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PubMed2004

Functional outcomes of acrylic intraocular lenses in pediatric cataract surgery.

PURPOSE: To evaluate the functional outcomes of in-the-bag implantation of acrylic intraocular lenses (IOLs) with posterior continuous curvilinear capsulorhexis (PCCC), without PCCC, with PCCC and anterior vitrectomy, and with PCCC and optic capture in pediatric cataract surgery. SETTING: Pediatric Ophthalmology Service, Guru Nanak Eye Centre, New Delhi, India. METHODS: Forty-two eyes of 25 children were included in this prospective study. All eyes had in-the-bag implantation of an AcrySof IOL (Alcon). Twenty-five eyes had had an anterior continuous curvilinear capsulorhexis (ACCC) (Group A). Seventeen eyes had PCCC along with ACCC (Group B), 4 had anterior vitrectomy combined with PCCC (Group C), and 6 had PCCC with IOL optic capture through the PCCC (Group D). Secondary opacification of the visual axis, visual acuity, and possible complications were observed and analyzed. RESULTS: The mean age of the patients was 78 months (range 36 to 144 months). The mean follow-up was 13 months (range 6 to 18 months). Four eyes (16%) in Group A developed visually significant posterior capsule opacification (PCO) involving the central visual axis and required secondary capsulotomy. All eyes in Groups B, C, and D had a clear visual axis at the last follow-up and did not require a secondary procedure. Minimal postoperative inflammation (ie, aqueous flare and IOL deposits ) was seen in all groups. The mean preoperative decimal best corrected visual acuity (BCVA) in Groups A, B, C, and D was 0.095, 0.055, 0.174, and 0.039, respectively. Postoperatively, the BCVA was 0.54, 0.66, 0.66, and 0.66, respectively. CONCLUSIONS: An optimal-sized ACCC followed by in-the-bag implantation of a foldable acrylic IOL helped maintain a clear visual axis by delaying the onset of PCO and leading to milder PCO. The benefits of a foldable acrylic IOL in pediatric cataract surgery can be increased by combining it with PCCC, with or without anterior vitrectomy, or with optic capture of the IOL.

Acrylic Resins↗
PubMed2004

Intraocular lens optic capture.

A continuous curvilinear capsulorhexis (CCC) provides a tear-resistant opening that allows use of a technique of capturing the intraocular lens (IOL) optic through the capsulorhexis opening when the opening is at least 1.0 to 2.0 mm smaller than the optic diameter. The technique provides stability and long-term centration of the IOL and prevents vitreous from extending anterior to the IOL. This paper reviews the current variations of optic capture including (1) haptics in the sulcus and IOL optic capture through a CCC, (2) haptics in the sulcus and IOL optic capture through an anterior capsule opening and a posterior CCC (PCCC), (3) haptics in the capsular bag and IOL optic capture through a PCCC, (4) haptics in the capsular bag and IOL optic capture through an anterior CCC, (5) haptics in the sulcus and IOL capture through a capsular membrane opening, and (6) haptics posterior to the capsular bag and IOL capture through a capsular membrane opening.

Capsulorhexis↗
PubMed2005

Drug-induced intraocular lens movement and near visual acuity after AcrySof intraocular lens implantation.

PURPOSE: To evaluate the factors influencing AcrySof intraocular lens (IOL) (Alcon Laboratories) movement and near visual acuity after cyclopentolate 1% and pilocarpine 2%. SETTING: Department of Ophthalmology, University of Ankara, Ankara, Turkey. METHODS: Thirty eyes of 22 patients with AcrySof IOL implantation were included in this prospective study. Near visual acuity (Jaeger) at 35 cm through best distance correction without an add and pupil diameter were measured and correlated with anterior chamber depth (ACD) measured with ultrasound biomicroscopy (UBM) after application of cyclopentolate 1% and pilocarpine 2%, respectively. The magnitude of the change in the ACD was correlated with the accommodation amplitude, patient age, time interval between surgery and imaging, preoperative axial length, capsulorhexis diameter, ACD during cycloplegia, IOL diameter, and presence of posterior capsule opacification (PCO). RESULTS: Near visual acuity significantly decreased after application of cyclopentolate 1% and increased after application of pilocarpine 2% (P < .001) in all eyes. The IOL moved anteriorly in 8 (26%) eyes and posteriorly in 22 (74%) eyes after pilocarpine 2%. There was no correlation between the ACD and near visual acuity under cyclopentolate 1% (r = 0.06, P > .05) or pilocarpine 2% (r = 0.04, P > .05). There was a moderate correlation between the anterior IOL movement and accommodation amplitude (P < .05, r = 0.42). There was no correlation between the magnitude of the IOL movement and patient age, time interval between surgery and imaging, the preoperative axial length, capsulorhexis diameter, ACD during cycloplegia, IOL diameter, and the presence of PCO (P > .05). CONCLUSIONS: There was better near visual acuity in all eyes with the AcrySof MAIOL, although most IOLs move slightly backward after of pilocarpine 2%. This points out pseudoaccommodation rather than pseudophakic accommodation. Ultrasound biomicroscopy is useful in determining the ACD and the relation between the IOL and the surrounding tissues after cataract surgery.

