Capsulorhexis, Hydrodissection and Hydrodilineation

Capsulorhexis, hydrodissection and hydrodilineation are essential preliminary steps for phacoemulsification surgery. They are among the most difficult parts of the surgery. Failure to complete these steps without a complication can make subsequent steps of phacoemulsification surgery difficult if not impossible.

Objectives:  At the conclusion of the session the resident will have an understanding of the principles of capsulorhexis, hydrodissection and hydrodilineation in phacoemulsification surgery and should be able to

• Describe the sequence of capsulorhexis, hydrodissection and hydrodilineation in phacoemulsification surgery
• Describe the characteristics of a well created capsulorhexis and state the consequences of a capsulorhexis that is too small, too large or that is not continuous
• Describe the role of stress and strain on the physics of capsulorhexis creation
• List techniques that help to improve the odds of success in capsulorhexis creation
• Describe techniques for rescuing a capsulorhexis that has ‘run out’

Before the session:
Please take the attached multiple choice pre-test.  It consists of 15 multiple choice questions that have been copied from the EyeMovies section of the AAO website.

Watch the following videos online:

• Capsulorhexis Introduction
• Needle and Forceps
• Primary Tear Out
• Retrieval Techniques
• Hydro Manoeuvres

These videos are part of the EyeMovies series on the AAO website. 

During the session before the lab:

Faculty will briefly review material from the videos, go over the answers to the pre-test and share their own experiences with and tips for learning these techniques.

During the session in the lab:

• ‘Warm up’ by creating several capsulorhexis with saran wrap or aluminum foil wrapped around peppermint candies. Use a cystotome needle for these.
• Move on to creation of at least two capsulorhexis in pig eyes. You will of course need to create an incision before the rhexis.
• Follow with hydrodissection and hydrodilineation in these eyes.
• After completing a rhexis and hydrodissection create a radial tear and attempt to use the retrieval technique to bring it back in.
• If time and materials permit, create an additional capsulorhexis with a forcep.
• If time and materials permit, create a ‘can opener’  capsulotomy.

References:

Seibel, B. The Physics of Capsulorhexis Section 5 in Phacodynamics Mastering the Tools and Technques of Phacoemulsification Surgery.  Fourth Edition. Slack. 2005

EyeMovies Phacoemulsification 1. Basic Techniques. Chapter 4 - Capsulorhexis.

• Basic Principles
• Forceps Alone
• Needle Alone
• Capsular Dyes
• Sizing & Enlargement

EyeMovies Phacoemulsification 1. Basic Techniques. Chapter 5 - Hydro Manoeuvres

• Hydro Manoeuvres
• Hydrodissection
• Hydrodelineation

EyeMovies Phacoemulsification 2. Complications. Chapter 4 – Capsulorhexis

• Capsulorhexis Complications: Overview
• The Small Rhexis
• Primary Rhexis Tear-Out
• Secondary Anterior Capsular Tear
• Completing Phaco with a Compromised Rhexis
• Rhexis Tear-Out Retrieval Techniques

After the Session:

Take the pre-test again as a post test.  Review your performance.

Plan to get into the lab at least twice over the next six weeks to practice (on your own, with other residents or with a fellow or faculty member)

• Incision Creation
• Capsulorhexis Creation
• Hydrodissection and hydrodelineation
• Corneal and scleral suturing