Precision pulse capsulotomy: Initial clinical experience in simple and challenging cataract surgery cases

Preventing the Argentinian flag sign and managing anterior capsular tears: A review

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.

Endothelial Cell Loss Following Cataract Surgery Using Continuous Curvilinear Capsulorhexis or Precision Pulse Capsulotomy

Purpose

To compare endothelial cell density (ECD), percentage of hexagonal cells (%Hex) and coefficient of variation (CV) in cell size following lens cataract surgery with phacoemulsification performed using Continuous Curvilinear Capsulorhexis (CCC) or Precision Pulse Capsulotomy (PPC).

Patients and Methods

Sixty-seven subjects were randomly assigned to undergo lens cataract removal with the capsulotomy step performed using either CCC or PPC. Specular microscopy images were obtained pre-operatively, 1 month and 3 months after surgery. ECD, %Hex and CV were analyzed in a masked fashion by an independent reading center.

Results

The mean percentage ECD loss at 1 month was 11.5% in the CCC group and 12.3% in the PPC group (P = 0.818; t-test). At 3 months, the mean percentage ECD loss was 11.7% in the CCC group and 12.4% in the PPC group (P = 0.815; t-test). The mean %Hex at 1 month was 54.3% in the CCC group and 54.7% in the PPC group (P = 0.695; t-test). At 3 months, the mean %Hex was 56.2% in the CCC group and 54.7% in the PPC group (P = 0.278; t-test). The CV at 1 month was 34.4% in the CCC group and 34.3% in the PPC group (P = 0.927; t-test). At 3 months, the CV was 32.7% in the CCC group and 33.4% in the PPC group (P = 0.864; t-test).

Conclusion

No differences in ECD loss, %Hex and CV were observed between patients who received CCC or PPC. PPC use during cataract surgery does not result in any increased endothelial cell loss beyond that normally associated with this surgery.

Automated precision pulse capsulotomy vs manual capsulorhexis in white cataracts: reduction in procedural time and resource utilization

PURPOSE

To compare the utility of precision pulse capsulotomy (PPC) with manual capsulorhexis for capsulotomy in white cataracts.

SETTING

Hospital-based academic practice.

DESIGN

Retrospective analysis of surgical case records and surgical videos from a single surgeon.

METHODS

Cases involving intumescent and nonintumescent white cataracts were identified. Capsulotomy outcomes, surgical outcomes, procedural time, and resource utilization, as well as patient demographic and health data, were analyzed and subjected to statistical testing.

RESULTS

15 cases of white cataract (10 intumescent and 5 nonintumescent) performed using continuous curvilinear capsulorhexis (CCC) were compared with 20 cases (9 intumescent and 11 nonintumescent) performed using PPC. The cases covered a period of 14 months before and 30 months after surgeon adoption of PPC. There were no significant differences between the 2 groups in patient age, sex, ethnicity, ocular history, medical history, and medications. PPC resulted in complete capsulotomies without tags or tears and intracapsular intraocular lens implantation with 360-degree capsular overlap in all 20 cases. There was 1 CCC case resulting in the Argentinian flag sign. Compared with CCC, PPC white cataract cases also demonstrated significant advantages in capsulotomy time, reduced use of trypan blue and ophthalmic viscosurgical device, and less overall procedural time.

CONCLUSIONS

PPC is a safe and highly effective method to create consistent capsulotomies in both intumescent and nonintumescent white cataracts. The use of PPC provides benefits of significant reductions in capsulotomy time, overall procedural time, and resource utilization, resulting in a streamlined treatment of these complex cataract surgery cases.