Accommodation, Ocular↗
PubMed2006

Phacoemulsification in anterior megalophthalmos.

This case outlines the phacoemulsification technique used to overcome the challenge of the hyperdeep anterior chamber, weak zonules, abnormal anterior capsule, and large capsular bag. Key steps included trypan blue staining of the anterior capsule, a large capsulorhexis, prolapse of the nucleus into the anterior chamber with phacoemulsification anterior to the capsulorhexis, and a posterior chamber-placed iris-clip intraocular lens. Successful visual rehabilitation is achievable in these anatomically challenging eyes.

Adult↗
PubMed2006

Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees.

PURPOSE: To measure the relative difficulty of each stage of phacoemulsification surgery performed by basic surgical trainees. SETTING: Mater Misericordiae University Hospital, Dublin, Ireland. METHODS: This prospective study comprised 100 consecutive cases of phacoemulsification performed by 8 trainee surgeons over an 11-month period. The trainees completed a questionnaire at the end of surgery, rating the degree of difficulty of 8 individual stages of phacoemulsification on a 5-point scale from 1 (very easy) to 5 (very difficult). RESULTS: At the start of the study, trainees had spent a mean of 9.4 months training. The mean preoperative best corrected decimal visual acuity was 20/70. The most difficult stages were phacoemulsification and capsulorhexis with the highest mean scores of 3.32 +/- 1.00 (SD) and 3.30 +/- 1.24, respectively and the lowest completion rates of 66.7% and 74.4%, respectively. The first 3 stages of peribulbar blockade (1.72 +/- 0.75), draping the surgical field (1.35 +/- 0.70) and corneal incision (1.97 +/- 0.72) were easiest and had close to a 100% completion rate. Hydrodissection, irrigation/aspiration, and intraocular lens insertion had difficulty rates of 2.42 +/- 0.92, 2.80 +/- 1.10, and 2.58 +/- 1.08, respectively, and completion rates of 92.3%, 78.4%, and 83.1%, respectively. Posterior capsule tear occurred in 9%, including 4% with vitreous loss; there was 1 case of zonular dehiscence. CONCLUSIONS: Trainee surgeons found phacoemulsification and capsulorhexis the most difficult stages of cataract surgery early in the learning curve. More time can be dedicated to mastering these steps in the wet lab.

Aged↗
PubMed2006

Routine posterior optic buttonholing for eradication of posterior capsule opacification in adults: report of 500 consecutive cases.

PURPOSE: To study the efficacy of posterior optic buttonholing (POBH) through a primary posterior capsulorhexis (PPCCC) to preserve full capsular transparency, and its potential as a routine alternative to standard in-the-bag implantation of sharp-edged optic intraocular lenses (IOLs). SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: After standard cataract removal, a PPCCC 4.0 to 5.0 mm in diameter was performed and the optic of a 3-piece IOL buttonholed posteriorly. One third of the eyes additionally had extensive anterior capsule polishing. All surgeries were performed under topical anesthesia. RESULTS: The first 500 consecutive surgeries were evaluated. In 11 eyes, POBH was not performed as planned. In 4 cases, anterior capsulorhexis fixation of the optic was used as an alternative. In the early series, vitreous entanglement was seen in 5 eyes, of which 1 case prompted translimbal anterior vitrectomy. No case of cystoid macula edema was observed. One case of peripheral retinal detachment in a highly-myopic eye 4 months postoperatively appeared to be unrelated to the surgery. All lenses were well-centered without tilt, and both capsule leaves remained clear especially after additional polishing. CONCLUSION: Posterior optic buttonholing precludes lens epithelial cells from accessing the retrolental space. The sandwiched posterior capsule blocks optic contact and thus fibrosis of the anterior capsule. Posterior optic buttonholing avoids after-cataract independent of optic edge design. Anterior capsule polishing adds to its efficacy by excluding any residual fibrosis. Surgery under topical anesthesia was well-controlled and safe. Posterior optic buttonholing may become a routine alternative to standard in-the-bag IOL implantation when supported by a longer follow-up.

