Video Presentation - VT37

Controlling the rhexis to Control the case: Capsulorhexis in difficult situations

Anterior capsulorhexis creation remains a critical yet challenging step in cataract surgery, particularly in advanced or compromised ocular conditions such as the following: In intumescent cataracts, elevated intralenticular pressure predisposes to runaway rhexis. Controlled decompression using needle aspiration, two-stage rhexis, cohesive OVDs, or femtosecond laser marking helps prevent the Argentinian flag sign and maintains capsular control. In NS5 with small pupil and fibrotic anterior capsule, limited access and reduced visibility demand adjuncts such as pharmacologic dilation, iris hooks or pupil expansion rings, repeated viscodilation, and micro-scissor cuts to overcome capsular fibrosis. In NS5 with zonular instability, rhexis creation must minimize zonular stress. Techniques like gentle capsular puncture, extensive OVD support, capsule hooks, capsular tension rings, and low-flow phaco parameters help stabilize the bag and prevent zonular dialysis.