Use of P1-P4 Purkinje reflections as a surrogate sign for intraoperative patient fixation

Circumferential, even anterior capsular overlap maximizes intraocular lens stability and posterior capsular opacification mitigation and provides best long-term outcomes for the cataract patient. P1 and P4 Purkinje reflections at patient fixation may provide a reliable marker for capsulotomy centration. However, patient fixation may be hindered during surgery because of anesthesia or light sensitivity. In this study, we demonstrate that the relationship between the P1 and P4 Purkinje reflections previewed prior to surgery when the patient is fixating may be recreated intraoperatively if fixation becomes difficult. The final position of P1 and P4 relative to one another at fixation is invariant in a given patient, but there are variations among patients. Knowledge of the P1 and P4 relationship can be used as a surrogate sign of patient fixation to assist in capsulotomy centration during cataract surgery.

Thermal Profile of Pulse Precision Capsulotomy: In vivo and in vitro Infrared Thermography Study

Purpose

This study aimed to elucidate the thermal safety of precision pulse capsulotomy (PPC) via in vivo and in vitro evaluation of the thermal profile using infrared thermography.

Methods

This prospective observational study enrolled 15 eyes from 15 participants who underwent cataract surgery using the Zepto PPC. All patients underwent temperature measurements of the incision site and the entire cornea using an infrared thermographer during the capsulotomy procedure. To accurately analyze the temperature change of the Zepto PPC, infrared thermography was performed with the Zepto handpiece while exposed to air and then in porcine eyes. Moreover, in each case, the difference in temperature change according to the use of an ophthalmic viscosurgical device (OVD) was also checked to determine the temperature buffering effect.

Results

In the clinical evaluations, the mean temperature elevation around the corneal incision and time duration from baseline to peak temperature during the Zepto capsulotomy were 4.0 ± 1.9℃ and 4.43 ± 1.26 s, respectively, with a mean peak temperature of 32.6 ± 2.0℃. The mean peak temperature and rise time of the naïve Zepto nitinol ring, as measured from the bottom side, were 109.0 ± 22.9℃ and 43.40 ± 11.06 s in the experimental procedures, respectively. In the porcine eyes, the mean elevation of temperature and rise time of the Zepto nitinol ring were 6.2 ± 1.6℃ and 11.67 ± 2.08 s with the use of OVDs, and 10.5 ± 3.3℃ and 14.00 ± 3.61 s without OVDs, respectively.

Conclusions

Zepto PPC has the potential to generate extremely high thermal energy, according to an in vitro study. However, the temperature rise of the Zepto capsulotomy can be minimized by using OVDs.

Precision Pulse Capsulotomy During Combined Penetrating Keratoplasty With Cataract Surgery and Intraocular Lens in Small Nondilating Pupil

OBJECTIVE

To demonstrate precision pulse capsulotomy (PPC) in an open-sky procedure and to evaluate its use during triple procedure keratoplasty in small nondilating pupils.

METHODS

This single-center retrospective case series study included 10 eyes (from 10 patients) with corneal opacity and poorly dilated pupils who were scheduled to undergo triple procedure keratoplasty. The main outcome measures were capsulotomy performance of the PPC device and intraoperative complications. Secondary outcome measures included postoperative best-corrected visual acuity, intraocular pressure, and other postoperative complications.

RESULTS

Complete free-floating capsulotomy was achieved in all 10 eyes. There were no cases of anterior capsule tears or tags. There were no postoperative complications that occurred in association with the PPC device.

CONCLUSIONS

The PPC device facilitates creation of a smooth, round, and appropriately sized anterior capsulotomy in open-sky surgeries, particularly in presence of small nondilating pupils.

Precision pulse capsulotomy: performance metrics and utility in routine and complex cases

PURPOSE

To evaluate precision pulse capsulotomy (PPC) performance.

SETTING

University and private practice in the United States and South Korea.

DESIGN

Multicenter retrospective analysis.

METHODS

The surgical videos of 337 cataract surgeries with PPC capsulotomy performed by 4 surgeons at 4 centers were used to assess capsulotomy outcomes including completion rate, diameter, roundness (ovality), and quality of capsular overlap.