Capsulorhexis↗
PubMed2006

Assessment of the strength of minicapsulorhexes.

PURPOSE: To evaluate the effect of age, size, position, and species on the strength of minicapsulorhexes. SETTING: Surgical Suite and Laser Laboratory, Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA. METHODS: Capsulorhexes 0.7 to 2.3 mm in diameter were made centrally or peripherally in 35 eye-bank eyes and 32 rabbit eyes. A custom-made instrument stretched the capsulorhexes until rupture. Load and stretch at rupture were recorded. RESULTS: Maximum load and stretch were 26.3 mN +/- 20.3 (SD) and 50% +/- 18% for central and 50.8 +/- 20.5 mN and 69% +/- 17% for peripheral capsulorhexes in eye-bank eyes and 19.8 +/- 15.2 mN and 38% +/- 13% for central and 13.5 +/- 9.5 mN and 30% +/- 7% for peripheral capsulorhexes in rabbit eyes. Peripheral capsulorhexes were stronger and more elastic than central capsulorhexes in eye-bank eyes, and maximum load and stretch increased statistically with the capsulorhexis diameter. CONCLUSIONS: Peripheral minicapsulorhexes were more resistant to rupture than central capsulorhexes in eye-bank eyes, probably because of increased lens capsule thickness at the periphery. An increase in capsulorhexis diameter increased the resistance to rupture.

Adult↗
PubMed2006

Effect of trypan blue staining on the density and viability of lens epithelial cells in white cataract.

PURPOSE: To assess the effect of anterior capsule staining with trypan blue 0.0125% on the density and viability of the lens epithelial cells (LECs). SETTING: Iladevi Cataract and IOL Research Center, Ahmedabad, India. METHODS: This randomized prospective study comprised 40 eyes having phacoemulsification for white mature cataract. Patients were randomized to have the anterior capsule stained with 0.1 mL trypan blue 0.0125% solution before the anterior capsulorhexis (Group 1, n = 20) or to have no anterior capsule staining before the anterior capsulorhexis (Group 2, n = 20). The density and viability of LECs were analyzed. The first 20 samples (10 from Group 1, 10 from Group 2) were stained with hematoxylin-eosin for cell density analysis using image-analysis software. The remaining 20 samples (10 from each group) were stained with a solution containing 0.5 microM calcein AM and 5 microM propidium iodide for 10 minutes at 37 degrees C for viability assay. RESULTS: The mean cell density in Group 1 (with staining) was 3533.15 cells/mm(2) +/- 664.01 (SD). This was significantly lower than the mean of 4235.59 +/- 414.93 cells/mm(2) in Group 2 (no staining) (P = .01). The mean capsule area covered with LECs (80.75% +/- 8.04% versus 94.63% +/- 3.78%) and the mean live LECs in the covered area (51.69% +/- 11.54% versus 68.67% +/- 9.15%) were also significantly lower in Group 1 (P = .002). CONCLUSION: Staining the anterior capsule with trypan blue affected the density and viability of LECs.

Capsulorhexis↗
PubMed2000

Early capsular distension syndrome after sulcus implantation of intraocular lenses.

Two cases of early capsular distension syndrome (cds) are presented. the first occurred after sulcus implantation of a 12.0 mm poly(methyl methacrylate) iol (5.0 mm optic, 10 degree anterior angulation). the second case occurred after sulcus implantation of a foldable silicone iol with optic capture (6.0 mm optic, no anterior angulation). both cases resolved after a neodymium:YAG laser anterior capsulotomy. Cataract surgeons should be aware of the possibility of CDS after sulcus implantation of an IOL in the presence of an intact capsulorhexis and posterior capsule. A small capsulorhexis and in-the-bag capture of the IOL optic are major predisposing factors in this setting.

