OBJECTIVE: To compare the histomorphologic changes on the anterior lens capsule by both epithelial and basement membrane side staining to those of only basement membrane side staining of the anterior lens capsule with Trypan Blue (TB).
METHODS: A cross-sectional study was done on 72 samples from patients who underwent cataract surgery between April 2021 and September 2022. After capsulorhexis of the TB-stained capsule, it was made into two halves externally and one half labeled as controls (sample A). The other half was immediately stained further with TB on the epithelial side and was taken as cases (sample B). Samples were analyzed for lens epithelial cells and basement membrane changes.
RESULTS: The loss of intactness of lens epithelial cells, partial or complete detachment of lens epithelial cells, degeneration of lens epithelial cells, and basement edema were significantly higher in cases compared to controls, whereas intactness of the basement membrane did not show any statistical significance between the two groups. There was a statistically significant decrease in cell density in cases compared to controls.
CONCLUSIONS: Staining the epithelial side of the capsular bag with TB is more detrimental to lens epithelial cells and paves the way for a further study of staining the capsular bag before intra-ocular lens implantation to reduce the incidence of posterior capsule opacification.

OBJECTIVE: To evaluate the effect of primary posterior continuous curvilinear capsulorrhexis (PPCCC) on the positional stability of IOLs.
METHODS: This study is a prospective intra-individual comparative randomized controlled trial including 31 patients (62 eyes). Eyes of the same patient were randomly assigned to the PPCCC group (18 right eyes and 13 left eyes) or group without PPCCC (NPCCC group). Eyes in both groups were implanted with a one-piece foldable hydrophobic acrylic IOL via routine cataract surgery. Patients in the PPCCC group underwent additional manual PPCCC before IOL implantation. Examinations were performed 1 day, 1 week, 1 month and 3 months postoperatively. IOL tilt (x, y), decentration (x, y), anterior chamber depth (z) and refractive prediction error data were collected and analyzed with Pentacam.
RESULTS: Postoperatively, the range of IOL position change over 3 months in PPCCC group was comparable to NPCCC group, which indicated smaller value in every tilt and decentration index. PPCCC eyes showed comparable tilt and decentration with NPCCC eyes in this study endpoint: mean tilt (x, y), decentration (x, y) and anterior chamber depth (ACD) were 1.04 ± 0.56°, 0.90 ± 0.64°, 0.239 ± 0.140 mm, 0.233 ± 0.133 mm and 4.01 ± 0.32 mm, respectively, in the PPCCC group vs. 1.09 ± 0.76°, 1.10 ± 0.82°, 0.252 ± 0.153 mm, 0.244 ± 0.155 mm and 4.01 ± 0.38 mm, respectively, in the NPCCC group. Refractive prediction error in the PPCCC group demonstrated a mild hyperopic shift vs. the NPCCC group (0.13 ± 0.50 vs. 0.05 ± 0.39; p = 0.208), and corrected distance visual acuity (CDVA) did not differ between the two groups (0.027 ± 0.014 vs. 0.059 ± 0.185; p = 0.377).
CONCLUSIONS: Comparable IOL tilt, decentration, ACD and refractive prediction error were observed in PPCCC eyes with that underwent routine cataract surgery. Little IOL position fluctuation and good visual acuity were shown in PPCCC group over time.
BACKGROUND: The study was registered at the Chinese Clinical Trial Register Center on May 27th, 2020 (protocol code ChiCTR2000033304, 27/05/2020).

OBJECTIVE: The smaller incision, new-generation implantable miniature telescope is a novel implant to optimize vision in retinal patients with central vision loss. Using Miyake-Apple techniques we visualized the device implantation, repositioning, and explantation, while noting capsular bag dynamics.
METHODS: Using the Miyake-Apple technique, we assessed capsular bag deformation after successful implantation of the device in human autopsy eyes. We assessed rescue strategies for converting a sulcus implantation to a capsular implantation and explantation strategies. We noted the occurrence of posterior capsule striae, zonular stress, and the haptics\' arc of contact with the capsular bag after implantation.
RESULTS: Acceptable zonular stress was observed during the successful implantation of the SING IMT. When it was implanted in the sulcus, one could reposition the haptics into the bag with two spatulas using counter-pressure in an effective strategy despite inducing tolerable, medium zonular stress. A similar technique, in reverse, allows safe explantation without damaging the rhexis or the bag, while inducing similar medium, tolerable zonular stress. In all eyes we examined, the implant considerably stretches the bag, inducing a capsular bag deformation and posterior capsule striae.
CONCLUSIONS: The SING IMT can be safely implanted without significant zonular stress. In sulcus implantation and explantation, repositioning of the haptic is achievable without perturbing zonular stress using the presented approaches. It stretches average-sized capsular bags to support its weight. This is achieved by an increased arc of contact of the haptics with the capsular equator.

