stability with the centered continuous curvilinear anterior opening [2–5]. In terms of improving the prognosis, CCC technique could supply a continuous opening with more smooth edges [6]. The morphology of anterior capsule affect position of lens and refractive outcome greatly [7]. CCC helps maintain the intraocular lens (IOL) in the correct position and overlaped by anterior capsule as showed in **Figure 1** which providing a more predictable effective lens position (ELP) [6]. In addition, The CCC technique could reduce the incidence of posterior capsular opacification (PCO) [8–10]. With the current widespread-use of multi-focus intraocular lenses and astigmatism-correcting intraocular lenses, Cataract surgery has entered the refractive age. Centered CCC(CCCC) play a crucial role in obtaining good postoperative visual quality. Tilt and decentration of the IOL can decrease visual acuity which could result in astigmatism [11, 12]. Okada et al. [13] confirmed that decentration of optic center by 0.4 mm could produce 0.25D change in spherical equivalent.

In this chapter, we will elaborate on several aspects include: preoperative preparation; the effects of incision on capsulorhexis. The two parts above mainly discuss the tools, head position of patient, exposure of surgical field of vision, red reflex of microscope, hand position of surgeon and importance of incision. Then capsulorhexis technique and special cases of capsulorhexis will be interpreted. In the end, we will introduce the advantage of femtosecond laser system in capsulorhexis and precautions.

#### **Figure 1.**

*Color photo of patient 3 months after CCCC. The margin of optic region was overlaped by anterior capsule full-circlely.*

### **2. Preoperative preparation**

#### **2.1 Tools for CCC**

Initially, a type of irrigating cystotome (designed by Charles Kelman) and a needle were employed in CCC. The first forceps, specifically used to conduct capsulorhexis, were designed by Peter Utrata in 1988,and are still used today.

Forceps were designed in different lengths, with columnar and flat handle (**Figure 2**) and the tips were curved and flat (**Figure 3**). Compared with columnar handle, the flat handle is easier for thumb and index finger to hold and middle finger to support and relatively more lighter. After the viscoelastic agent was injected into the front chamber, the anterior capsule is flattened. The flat tip has more room to move around in the anterior chamber. The curved tip generate height difference in the anterior chamber. Limited by the incision, the movement of curved tip is restricted. The choice of length, depends on the habit and hand size of the operator and the last choice of columnar and flat handle or curved and flat tip depends on the habit too.

Aim to reduce the incidence of infection after operation especially to decrease surgically induced astigmatism and the influence on corneal optical performance in refractive cataract surgery, corneal incision size was reduced from over 3 mm to less

**5**

**Figure 4.**

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

than 2 mm [14–19]. The related equipment is also required to be further improved. Smaller incisions limit the movement of traditional capsular forceps. Calladine-Inamura Capsulorhexis Forceps increases the opening and closing range of the tip in the anterior chamber by the hinge design on the forearm as showed in **Figure 4** to complete capsulorhexis through small incision. Ikeda MICS Capsulorhexis Forceps is tube designed with small diameter as 0.7 mm (showed in **Figure 5**) could enter

Scales of 5 mm and 2.5 mm are marked on some of the flat-tipped forceps, as shown in **Figure 6**, which can be useful as a measurement reference for the operator.

The position of the head is vital to ensure the centrality of the AC opening. The patient's head should be kept horizontal for the lens plane to remain horizontal

*Calladine-Inamura Capsulorhexis forceps. Hinge design on the forearm in a and the detail in B.*

anterior chamber for capsulorhexis through small paracentesis.

**2.2 Patient's head position**

*Different designs of forceps tip. A is flat and B is curved.*

**Figure 3.**

**Figure 2.** *Different designs of forceps handle. A is columnar and B is flat.*

*Current Cataract Surgical Techniques*

**2. Preoperative preparation**

Initially, a type of irrigating cystotome (designed by Charles Kelman) and a needle were employed in CCC. The first forceps, specifically used to conduct capsu-

*Color photo of patient 3 months after CCCC. The margin of optic region was overlaped by anterior capsule* 

Forceps were designed in different lengths, with columnar and flat handle (**Figure 2**) and the tips were curved and flat (**Figure 3**). Compared with columnar handle, the flat handle is easier for thumb and index finger to hold and middle finger to support and relatively more lighter. After the viscoelastic agent was injected into the front chamber, the anterior capsule is flattened. The flat tip has more room to move around in the anterior chamber. The curved tip generate height difference in the anterior chamber. Limited by the incision, the movement of curved tip is restricted. The choice of length, depends on the habit and hand size of the operator and the last choice of columnar and flat handle or curved and flat tip depends on

Aim to reduce the incidence of infection after operation especially to decrease surgically induced astigmatism and the influence on corneal optical performance in refractive cataract surgery, corneal incision size was reduced from over 3 mm to less

lorhexis, were designed by Peter Utrata in 1988,and are still used today.

**2.1 Tools for CCC**

**Figure 1.**

*full-circlely.*

the habit too.

**4**

**Figure 2.**

*Different designs of forceps handle. A is columnar and B is flat.*

**Figure 3.** *Different designs of forceps tip. A is flat and B is curved.*

than 2 mm [14–19]. The related equipment is also required to be further improved. Smaller incisions limit the movement of traditional capsular forceps. Calladine-Inamura Capsulorhexis Forceps increases the opening and closing range of the tip in the anterior chamber by the hinge design on the forearm as showed in **Figure 4** to complete capsulorhexis through small incision. Ikeda MICS Capsulorhexis Forceps is tube designed with small diameter as 0.7 mm (showed in **Figure 5**) could enter anterior chamber for capsulorhexis through small paracentesis.

Scales of 5 mm and 2.5 mm are marked on some of the flat-tipped forceps, as shown in **Figure 6**, which can be useful as a measurement reference for the operator.