RESULTS

PPC use resulted in 99.4% free-floating capsulotomies from 337 cases. Video image analysis in a subset (n = 52) yielded a mean capsulotomy diameter of 5.0 mm ± 0.16 mm SD (95% CI, 4.96-5.04 mm). Capsulotomies were round to slightly oval at the end of the case with a mean ovality of 3.0% ± 2.86% (95% CI, 2.22%-3.78%; 360 degrees capsular overlap was obtained in 98% of cases. The offset of the capsulotomy center with the intraocular lens (IOL) optic center was 197 μm ± 122 μm (SD) (95% CI, 148-246 μm). PPC was used successfully in traumatic cataracts with compromised anterior and posterior capsule, phacodonesis, intumescent cataract with constricted pupil, and zonular dialysis and in penetrating keratoplasty with open-sky extracapsular cataract extraction.

CONCLUSIONS

Surgeons obtained good PPC capsulotomy outcomes in routine and challenging cases. Little variation was observed in achieving free-floating capsulotomies with approximately 5.0 mm diameter and complete capsular overlap. Variation was observed in the amount of offset between the capsulotomy center and the center of the IOL optic. PPC was useful in cases with multiple comorbidities that challenge capsulotomy performance.

Early results of circularity and centration of capsulotomy prepared by three different methods

AIM

To compare the difference of capsulotomy produced by precision pulse capsulotomy (PPC), manual (M-CCC), and femtosecond laser assisted capsulotomy (FLAC) in relation to intraocular lens (IOL) centration, circularity and its effect on visual outcomes.

METHODS

Prospective, non-randomized comparative study conducted at LV Prasad Eye Institute, Hyderabad, India. Sixty eyes of 52 patients were grouped into 3 (FLAC, PPC and M-CCC) based on capsulotomy techniques used. Twenty consecutive eyes with uneventful phacoemulsification and with no comorbidities affecting the capsulotomy or visual outcome were included in each group. The main outcome measure was IOL centration in relation to capsulotomy and pupil. Secondary outcome measures were post-operative visual acuity, manifest refraction and aberration profile between groups.

RESULTS

At 5wk the visual, refractive outcomes and endothelial cell density were comparable between the 3 groups. The median circularity index of FLAC was statistically significantly different to M-CCC or PPC (1-10) groups (P<0.01) but PPC (11-20) was comparable to FLAC. Decentration of IOL center in relation to capsulotomy was seen only between the PPC (1-10) group and FLAC group (P=0.02). The IOL was well centered in relation to the pupil in all the groups (P=0.46). The quality of vision parameters like the higher order aberrations, spherical aberration, coma, trefoil, modular transfer function, and Strehl ratio were comparable between the groups.

CONCLUSION

Our study shows that despite differences in the morphology of capsulotomy produced by PPC, M-CCC, FLAC a well-centered IOL can be achieved. The measured capsular morphology parameters do not affect visual outcomes.

Clinical Results After Precision Pulse Capsulotomy

Purpose

To compare residual refractive error and complication rates between eyes undergoing a manual capsulotomy and those receiving a precision pulse capsulotomy using an automated device.

Patients and Methods

This study was a non-interventional two-arm retrospective chart review of clinical results after bilateral cataract surgery or refractive lens exchange (RLE) surgery with a monofocal toric intraocular lens (IOL) or a trifocal IOL where a manual capsulorhexis (Manual) or automated precision pulse capsulotomy (PPC) was performed.

Results

Exams from 243 eyes (122 PPC, 121 Manual) from 124 patients were reviewed; about 75% of which had a trifocal IOL implanted. There was no statistically significant difference in the MRSE with either IOL type, or overall. The overall percentage of eyes with residual refractive cylinder ≤ 0.50 D was significantly higher in the PPC group (89% vs. 79% in the manual group, p = 0.03), primarily driven by results with the toric IOL. Best corrected distance visual acuity was not statistically significantly different by group. Capsulotomy-related complications were lower in the PPC group relative to the manual group (4.1% vs. 6.6%), but this result was not statistically significant (p = 0.38).