Aged↗
PubMed2000

Phacoemulsification in eyes with white cataract.

PURPOSE: To study the results of phacoemulsification in eyes with white cataract. SETTING: Aravind Eye Hospital, Madurai, India. METHODS: This retrospective study comprised 212 consecutive patients with white cataract: 192 mature (90.6%), 11 intumescent (5.2%), and 9 hypermature (4.2%). Patients had phacoemulsification and continuous curvilinear capsulorhexis. After the nucleus was removed by the divide and conquer or the phaco chop technique, a posterior chamber intraocular lens was implanted. Preoperative and intraoperative findings, as well as postoperative outcomes, were analyzed. RESULTS: Intraoperative complications included premature entry of the tunnel into the anterior chamber in 4 eyes (1.9%), incomplete capsulorhexis in 60 (28.3%), posterior capsular tear in 4 (1.9%), conversion to a manual nonphacoemulsification technique in 4 (1.9%), intraoperative miosis in 7 (3.3%), and iris chafing in 2 (0.9%). Mean phacoemulsification time was 2.03 minutes (range 0 to 5.8 minutes). A best corrected visual acuity of 6/9 or better was attained in 131 patients (61.8%) on the first postoperative day and in 199 patients (93.9%) at 1 month. Postoperative complications included moderate transient striate keratopathy with corneal edema in 12 eyes (5.7%) and iritis in 2 (0.9%). CONCLUSIONS: Phacoemulsification was a safe and effective technique to remove white mature cataract in eyes in a developing country.

Adolescent↗
PubMed2001

Optic capture of the AcrySof intraocular lens in pediatric cataract surgery.

PURPOSE: To assess the results of acrylic intraocular lens (IOL) optic capture in children with cataract. SETTING: Department of Ophthalmology, Hospital de Clínicas José de San Martín, and Instituto de la Vision, School of Medicine, University of Buenos Aires, Argentina. METHODS: Eight children had cataract surgery. After lens and cortex aspiration, an AcrySof (Alcon) IOL was implanted in the bag. A primary posterior capsulorhexis was performed. The optic edges were slipped through the posterior capsule leaflets. Clarity of the visual axis, preoperative and postoperative best corrected visual acuities (BCVAs), and refraction were evaluated. RESULTS: The visual axis remained clear in all cases. No case required a secondary procedure. The mean preoperative BCVA was 0.06 +/- 0.06 (SD). Postoperatively, the mean BCVA was 0.88 +/- 0.11 and the mean spherical equivalent, +0.62 +/- 1.31. The mean follow-up was 28.9 +/- 5.3 months. CONCLUSION: Results show that the optic of an acrylic IOL may be captured through a posterior capsulorhexis in pediatric cataract surgery, combining the advantages of optic capture with a smaller incision and a decreased inflammatory response.

Acrylic Resins↗
PubMed2002

Trypan blue as an adjunct for safe phacoemulsification in eyes with white cataract.

PURPOSE: To assess the feasibility, risks, and postoperative outcomes of phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation in cases of white cataract with the use of trypan blue as an adjunct for performing continuous curvilinear capsulorhexis (CCC) in the absence of a red reflex. SETTING: Dr. Agarwal's Eye Hospital, Chennai, India. METHODS: This prospective study comprised 52 eyes of 52 patients with white cataract that had phacoemulsification through a clear corneal temporal incision with PC IOL implantation. In all the cases, trypan blue was used under air to stain the anterior lens capsule and the karate-chop technique was used to emulsify the nucleus. The mean follow-up was 192.2 days. RESULTS: Trypan blue adequately stained the anterior lens capsule in all cases. The CCC was completed uneventfully in 96.15% eyes; 3.85% of cases had to be converted to a conventional extraction technique because of the loss of the CCC. The mean phacoemulsification time was 2.2 minutes. Intraocular complications included incomplete capsulorhexis (3.85%) and pupillary miosis (3.80%). Postoperatively, 3 eyes (5.77%) had corneal edema (striate keratopathy) and 1 eye (1.9%) had fibrin in the anterior chamber. Five eyes (9.61%) had more than 2+ cells and flare at 2 weeks. All responded well to intensive topical and subconjunctival steroids. There were no cases of endophthalmitis. The mean central endothelial cell loss, measured in 37 eyes, was 8.5%. Of the 4 eyes (7.69%) that had increased intraocular pressure (IOP) postoperatively, all responded well to medications and the IOP was normal by the second postoperative week. Fifty eyes (96.16%) had a final best corrected visual acuity of 20/30 or better. In 2 cases, the final visual acuity was worse than 20/200 because of preexisting posterior segment pathology. CONCLUSION: Phacoemulsification using trypan blue was safe and effective in managing white cataract and had a high success rate.