OBJECTIVE: To investigate the prevalence and surgical outcome of lens capsule disruption (LCD) in dogs undergoing cataract removal.
METHODS: Medical records of 924 eyes undergoing phacoemulsification were analyzed retrospectively.
METHODS: Routine cataract surgeries with or without LCD were included. Any LCD other than routine anterior capsulorhexis was defined as LCD and classified according to location and etiology. Odds ratios (OR) were calculated for maintaining vision, implantation of an artificial intraocular lens (IOL), and enucleation.
RESULTS: In total, 520 eyes were included. A LCD occurred in 145 eyes (27.8%; 145/520) and affected the posterior (85.5%; 124/145), anterior (6.2%; 9/145), and equatorial lens capsule (4.8%; 7/145) and at multiple locations (3.4%; 5/145). The etiology of the LCD was spontaneous preoperative in 41 eyes (28.3%; 41/145), accidental intraoperative in 57 eyes (39.3%; 57/145), and planned in 47 eyes (32.4%; 47/145). Disruption did not increase the odds of enucleation (OR = 1.48, 95% confidence interval [CI] 0.56-3.67; p = .36). The presence of LCD significantly increased the risk of losing vision 1 year post-operatively (OR = 8.17, 95% CI 1.41-84.93; p = .007) associated with retinal detachment. However, this was not present at 2 years follow-up or in PCCC cases at any time point. An IOL was implanted in 108 eyes (108/145; 75.2%) with LCD and in 45/47 (95.7%) eyes with a PCCC.
CONCLUSIONS: Increased surgeon awareness of possible intraoperative, accidental LCDs is important, as LCDs were relatively common and associated with increased odds for vision loss after 1 year in the present study. A prospective study investigating the causes of intraoperative, accidental LCD is warranted.

OBJECTIVE: To evaluate the learning curve of continuous curvilinear capsulorhexis (CCC) and to assess the number of surgeries required to master it among residents in a postgraduate teaching institute.
METHODS: The present prospective observational study was based on the completion time and complication rates related to CCC performed using various techniques by 10 students in the 2nd (JR2) and 3rd-year (JR3) of residency. CCC was performed either by a cystotome or capsulorhexis forceps or by a combined method in 253 eyes, of which 160 eyes (63.2%) were operated by JR3 and 93 (36.8%) by JR2. The complication rates were studied with respect to the number of capsular extensions, posterior capsular rent (PCR), zonular dehiscence, need for senior surgical assistance, and nucleus drop.
RESULTS: The average time required for the completion of CCC was 412 ± 90.5 s. The average number of times residents required to fill the anterior chamber with viscoelastic was 6.9 ± 1.4. The average size of CCC was 7 ± 0.66 mm. Extended CCC was the most common complication. JR2 required assistance from a senior surgeon in 47 eyes (50.5%), whereas JR3 required assistance in 39 eyes (24.4%) (P = 0.0001). The rate of PCR was not significantly different in JR2 (7.5%) and JR3 (8.8%).
CONCLUSIONS: CCC is a difficult step to master in the trainee. Focusing and practicing on this step will help to reduce the complications and maximize proficiency. Approximately 6-eight surgeries are required to master CCC.

