Capsulorhexis was pioneered and popularized by Howard Gimbel. Capsulorhexis is probably the most challenging to learn in cataract surgery, in other words, once a good rhexis is done half the battle is won. All the Post- Graduates and beginners struggle to do rhexis. This article has compiled small tips and tricks to do rhexis better.

Ideally, rhexis should be continuous and curvilinear i.e Circular, Central & of Correct size (5.5-6 mm).

1. Circular: for proper IOL centering and stabilization in the bag
2. Continous: to prevent rhexis extension
3. Correct size: for IOL centering and to ensure anterior capsule overlapping IOL optic 360 degrees.

It can be done with the help of a double bent 26 G/27 G needle or rhexis forceps.

Let's break the table and use the advantages of a needle

Needle (Cystitome)

• Advantages
  • Cheap, Disposable, Universally available
  • Customized
  • Small diameter, lightweight
  • Can be done through side port so less chance of AC shallowing
• Disadvantages
  • Less precise control
  • With the needle, it is difficult to bring rhexis margin back in case of extension
  • Risk of inadvertent capsule nick/tear
  • The sharp end of the needle can cause wound damage during insertion or removal.

Utrata Forceps

• Advantages
  • Precise control
• Disadvantages
  • Bulky vs needle
  • Sudden movements can cause rhexis damage
  • Needs bigger entry port, needs to be done through the main port so the risk of repeated AC shallowing

Prerequisites of doing rhexis

• Clear media: Clear cornea, well-dilated pupil
• Put viscoelastic over the cornea for better visibility.
• Should be done at higher magnification.
• Fill the chamber with viscoelastic.
• Try moving the eye around to get the best possible red reflex.
• Globe should be well stabilized while doing the procedure.

Tips to achieve ideal capsulorhexis:

Tip No.1 Practice Practice Practice…..

• The surgeon should have stable hands and practice fine intraocular micro-movements. Stereoscopic viewing with proper depth perception is essential.
• Theoretical concepts about physics behind tearing and shearing forces, which are in play during the rhexis process, should be read and well understood
• You can practice rhexis on the plastic film of lens box or use poached tomatoes or potatoes.

Tip No. 2 Keep Anterior chamber deep

• Use a softshell technique to deepen the AC and make the anterior capsule flat.
• Use the side port for all your maneuvers, it prevents leakage of viscoelastic.
• Avoid undue pressure on the eyeball
• Keep refilling viscoelastic as and when required

Tip No. 3 Don’t limit yourself to one technique

• One should be well versed with cystitome and Utrata forceps.

• You might have to use either one or combination of both depending on the situation

Tip No. 4 Proper visualization

• Use trypan blue dye to stain the anterior capsule and improve visualization.
• Increasing the magnification, “you see well-you do well”. Higher magnification also improves visualization and can help you in early identification of extension.
• Retro-illumination is one of the greatest tools available to us in the microscope. It makes use of coaxial illumination to increase the Red Glow.
• Proper patient positioning is also a measure to improve red reflex when the iris lens diaphragm is parallel to the ground the red improve as the microscope becomes coaxial and one has a good red glow

Tip No. 5 Always keep the Flap flat over the anterior capsule.

• When the flap is crumpled, the cut /leading edge of rhexis is not visible, increasing the risk of irregular rhexis or extension.
• By keeping the flap well spread and flat over the anterior capsule you would improve your control and it is very easy to achieve the desired size and shape.