Conclusion

Significantly more eyes had refractive cylinder ≤0.50 D in the PPC group. For all other measures, the automated PPC device produced clinical results equivalent to those achieved with a manual capsulorhexis.

Evaluation of Lens Capsule Stability Using Capsular Tension Ring, Iris Retractor, and Capsule Expander Using a Porcine Model With Zonular Dehiscence

Purpose

We evaluate the efficacy of capsular tension rings (CTRs), iris retractors (IRs), and capsule expanders (CEs) in stabilizing the lens capsule under different degrees of zonular dehiscence using a porcine model.

Methods

We developed an experimental model that can be used to observe the dynamics of lens capsules with different degrees of zonular dehiscence during phacoemulsification and aspiration (PEA). PEA was performed without any aid (control) and with devices. A CTR was used for a dehiscence of 30°, 45°, 60°, 90°, 120°, 150°, and 180° and one to four IRs or one to three CEs were used for a dehiscence of 90°, 120°, and 180°. The retention rate, calculated as the area of the capsular bag during PEA divided by the area before zonular dissection, and the number of lens fragments dropped into the vitreous cavity during PEA were examined and compared among the control and experimental groups.

Results

The retention rate increased significantly with the use of devices compared to the control (P < 0.05). The number of dropped lens fragments decreased by one or less with the use of CTR, one IR, or one CE for 90°, two IRs, or one or two CEs for 120°, and three or four IRs, or two or three CEs for 180° of zonular dehiscence.

Conclusions

The experimental porcine eye model with zonular dehiscence makes it possible to observe the entire configuration of the lens capsule, and demonstrates differences in the efficacy of capsular bag retention with CTR, IR, and CE.

Precision pulse capsulotomy complicated by radial tear of the anterior capsule: a proposed mechanism

Zepto precision pulsed capsulotomy is an emerging technology aimed at providing a safer and more reproducible anterior capsulorhexis, with potential advantages in challenging cases. Initial reports suggest high safety, and thus far to our knowledge, no complications have been reported. Herein we report an unexpected complication. After the pulse delivery phase on a routine cataract case, a radial tear of the anterior capsule was observed. Upon careful review of the surgery video, an air bubble was noted, at the precise clock hour of the radial tear, trapped between the device wire and capsule. This air bubble presumably prevented the transfer of rapid phase transition at this site, interfering with capsule cleavage, and resulting in incomplete capsulotomy. Based on this observation, if a trapped air bubble is observed after the vacuum phase, we recommend applying more vacuum or disengaging and reattaching, before proceeding to the pulse delivery stage.

Thermal capsulotomy: Initial clinical experience, intraoperative performance, safety, and early postoperative outcomes of precision pulse capsulotomy technology

PURPOSE

To assess the clinical safety and performance of a new thermal capsulotomy device in patients having cataract surgery.

SETTING

Launceston Eye Institute, Launceston, Tasmania, Australia.

DESIGN

Prospective case series.

METHODS

This single-surgeon consecutive series comprised eyes having capsulotomy with a precision pulse capsulotomy (PPC) device (Zepto). Baseline demographic information and preoperative, intraoperative, and early postoperative outcomes, including complications, intraocular pressure (IOP), flare photometry, corneal and retinal thickness, and specular microscopy were collected and analyzed. Outcomes included PPC performance, intraoperative complications, effective phacoemulsification time, IOP, postoperative inflammation, corneal edema, endothelial cell density, functional evaluation of the corneal endothelium, retinal thickness, cost-effectiveness, and early postoperative visual acuity.

RESULTS

The study evaluated 100 eyes. Complete free-floating capsulotomy was achieved in 70 eyes (72%). Focal attachments were identified in 17 eyes (18%) and broad attachments in 10 eyes (10%). Intended PPC capsulotomy failed in 3 eyes due to operator or device error. Anterior capsule tears occurred in 4 eyes (4%); otherwise, there were no significant safety signals in the early postoperative period. There was no evidence of a learning curve effect; however, use of a dispersive ophthalmic viscosurgical device (OVD) is postulated as influencing capsulotomy completeness.

