Continuous curvilinear capsulorhexis (CCC) is a vital step during phacoemulsification surgery. Capsule staining with trypan blue has been advocated by many surgeons to enhance visualization during surgery in mature cataract,1,2 but its role in phacoemulsification of immature cataracts by trainee surgeons has not been highlighted. We analyzed the results of phacoemulsification of immature cataracts performed by trainee surgeons with and without the use of trypan blue for capsule staining.
Two trainee surgeons were initiated into phacoemulsification of immature senile cataracts under our supervision. The patients selected for cataract extraction were between 50 and 55 years of age and had an immature senile cataract (grade 2 nuclear sclerosis) with a good fundal glow. Each surgeon performed 10 cases of clear corneal phacoemulsification under peribulbar anesthesia. The initial 5 cases were performed with anterior capsule staining (Group 1), and the subsequent cases were performed without staining (Group 2). Stop-and-chop nucleotomy was used for nuclear management.
The CCC was initiated with a bent 26-gauge needle and completed with a capsulorhexis forceps. If the trainee surgeon lost visualization of the flap and could not complete the CCC at any time or there was a tendency for the CCC to extend to the periphery, the case was taken over by the senior surgeon (R.B.V./T.D.). Routine phacoemulsification surgery was then performed using stop-and-chop nucleotomy. A foldable acrylic intraocular lens was implanted at the end of the surgery. Any intraoperative complication, such as a tear in the CCC during chopping or a posterior capsule rupture, was noted.
In Group 1, the trainee surgeons were able to complete the CCC on their own. In Group 2, the CCC was successfully performed in only 3 (30%) cases (2 by 1 surgeon and 1 by the other surgeon). In the remaining 7 cases (70%), the senior surgeon had to complete the CCC. A complete CCC was eventually achieved in all the eyes in Group 2. During phacoemulsification, a tear in the CCC margin occurred in 1 eye (10%) in Group 1 and in 5 eyes (50%) (3 by the first surgeon and 2 by the second surgeon) in Group 2. A posterior capsule tear did not occur in any eye in Group 1 but occurred in 1 eye in Group 2 because of an extension of the CCC tear posteriorly. All eyes achieved a best corrected visual acuity of 20/30 or better 1 week after surgery.
The CCC is the most crucial step for a surgeon converting to phacoemulsification, and trainee surgeons often find this step difficult. Capsule staining with vital dyes such as trypan blue has been an important innovation that aids ophthalmic surgeons in performing a CCC.3 However, the role of the dye has not been emphasized for performing a CCC in immature cataracts, especially during the learning curve for phacoemulsification. We have observed that trainee surgeons may have difficulty performing a CCC even in immature cataracts with a good fundal glow. This study highlights the fact that capsule staining facilitates the CCC in immature cataracts and should be used in all cases of phacoemulsification performed by a trainee surgeon. The use of capsule staining dye allows visualization of the CCC margin throughout the surgery. This helps reduce the incidence of complications during the learning curve of phacoemulsification surgery. We therefore advocate the use of capsule staining for all trainee surgeons who are performing phacoemulsification of immature cataracts.
Tanuj Dada MD
Manotosh Ray MD
Prashant Bhartiya MD
Rasik B. Vajpayee MBBS, MS
aNew Delhi, India
1. Melles GRJ, Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining in cataract surgery. J Cataract Refract Surg 1999; 24:7-9
2. Pandey SK, Werner L, Escobar-Gomez M, et al. Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J Cataract Refract Surg 2000; 26:1052-1059
3. Werner L, Pandey SK, Escobar-Gomez M, et al. Dye enhanced cataract surgery. Part 2: learning critical steps of phacoemulsification. J Cataract Refract Surg 2000; 26:1060-1065