BACKGROUND: Differences between programmed capsulorhexis diameter and actual resulting capsulorhexis diameter (ARCD) are commonly encountered in femtosecond laser-assisted cataract surgery (FLACS). The purpose of this study was to identify the preoperative ophthalmic variables influencing capsulorhexis diameter index (CDI) in FLACS for adults and create a multiple linear regression model for obtaining a more accurate capsulorhexis diameter.
METHODS: This retrospective study involved sixty-seven eyes of 44 patients who received FLACS and intraocular lens implantation. The ARCD was measured using anterior segment swept-source optical coherence tomography (CASIA 2). Keratometry (K1, K2 and average K), anterior chamber depth (ACD), lens thickness (LT), anterior chamber width (ACW), white-to-white (WTW), curvature radius of anterior lens capsule (Front R) and axial length (AL) were all measured preoperatively. Based on the derived data, LT/ACW, LT/AL, LT/ACD and LT/ACW/Front R were calculated. The ratio of the programmed capsulorhexis diameter and ARCD was defined as the CDI. Correlation analysis was conducted to examine the relationship between preoperative variables listed above and the CDI. Multiple linear regression analysis was applied to select the most influential preoperative variables on CDI.
RESULTS: ACD, LT, ACW, Front R, AL, LT/ACW, LT/AL, LT/ACD, and LT/ACW/Front R showed significant correlation with CDI. Front R and LT/ACW/Front R were selected as constants in the multiple linear regression model using stepwise variable selection. The following equation represents the multiple linear regression model: CDI = 1.306-4.516 × LT/ACW/FrontR-0.011 × Front R, when P < 0.0001, adjusted R-squared = 0.919, variance inflation factor = 8.389, and Durbin-Watson ratio = 1.846. Predicted postoperative capsulorhexis diameter (PPCD) equation was created based on CDI equation as follows: PPCD = programmed capsulorhexis diameter × 1.306-4.516 × LT/ACW/FrontR-0.011 × Front R.
CONCLUSIONS: Front R and LT/ACW/Front R were found to be the most significant influencing factors of capsulorhexis size. CDI and PPCD calculation equations presented in this study may be useful in setting up more accurate programmed capsulorhexis diameter for FLACS in adults, resulting in a precise ARCD.

To explore the clinical efficacy of quadruple surgery (anterior segment pars plana vitrectomy + phacoemulsification + posterior capsulorhexis + intraocular lens (IOL) implantation + trabeculectomy) and dual surgery (phacoemulsification + IOL implantation + trabeculectomy) to treat medically uncontrolled acute primary angle-closure glaucoma (APACG). The clinical data of 44 patients (45 eyes) with APACG treated in the Department of Ophthalmology of Taihe Hospital were retrospectively analyzed. They were divided into 2 groups based on quadruple surgery and dual surgery. There were 20 patients (20 eyes) underwent quadruple surgery in group A. And there were 24 patients (25 eyes) dual surgery in group B. The changes in intraocular pressure (IOP), visual improvement, and complications were observed between the 2 groups preoperatively and 1 month, 3 months, and 6 months postoperatively. Preoperative best corrected visual acuity (BCVA) was the influencing factor of postoperative BCVA at 1 month, 3 months and 6 months. Before surgery, the mean IOP of group A was significantly higher than that of group B (P < .001), and no significant difference was found in the BCVA, age, gender, eyes, axial length (AL), anterior chamber depth (ACD) (PBCVA = 0.12, Page = 0.76, Peyes = 0.20, Pgender = 0.37, PAL = 0.94, PACD = 0.08). On comparison at postoperative 1week, there was no significant difference in the IOP and BCVA between the 2 groups (PIOP = 0.64, PBCVA = 0.66). The mean IOP of group A was significantly lower than that of group B 1 month, 3 months, and 6 months postoperatively (P1month = 0.002, P3months < 0.001, P6months < 0.001). The degree of visual acuity recovery was significantly higher in group A at 1 month, 3 months, and 6 months postoperatively (P1month = 0.03, P3months = 0.02, P6months = 0.02). During treatment, the incidence of complications in group B was significantly higher than that in group A (P < .01). The clinical efficacy of anterior segment pars plana vitrectomy combined with posterior capsulorhexis, phacoemulsification, and trabeculectomy elicits clinical safety in treating medically uncontrolled APACG. It has remarkable effects and leads to a significant decrease in the occurrence of complications.

