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Capsulorhexis: Flat Tear vs Fold/Lead

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Title: Capsulorhexis: Flat Tear vs Fold/Lead
Author (s): Troy Teeples, MSIV, Nikko Ronquillo, MD, Tara Hahn, MD, Jeff Pettey, MD
Photographer: Troy Teeples, MSIV University of Utah School of Medicine
Date: 8/8/2018
Keywords/Main Subjects: Capsulorhexis, lens capsule, cataract surgery

Brief Description: A crucial step in cataract surgery is the creation of a capsulorhexis, performed to make cataract extraction and IOL placement possible. Here we discuss two possible techniques of capsulorhexis creation.


Capsulorhexis is a technique performed by removing a portion of the anterior lens capsule with the use of stretch and shear forces. A correctly-sized and well-centered capsulorhexis allows adequate access to nuclear material and prevents complications such as IOL tilt post-operatively. In routine cataract surgery, the ideal capsulorhexis is a 5.0 – 5.25mm diameter round opening in the anterior lens capsule. There are multiple techniques used in the creation of a capsulorhexis. Demonstrated in this video are both a fold/lead and a flat tear technique.

Technique Description:

An optional step prior to making a capsulorhexis is the use of a ring caliper on the cornea, as seen in the first segment of this video (ring caliper footage taken from a separate case). A ring caliper is used to make a circular corneal impression approximately 5mm in diameter to guide the surgeon in making a well-centered and correctly-sized capsulorhexis. To begin the capsulorhexis, the central portion of the anterior lens capsule is punctured using either a bent needle, called a cystotome, or the tips of the capsulorhexis forceps. In this video, a capsulorhexis forceps is used. A flap from the anterior capsule is then gently grasped by the capsulorhexis forceps and a circular tear is begun clockwise or counterclockwise.

In the fold/lead technique, the capsular flap is folded towards the center prior to re-grasping. It important that the surgeon re-grasps the capsular flap close to the lens to maintain control while making a tear in the capsule. Multiple grasping maneuvers are necessary to be close to the leading edge of the tear. In contrast, with the flat tear technique the surgeon grasps the capsule flap and completes the 360-degree capsulorhexis with less re-grasping maneuvers. To achieve this, tangential forces are required as the leading edge of the tear is farther from the flap being held by the forceps. Care must be taken to pull with the correct amount of force and in the correct vector, to avoid radializing the capsulorhexis and creating posterior capsular tears. When the capsulorhexis is complete, the torn portion of the capsule is removed from the eye and discarded.

In this video, the first half of the capsulorhexis (3 o’clock to 9 o’clock) is performed using the fold/lead technique, whereas the second half of the 360-degree capsulorhexis is performed using the flat tear technique.

Faculty Approval by: Jeff Pettey, MD
Identifier: Moran_CORE_25259
Copyright statement: Copyright Teeples, ©2018. For further information regarding the rights to this collection, please visit:
Disclosure (Financial or other): None