CONCLUSIONS

The PPC device created round, reproducible, appropriately sized capsulotomies in 72% of eyes. The incidence of incomplete capsulotomy and radial tear rate was high and was possibly associated with the use of a dispersive OVD.

Comparison of postoperative axial stability of intraocular lens and capsulotomy parameters between precision pulse capsulotomy and continuous curvilinear capsulotomy: A prospective cohort study

OBJECTIVES

The aim of this study was to verify the safety and stability of precision pulse capsulotomy (PPC) by comparison of the axial stability of the intraocular lens (IOL) and the capsulotomy parameters during 6 months of follow-up after cataract surgery using PPC or the conventional method (continuous curvilinear capsulorhexis, CCC).

DESIGN

Prospective observational study.

SETTING

Tertiary referral center.

SUBJECTS

Fifty nine eyes of 59 candidates for cataract surgery.

INTERVENTIONS

PPC (33 eyes) or CCC (26 eyes).

OUTCOME MEASURES

The anterior capsule opacification grade and effective lens position (ELP) were measured 1 week and 1, 3, and 6 months postoperatively.

RESULTS

No significant difference in the mean anterior capsule opacification grade or the effective lens position was found between the PPC and CCC groups at any time point; however, the standard deviation and root mean square of the effective lens position were significantly lower in the PPC group than in the CCC group during follow-up (P = .002 and P = .011, respectively). There was a significantly lower discrepancy between the intended vs achieved capsulotomy area and better circularity in the PPC group than in the CCC group at all time points.

CONCLUSIONS

The overall variability in effective lens position was less when cataract surgery was performed using PPC than when performed using CCC. Circularity was better and had a more predictable size with PPC than with CCC.

Precision pulse capsulotomy in challenging cataract surgery cases

Purpose

To evaluate the use of the precision pulse capsulotomy (PPC) device for challenging cataract surgery cases.

Patients and methods

This single-center retrospective case series study comprised of 43 eyes (from 35 patients) that were challenging cataract surgery cases with poorly dilated pupils, anterior subcapsular opacity, white cataract, brunescent cataract, and corneal opacity. This was  conducted at the Busan Sungmo Eye Hospital (Busan, Republic of Korea) to assess the performance of the PPC device through a 2.2-mm clear corneal incision width, followed by the phacoemulsification technique and intracapsular intraocular lens fixation. The main outcome measurement was the anterior capsulotomy performance of the PPC device and the development of intraoperative complications. At postoperative 2 months, visual acuity, endothelial cell count, and refractive error were measured.

Results

No cases of anterior capsule tears or tags occurred. All 43 eyes received circular, 360-degree, free-floating, and appropriately sized anterior capsulotomies. During 2 months of follow up, no postoperative complications occurred in association with the PPC device.

Conclusion

The PPC device facilitated the creation of a precise, round, appropriately sized anterior capsulotomy in challenging cataract surgery cases. Further investigations are required to understand the long-term safety and efficacy of the PPC device.

Precision pulse capsulotomy: an automated alternative to manual capsulorhexis in paediatric cataract

Objective

To report our operative experience with precision pulse capsulotomy (PPC) for anterior capsulotomy in a paediatric cataract series.

Methods and analysis

This study is a retrospective interventional, descriptive series of consecutive paediatric eyes (≤16 years) undergoing cataract surgery using PPC. Surgical time and the time required to perform PPC was recorded. Any intraoperative and postoperative adverse events were noted. Postoperatively, visual acuity, anterior segment examination and intraocular pressure (IOP) were recorded for all children at day 1, 1 week and 1 month.