BACKGROUND: To compare safety and effectiveness between standard position and adjusted distance pre- and post-anterior capsule of femtosecond laser capsulotomy in white cataracts surgery.
METHODS: Selected white cataracts that underwent LenSx femtosecond laser capsulotomy were randomized into groups A (standard position, with 300 µm symmetrically pre- and post-anterior capsule), B (increased distance with 400 µm symmetrically pre- and post-anterior capsule), and C (unsymmetrical distances of 200 µm pre- and 400 µm post-anterior capsule, respectively). All these surgeries were performed by the same experienced surgeon. Complications, including incomplete capsulotomy and capsule tears, were recorded. In addition, femtosecond capsulotomy and phacoemulsification parameters, IOLs centrality and corrected distance visual acuity were assessed.
RESULTS: A total of 113 eyes were included in this study. There were 8 (21.6%) incomplete capsulotomy and 1 anterior capsule tear in group A. Meanwhile, only 2 eyes (5.1%) had incomplete capsulotomy with none showing capsule tear in group B. In group C, only 1 eye (2.7%) had incomplete capsulotomy and no capsule tear occurred. Mean femtosecond laser capsulotomy time was longer in group B compared with groups A and C. Average cumulative dispersed energy, IOL centrality and corrected distance visual acuity were similar in all groups.
CONCLUSIONS: Appropriate adjustment on femtosecond laser capsulotomy distance by reducing pre-anterior capsule and increasing post-anterior distance, may decrease incomplete capsulotomy and be more effective in white cataracts surgery.
BACKGROUND: Clinical trial registration number: ChiCTR2100043863.

OBJECTIVE: To analyse the occurrence and potential causes of lens capsule-related complications during femtosecond laser-assisted cataract surgery (FLACS).
METHODS: This prospective consecutive cohort study included the first 1600 eyes (from 1140 consecutive patients) who received FLACS performed by the same surgeon from May 2015 to December 2018. The potential causes and characteristic signs of capsulotomy-related complications, including incomplete capsulotomies and radial anterior capsule (AC) tears, were summarised based on the agreement of two ophthalmologists after they analysed the surgical videos. Subgroup analysis was conducted to characterise the capsulotomy learning curve.
RESULTS: Of the 1600 eyes, 52 (3.25%) had incomplete capsulotomies and 22 (1.38%) had radial AC tears. The most common causes of incomplete capsulotomies were eye tilt (16 eyes, 30.77%), air bubbles or ocular secretions at the interface (14 eyes, 26.92%) and white cataracts (7 eyes, 13.46%). Additionally, 54.55% (12/22) of AC tears were due to incomplete capsulotomy and secondary capsulorhexis. A significant difference was noted between the first 200 eyes and subsequent groups in terms of the incidence of incomplete capsulotomies. No difference was observed in the incidence of AC tears after the initial 100 procedures.
CONCLUSIONS: The most common causes of incomplete capsulotomies were eye tilt and air bubbles or ocular secretions at the interface. Secondary capsulorhexis after incomplete capsulotomy is the main risk factor for AC tears. There was a steep learning curve for laser capsulotomy in the first 100 operated eyes, as evidenced by the higher complication rate, but this stabilised after 200 procedures.

BACKGROUND: To identify the capsule enlargement index after femtosecond laser-assisted anterior capsulorhexis in 2-6-year-old children who underwent congenital cataract surgery.
METHODS: In this prospective case series study, femtosecond laser-assisted anterior capsulorhexis was performed in patients with congenital cataract, aged 2-6 years. The actual achieved capsulorhexis diameters were measured with Digimizer version 4.2.6. Correlation coefficient (r) and multiple linear regression analysis were used to evaluate the variables that could potentially influence anterior capsulorhexis enlargement index (E).
RESULTS: This prospective study enrolled 28 eyes of 22 patients with congenital cataract. The mean age of the patients at surgery was 4.67 years ±1.54 (standard deviation [SD]). \"E\" of the 28 cases was 1.211 ± 0.039 (SD). Correlation analysis showed that \"E\" correlated significantly with the anterior chamber depth (ACD) (r = - 0.469, p = 0.021) and axial length (AL) (r = 0.452, p = 0.027). The following formula was developed by using multivariable linear regression analysis: Predicted E = 1.177-0.052 × ACD + 0.009 × AL, R2 = 0.346 (F = 4.396, p = 0.046).
CONCLUSIONS: The anterior capsulorhexis enlargement index and its calculation formula could help to set up an accurate programmed capsulorhexis diameter for femtosecond laser-assisted congenital cataract surgery in children aged 2-6 years. Thus, an appropriate actual capsulorhexis diameter could be achieved.