Aged↗
PubMed2002

Formalin-induced cataract in goat eyes as a surgical training model for phacoemulsification.

We compared 2 techniques of inducing cataract in enucleated goat eyes as a training model for phacoemulsification. The cataract was induced using 0.2 to 0.5 mL of formalin 20%. In 10 eyes, formalin was injected through a clear corneal side port into the nucleus after capsulorhexis and in 10 eyes, through the pars plana before capsulorhexis. The pars plana technique achieved a cataract of different grades of nuclear hardness with the added advantage of anterior capsule elasticity closely simulating that of senile cataract but without compromising corneal clarity.

Animals↗
PubMed2003

Viscoanesthesia. Part II: toxicity to intraocular structures after phacoemulsification in a rabbit model.

PURPOSE: To investigate the toxicity of a solution that combines sodium hyaluronate 1.5% with lidocaine (0.5%, 1.0%, or 1.65%) to intraocular structures. SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Phacoemulsification was performed in both eyes of 29 rabbits. They were divided into 3 groups; in each group (n = 7), 1 viscoanesthetic solution was used before capsulorhexis. After irrigation/aspiration, 0.2 mL of the solution was purposely left in the capsular bag. In 1 rabbit in each group, the solution was injected into the vitreous cavity through a posterior capsulorhexis. In 8 rabbits used as controls, balanced salt solution (BSS(R)) (n = 4) or sodium hyaluronate 1.5% (n = 4) was injected into the vitreous cavity. Enucleations were performed 15, 30, and 60 days postoperatively. Histological sections were cut and stained with hematoxylin-eosin, periodic acid-Schiff, and Masson trichrome stains. RESULTS: Light microscopic evaluation of the eyes enucleated after 15, 30, and 60 days in the study and control groups showed similar findings in intraocular structures such as the ciliary body and retina. No evidence of an inflammatory reaction, cell necrosis, or cell degeneration was observed in the histological sections. CONCLUSIONS: The use of viscoanesthesia during phacoemulsification appeared to be safe, with no histologic abnormalities observed with the 3 lidocaine concentrations. The efficacy of the anesthetic effects of these solutions will be addressed in clinical trials.

Anesthetics, Local↗
PubMed2003

Phacoemulsification with transpupillary silicone oil removal and lens implantation through a corneal incision using topical anesthesia.

PURPOSE: To evaluate phacoemulsification combined with transpupillary silicone oil removal and foldable intraocular lens (IOL) implantation through a single corneal incision and planned posterior capsulorhexis after pars plana vitrectomy using topical anesthesia. SETTING: Department of Ophthalmology, University of Bari, Bari, Italy. METHODS: This noncomparative nonrandomized noncontrolled interventional case series comprised 34 consecutive patients (34 eyes). The mean age of the 25 men and 9 women was 54.4 years +/- 13.3 (SD). A mean of 8.2 +/- 9.4 months after silicone oil injection, patients had phacoemulsification with transpupillary silicone oil removal and foldable acrylic IOL implantation through a single corneal incision and a planned posterior capsulorhexis under topical anesthesia. Patients were operated on by the same surgeon. Visual acuity, the frequency of retinal redetachment, secondary cataract and vitreous hemorrhage formation, subjective pain and discomfort, the duration of surgery, and intraocular pressure (IOP) were noted. The mean follow-up was 9.4 +/- 5.1 months (range 4 to 21 months). RESULTS: Vision improved or stabilized in 88.2% of eyes. Retinal redetachment occurred in 4 eyes (11.8%) and transient vitreous hemorrhage in 1 (2.9%). All patients reported minimal discomfort during the procedure. The mean duration of surgery was 17 +/- 4 minutes. There was no significant intraoperative or postoperative IOP variation. CONCLUSIONS: Combined phacoemulsification, transpupillary silicone oil removal, and IOL implantation through a single corneal incision under topical anesthesia was safe and effective. In general, the visual outcomes were good with improvement in visual acuity.