Results

21 eyes of 14 patients were included in the study, with the median age at surgery of 6.0 years (IQR; 5-7.75, range=1–16 years). Male to female ratio was 11:3. 13 eyes had lamellar cataract, 3 eyes had total cataract, 2 had posterior subcapsular cataract, 2 had traumatic cataract, while 1 eye had sutural cataract. Median surgical time was 26 min (IQR 21-32) and median PPC time was 75.0 secs (IQR 56-86.5). The anterior capsulotomy was round and complete in most cases, except in one case due to faulty suction. All patients underwent a successful in the bag implantation of intraocular lens with capsulotomy margins overlapping the optic edges in 19 eyes (90%). Median PPC size was 5.54 mm (n=9, IQR 5.39 -5.75) which was slightly larger than expected. None of the cases had any intraoperative or postoperative adverse events with no radial tears of capsulotomy. Postoperatively, the mean final follow-up was 5.71+3.20 weeks.

Conclusion

To conclude PPC can be used as an alternative to manual continuous curvilinear capsulorhexis in paediatric cataract surgery producing round well- centred and strong capsulotomy with an easier learning curve.

Techniques of anterior capsulotomy in cataract surgery

Optimal outcomes of a cataract surgery largely depend on the successful performance of an anterior capsulotomy. It is one of the most important steps of modern cataract surgery which reduces the risk of capsular tears and ensures postoperative stable intraocular lens (IOL). Anterior capsulotomy is considered ideal if it is round, continuous, well-centered, and overlaps the implanted IOL around its circumference. If any of these features is missing, it can be a cause of impedance for desired surgical and visual outcomes. Manual can opener and manual capsulorhexis are the routine standard techniques employed for manual extracapsular cataract extraction and phacoemulsification, respectively. Recent increasing use of femtosecond laser cataract surgery has allowed cataract surgeons to obviate inherent inaccuracies of manual anterior capsulotomy techniques. There is an ongoing quest to find an ideal, risk free, and surgeon-friendly technique of anterior capsulotomy that can be employed for surgery in all types of cataracts.

Advances in capsulorhexis

PURPOSE OF REVIEW

Continuous curvilinear manual capsulorhexis is currently the standard of cataract surgery. In the past several years, new technologies have been developed to improve the consistency and safety of capsulorhexis creation. This article reviews the most recent technologies in capsulotomy formation and their advantages and disadvantages.

RECENT FINDINGS

Guidance devices, femtosecond laser capsulotomy and precision pulse capsulotomy improve the centration, circularity and precision of anterior capsulorhexis and capsulotomy. These developments show particular promise for complex cataract surgeries, though clinical data on the refractive outcomes and complication rates of these technologies are currently limited and warrant additional investigation.

SUMMARY

New technological advances in capsulorhexis help surgeons achieve a more ideal capsulotomy geometry. Whether this translates into more predictable refractive outcomes and safer surgeries remains an area of future study.

Precision pulse capsulotomy in phacoemulsification: Clinical experience in Indian eyes

Purpose:

To evaluate the surgical outcome of precision pulse capsulotomy (PPC) in phacoemulsification surgery.

Methods:

One hundred twenty-three eyes of 99 consecutive patients who underwent phacoemulsification with PPC through a 2.8 mm clear corneal incision were prospectively studied at a tertiary care centre. The size, shape of capsulotomy and intraoperative capsulotomy, and surgery-related complications were noted. Visual outcome, IOL stability, and signs of capsular opacification/contraction were evaluated at 3 and 6 months.

Results:

The mean age of patients was 49.5 ± 7.77 years. Complete, circular capsulotomy averaging 5.5 mm diameter was achieved in 117 of 123 eyes. In seven eyes, we experienced complications like capsulorhexis tear (n = 6) and inadvertent iris capture (n = 1). Probe malfunction occurred in six cases. Stable intracapsular intraocular lens (IOLs) fixation and centration was achieved in all eyes. None of the eyes had any significant posterior capsular opacification or capsular contraction at 3 and 6 months. In one eye anterior capsular opacification at the capsulotomy edge was noted at 6 months.

