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C-Rhexis” the surgical grail in intumescent mature cataract

Article in Indian Journal of Clinical and Experimental Ophthalmology · January 2016

DOI: 10.5958/2395-1451.2016.00007.X

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Original Research Article

C-Rhexis” the surgical grail in intumescent mature cataract

Sahil Bhandari1,*, Manas Nath2, Prasanth Gireesh3
1Fellow,Dept. of Vitreo-retinal Sevices,
2,3Consultant,
Dept. of Cataract and Refractive Services,
Aravind Eye Hospital, Pondicherry, India

*Corresponding Author
E-mail: sahilstanlean@[Link]

Abstract
Background: Capsulorhexis in intumescent mature cataract has high chance of peripheral extension. This paper aims at
describing a modified “C- rhexis technique”, with the unique mechanism of “simultaneously acting unidirectional vector forces”
for virtually eliminating the risk of peripheral extension.
Methods: Retrospective analyses of patients who were diagnosed to have intumescent mature cataract and underwent surgical
intervention by a single surgeon using the modified “C-rhexis technique” were included.
Results: A total of 125 eyes were included. None of the eyes experienced any capsular tag or peripheral extension of rhexis.
Conclusion: In the nutshell, the “C-rhexis” virtually eliminates the risk of peripheral extension of capsulorhexis due to its unique
“simultaneously acting unidirectional vector forces”. It can be easily mastered, creates an adequate size rhexis in first attempt,
does not require expensive instruments and can be advocated in both MSICS and phacoemulsification.

Keywords: C-rhexis1, Intumescent cataract2, Rhexis extension3, Uni-directional vector4

Access this article online Materials and Methods

Quick Response Surgical Technique: Informed consent was obtained
Code: Website: from all the patients before proceeding for the
[Link] intervention. The study was approved by Institutional
Review Board and follows the tenets of the Declaration
of Helsinki. The proposed “C–flap” technique can be
DOI:
10.5958/2395-1451.2016.00007.X performed in both manual small incision cataract
surgery (MSICS) and Phacoemulsification (PE).
Routine aseptic preparation of patient is followed and
Introduction either sclerocorneal tunnel (MSICS) or clear corneal
Continuous Curvilinear Capsulorhexis (CCC) is tunnel (PE) is fashioned. Tryphan blue 0.06%
one of the crucial surgical step especially in (AUROBLUE, AUROLAB, India) is used to stain the
intumescent mature cataract1. Due to high anterior lens capsule (ALC). Dispersive viscoelastics
intralenticular pressure2 there are chances of radial are used to fill the anterior chamber (AC) after removal
extension with the first nick leading to Argentinean flag of tryphan blue. A cystitome fashioned from 26 gauge
sign. In order to avoid it, several methods1-8 have been needle is used through side port incision (PE) or
devised. The main aim of these techniques have been to primary tunnel (MSICS) to create a ‘C’ shaped opening
reduce intralenticular pressure,6 avoid fluctuation in (3mm by 1mm) in the ALC starting from the center
anterior chamber,5 enhance visibility,7 decompress (Fig. 1A, 2B, 3A) and anti-clockwise. Liquefied
posterior lenticular pressure2 and create two stage cortical fluid is aspirated by 25 gauge hydro dissection
capsulorhexis.8 cannula through side port incision to decompress the
However, these techniques raise few questions lens (fig. 1B, 2C, 3B) and reduce the intralenticular
pertaining to surgical complexity,5 surgical expertise8 pressure. AC is refilled with dispersive viscoelastic
and the need of expensive instruments like substance. Simultaneously, the capsular flap is flipped
endoilluminator1 in its performance. Looking at these over and flattened. Capsulorhexis forceps or cystitome
limitations, we have devised a modified technique, (fig. 1C, 2D, 3C) can be used to extend the base of the
which is both simpler and reduces the rate of flap and rhexis is completed in regular curvilinear
complications. manner under the scaffold of viscoelastics. Rhexis
expansion (double rhexis) can be performed in MSICS,
if the rhexis appears to be small for the nucleus size.
Rest of the steps are similar to any standard surgical
maneuver.

Indian Journal of Clinical and Experimental Ophthalmology, January-March,2016;2(1): 38-41 38

Sahil Bhandari et al. C-Rhexis” the surgical grail in intumescent mature cataract

Fig. 1: Animatic representation (anticlockwise) of “C-rhexis technique”. (A) Creation of “C-incision” in the
anterior capsule. (B) Decompressing the lens with hydrodissection cannula. (C) Continuing rhexis with
forceps. (D) A well centered round rhexis in intumescent mature cataract

Fig. 2: Stepwise creation (A-D; anticlockwise) of “C-rhexis” technique in

phacoemulsification from side port incision

Fig. 3: Stepwise creation (A-D; anticlockwise) of “C-rhexis” technique in

MSICS from main tunnel
Indian Journal of Clinical and Experimental Ophthalmology, January-March,2016;2(1): 38-41 39
Sahil Bhandari et al. C-Rhexis” the surgical grail in intumescent mature cataract

Fig4: Depicting the same direction vector forces in “C” – incision (A) in comparison to
opposing vector forces in straight puncture (B)

