Part V

Reliability and confidence in complex cases.

In this fifth part of the Complex Cases, Simplified series, Dr. José Luis Güell shares his experience and tips for capsulorhexis in microincision cataract surgery.

José Luis Güell, MD, PhD. Founding member of IMO (Instituto de Microcirugía Ocular) in Barcelona and coordinator of the Corneal and Refractive Surgery department. Founding member and past president of the EuCornea (European Society of Cornea Specialists). Dr. Jose Luis Güell holds a PhD in Ophthalmology from Barcelona University and he is a Master Professor at IMO, Spain.

Introduction

Small incisions and an atraumatic approach require micro-instrumentation for best patient outcomes. MicroSurgical Technology (MST) micro-instruments help tackle difficult cases and allow for small incisions therefore alleviating larger traumatic wounds.

With MST’s team, I was involved in the development of the Güell Capsulorhexis Forceps — a micro-instrument designed to achieve continuous curvilinear capsulorhexis in a controlled fashion.

Maintaining small precise incisions

I frequently use micro-instruments to ensure smaller, more precise incisions and ease of movement intra-operatively. I use the Güell Capsulorhexis Forceps in both routine and more complex cases such as white cataracts to create capsulorhexis.

Figure 1 Güell Capsulorhexis Forceps.

The instruments in action — recent cases

Recently, I had three white cataract cases where I utilised the Güell Capsulorhexis Forceps. First, I opened the rhexis with the forceps and, using a cannula, I aspirated some of the liquid content of the crystal lens in order to reduce the intra-lens pressure. Continuing my technique, I then follow the rhexis with the forceps.

The capsulorhexis is of paramount importance and centration a key step to get right if surgery is to be successful, therefore forceps designed with precision in mind greatly helps me achieve good centration and a perfect rhexis.

The capsulorhexis I achieve with the forceps, is precise. The instrument helps me deliver consistency and it allows for the creation of a very precise capsulotomy.

Centration is key

A good capsular opening for the anterior capsule is essential for the correct centration of the lens and to avoid dislocation.

Tip: The size and the precision of the rhexis is extremely relevant because it is directly related with the torsional stability of the intraocular lens you are working with. You will need to create a rhexis adapted to the intraocular lens you are going to use. Centration would be more important for three pieces lenses or lenses that has a high possibility of rotation or those with a small optical diameter. Additionally, size and centration will not be as important in mono block one-piece lenses. Obviously sizing and centration of the rhexis is one of the most important steps in cataract surgery, especially using premium lenses.

Why the Güell Capsulorhexis Forceps

I use these forceps in most of my cases because, firstly, I can work with them through incisions as small as 20 gauge. Secondly, the size of the forceps allows me to work through these small incisions without interfering with the incision itself, i.e. I can open and close the tip of the forceps without capturing any of the surfaces of the incision, something that is a problem with some other capsulorhexis forceps. I would say that this is the main advantage, together with the fact that there are some lines that might help the surgeon in measuring inside the anterior chamber, if you need it. Of course, some surgeons have the size of the capsulorhexis in their eye given the years of experience, others visualize the rhexis digitally via microscope or mark the cornea. However, the markings on the forceps provide a nice added option to check and control the rhexis without a need for additional instrument or device.

Figure 2 Güell Capsulorhexis Forceps in use (Courtesy of Dr Güell)

Also, the very distant tip allows me to use just one of the sides of the tip, if you use only one, it can be easily used to perforate the capsule before grasping it. With some other forceps, you first need to go in with a needle or with a cutting instrument to make that first opening and then you introduce a second instrument, the forceps, to create the rhexis. With these forceps it allows me to use the same tip and therefore eliminate introducing the instrument twice inside the eye.

Figure 3 Using the Güell Capsulorhexis Forceps to perforate the capsule (Courtesy of Dr Güell)

Specific Features

  • The Güell Capsulorhexis Forceps features a viewport, allowing visibility through the grasping tips. In comparison with the Seibel Capsulorhexis Forceps, the tip gap has been reduced, so it is easier to use in the anterior space; the overall tip height is 40% smaller; and the tip end is shorter, minimizing even further any chance of incision catch. The cannula angle is steeper, which will help surgeons who create scleral or near clear corneal incisions.
  • The rhexis ruler features no numbers, but the laser marks ascend from 1mm to 2mm at 0.2mm increments, and from 2mm to 6mm at 0.5mm increments.
  • The Güell Capsulorhexis Forceps are available with sharp tips so that the surgeon can initiate the tear using the forceps, eliminating the need for a cystotome.

Conclusion

The importance of evenly centred and consistent capsular opening for cataract surgery and the use of premium IOLs is unquestionable. Nowadays, we have multiple options that help us achieve a suitable rhexis, but my choice remains with the Güell Capsulorhexis Forceps due to its small-incisional design, delicate tips, and enhanced visibility.

Key Learnings

The smallest incisions help reduce potential traumatic effect of the procedure.

Manage your maneuvers — the micro-instruments facilitate precision, space and controlled movements through micro-incisions.

Ensure maximum visibility while initiating continuous curvilinear capsulorhexis.

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MicroSurgical Technology — MST

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