Conclusion:

PPC is a useful device for achieving a perfectly round capsulorrhexis. However, it has a learning curve and chances of skip areas in capsulorhexis, capsular tag, and its extension should be kept in mind. Special care should be taken in initial cases and while operating on eyes with poorly dilating pupil and mature cataracts.

Zepto-rhexis: A new surgical technique of capsulorhexis using precision nano-pulse technology in difficult cataract cases

Several techniques are used to make a capsulorhexis in white mature cataract cases as needle cystotome, Utrata capsulorhexis forceps, microincision capsulorhexis forceps, femtosecond Laser, etc. Zepto precision nano-pulse capsulotomy device (Mynosys Cellular Devices; Fremont, CA, USA) is Food and Drug Administration approved, a disposable capsulotomy device that uses low-energy pulses to create a precise central capsulorhexis, independent of pupil size, corneal clarity, or lens density. In this article, the authors report their experience of performing anterior circular curvilinear capsulorhexis with Zepto precision nano-pulse capsulotomy device in challenging cataract cases done at our center. The Zepto handpiece device was inserted through 2.8 mm clear corneal incision. Results of our study in 3 cataract cases (intumescent cataract, morgagnian cataract, and cataract with small pupil) revealed that the precision pulse capsulotomy technology mechanically and simultaneously cleaves all 360° of the apposed capsule of without cauterizing it, creating CCC of 5.2 mm size.

Managing the posterior polar cataract: An update

Posterior polar cataracts (PPC) have always been a challenge for cataract surgeons due to their inherently higher propensity for posterior capsule rupture. Over the years, several technical modifications have been suggested to enhance safety and reduce posterior capsule rupture rates in these polar cataracts. This review article tries to present the various techniques and strategies to published in literature to manage PPCs. It also discusses pearls for making surgery more reproducible and consistent, as well as the role of newer diagnostic and surgical technology based on the published literature on the subject.

Zepto precision pulse capsulotomy: A new automated and disposable capsulotomy technology

Despite the appeal of an automated method of creating a perfectly circular anterior capsulotomy, global adoption of femtosecond laser capsulotomy (FSLC) has been limited by its high acquisition and per case cost. In addition, the femtosecond laser's large size and the need for eye docking create surgical efficiency and workflow challenges. The Zepto precision pulse capsulotomy (PPC) technology creates a circular anterior capsulotomy of a precise diameter using a disposable handpiece and tip that are used in the normal surgical sequence. Extensive preclinical and clinical testing has resulted in the US Food and Drug Administration (FDA) approval of the technology. Zepto PPC holds promise for complicated eyes such as those with intumescent or brunescent lenses, zonulopathy, or small pupils. This paper and the accompanying videos describe and demonstrate the technique and review the published studies.

Femtosecond laser-assisted versus phacoemulsification for cataract extraction and intraocular lens implantation: clinical outcomes review

PURPOSE OF REVIEW

Femtosecond laser-assisted cataract surgery (FLACS) has gained popularity in recent years with the new technology suggesting potential improvements in clinical and safety outcomes over conventional phacoemulsification cataract surgery (PCS). A decade since the advent of FLACS has given time and experience for laser technology to develop in maturity, and better quality evidence to become available. This review evaluates current evidence on the clinical and safety outcomes for FLACS in comparison to PCS.

RECENT FINDINGS

FLACS technology continues to improve and with it our confidence in tackling more complex patient indications. Concurrently other new technologies such as precision pulse capsulotomy also look to deliver the biomechanically ideal 5.2 mm capsulotomy, particularly as there remain suggestions from large studies and meta-analyses of raised capsular complications with FLACS compared with PCS and IOL technology responding to advantages of a consistent capsulotomy. Visual benefits of FLACS over and above PCS also remain to be conclusively demonstrated, with equivalence but not superiority. Economic modelling continues to indicate that FLACS remains 'not' cost-effective.

SUMMARY

FLACS can be considered non-inferior to conventional PCS in term of safety and clinical outcomes. However, FLACS has yet to demonstrate an overall cost-benefit to the patient.