Acrylic Resins↗
PubMed2003

Effect of infusion bottle height on lens power after lens refilling with and without a plug.

PURPOSE: To evaluate the influence of intraoperative infusion bottle height on the power of refilled pig lenses. SETTING: Research Laboratory, Pharmacia Intraocular Lens Manufacturing Plant, Groningen, The Netherlands. METHODS: This study comprised 2 groups of pig eyes. In 1 group, the lens was refilled with silicone oil using a plug to close the capsulorhexis; in the other group, no plug was used. The anterior chamber depth, lens thickness, and vitreous chamber depth were measured by A-scan ultrasound. The total refraction was measured with a Hartinger refractometer. Measurements were performed with the infusion bottle at 0 cm, 25 cm, 50 cm, 75 cm, and 100 cm above eye level. Calculations using a model eye were performed to evaluate the change in lens power based on empirical data. RESULTS: The mean change in the power of refilled lenses caused by varying the height of the infusion bottle was 1.8 diopters. Lenses refilled with a plug had a thickness similar to that of natural lenses. Lenses refilled without a plug were significantly thinner (P<.05). The power of lenses refilled with a plug was significantly higher that of lenses refilled without a plug (P<.05). CONCLUSIONS: During lens refilling, infusion bottle height influenced the resulting lens power. Using a plug to close the capsulorhexis resulted in refilled lens dimensions similar to those of the natural lens.

Animals↗
PubMed2004

Effect of haptic design on change in axial lens position after cataract surgery.

PURPOSE: To compare the postoperative changes in anterior chamber depth (ACD) between single-piece and multipiece AcrySof intraocular lenses (IOLs) (Alcon Laboratories, Inc.) and their effect on the postoperative refractive shift. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This prospective randomized bilateral study with intraindividual comparison comprised 104 eyes of 52 consecutive patients with age-related cataract. All patients had standardized cataract surgery with a temporal self-sealing incision, phacoemulsification, and IOL implantation in the capsular bag. The first 30 patients received a single-piece, 5.5 mm optic IOL (AcrySof SA30) in 1 eye and a multipiece IOL (AcrySof MA30) in the other eye. Another 22 patients received the corresponding 6.0 mm optic models (AcrySof SA60 and AcrySof MA60, respectively). Anterior chamber depth measurements and evaluation of the change in ACD during the first 6 postoperative months were performed using partial coherence laser interferometry. The amount of change in capsulorhexis size during the first 6 postoperative months was assessed using standardized retroillumination photographs. RESULTS: Single-piece IOLs shifted significantly less postoperatively than multipiece IOLs. The multipiece IOLs shifted forward, especially from 1 day to 1 month. The change in the capsulorhexis area was similar between IOL types. CONCLUSIONS: Single-piece AcrySof IOLs shifted minimally after the first postoperative day; therefore, the prescription for spectacles in eyes with this IOL can be obtained soon after surgery.

Anterior Chamber↗
PubMed2004

Three-step technique for staining the anterior lens capsule with indocyanine green or trypan blue.

A 3-step technique for staining the anterior lens capsule was developed to optimize the use of a capsule dye (trypan blue or indocyanine green) during capsulorhexis. After the injection of a viscoadaptive ophthalmic viscosurgical device (OVD) (sodium hyaluronate 2.3% [Healon 5]), which fills the anterior chamber, balanced salt solution (BSS) is gently injected onto the anterior capsule, creating a wafer-thin, fluid-filled space beneath the OVD. The dye is slowly injected through a 27-gauge cannula (Duckworth & Kent), selectively mixing with the BSS and allowing relatively accurate painting of the anterior capsule, approximating the size and shape of the intended capsulorhexis. This 3-step technique avoids the use of air as well as the uncontrolled dispersion and excessive accumulation of dye within the OVD.

Capsulorhexis↗