Discussion in contrary to what has been discussed by Arshinoff et

Figueiredo et al2 gave new nomenclature to al.9 In their letter to editor Arshinoff et al9 have
different types of white cataract and described the role mentioned that raising the anterior chamber pressure by
of posterior intralenticular pressurized compartment in injecting high molecular weight viscoelastics, the
Argentinean flag sign. Different methods1-8 of rhexis anterior capsule curvature is altered from convex
formation in fluid filled pearly white cataract was anteriorly to concave anteriorly, thus redirecting the
devised in order to combat the dreaded complication of rhexis extension force inwards, but as per our study
peripheral extension. We have devised a modified “C- results and the technique described, the equalization of
flap” technique to improvise the same. intralenticular and anterior chamber pressure occurs
In our technique main modification is the creation immediately after the creation of “C” incision which
of a “C” shaped incision in ALC instead of a straight neutralizes any chance of rhexis extension even in the
puncture. The benefit of “C” incision over a puncture is presence of pressure variation. Thus a well-constructed
that the vector forces acting on the ends of C-flap are in “C-flap rhexis” negates the need of high molecular
the same direction (fig. 4A) instead of opposing forces weight cohesive OVD which would otherwise be
in straight incision; this facilitates synergism to pull the required to compensate for the intralenticular positive
edges of the nick to the periphery (fig. 4B). Secondly, pressure.10
the curvilinear part of “C” incision is equivalent to an The difficulties associated are primarily concerned
arc of rhexis which provides sufficient resistance with the formation of an adequate “C” incision. Ideally
towards any peripheral extension. Lastly the “C” the “C” incision should start at the center of capsule and
incision immediately provides a wider area for the the size should range approximately between 2mm by
pressurized anterior intralenticular chamber to 1mm to 3mm by 1mm. With minimal experience of few
decompress as compared to anterior capsule puncture. cases this can easily be mastered. It could be argued
This helps in hastened equilibrium between the upon that our technique involves a central puncture in
intralenticular and AC pressure. the anterior capsule which could still increase the risk
Figueiredo et al2 have described the Brazilian of peripheral extension. In this regard the author’s
technique for prevention of Argentinean flag sign. would like to stress upon the need of immediate
Though the technique is effective, theoretically there extension of central puncture into “C” incision which
still is a risk of peripheral extension during central can completely avoid the above mentioned problem. In
puncture of ALC (fig. 4B). Also there may be mild clinical practice we have noticed that even if there is an
fluctuation in AC while injecting viscoelastics through extension of the initial puncture, it never goes beyond 1
the main wound which could also increase the chances or 2mm due to the dynamics of “C” incision.
of peripheral extension. In case of “C” flap rhexis, we The size and position of “C” incision is important,
noticed that even if there is fluctuation of AC rhexis because an eccentric and larger flap would otherwise
doesn’t get extended as the acting vector forces are not increase the risk of peripheral extension due to
in opposite directions, also, we experienced that in most peripheral proximity of one edge of flap. On the
of the cases, a rhexis created in the first attempt would contrary a smaller flap would lead to smaller rhexis in
be large enough to avoid the need of rhexis expansion. 2 the first attempt defying the whole purpose of single
As compared to the technique described by stage rhexis. Another significance of the size is that it
Bhattacharjee et al,1 our technique holds the advantage aids in formation of an adequate diameter rhexis
of single step rhexis. Also, there is no essential especially for MSICS cases.
requirement for cohesive viscoelastic and we have been Finally concluding, the “C-rhexis” virtually
using dispersive viscoelastic like hydroxyl propyl eliminates the risk of peripheral extension of
methyl cellulose (HPMC) for AC maintenance. This is capsulorhexis due to its unique “simultaneously acting
Indian Journal of Clinical and Experimental Ophthalmology, January-March,2016;2(1): 38-41 40
 Sahil Bhandari et al. C-Rhexis” the surgical grail in intumescent mature cataract

unidirectional vector forces”. It can be easily mastered,

creates an adequate size rhexis in first attempt, does not
require expensive instruments and can be advocated in
both MSICS and phacoemulsification.

Results
“C” flap rhexis technique was performed on a total
of 125 eyes with intumescent white cataract by a single
surgeon (M.N.) during April 2014 to December 2014.
Out of these 125 eyes, MSICS was performed in 87
eyes and the remainder 38 eyes had
phacoemulsification. In total 67 of the MSCIS eyes and
30 of the Phacoemulsification eyes had a circular well
centered rhexis; rest of the eyes had irregular but
curvilinear rhexis. None of the eyes had any capsular
tags. Intraoperative peripheral extension was neither
experienced during creation of ‘C’ incision nor during
the continuation of capsulorrhexis in both MSICS and
phacoemulsification.
Of all MSICS eyes, double rhexis was done only in
6 eyes as the nucleus size was sufficiently larger than
the capsulorrhexis opening. Neither of the eyes during
phacoemulsification required a double rhexis.
Postoperatively 105 eyes (84%) had uncorrected visual
acuity of 20/40 or better.

Conflict of Interest: None

Source of Support: Nil

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