Manual CTR insertion technique helpful in resident training

I highly recommend the technique for manual capsular tension ring (CTR) insertion described by Angunawela and Little (B.C. Little, MD, R.I. Angunawela, MD, “Capsular Tension Ring Complications and Fish-Tail Technique for Stress-Free Insertion,” presented as a video at the 2007 ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 2007).¹ I have used this technique independently for several years and found it particularly useful in the training of resident surgeons at my institution. We call it the “alpha technique” for much the same reason the authors refer to it as the “fish-tail.” When crossed, the ends of the ring resemble a lower-case Greek alpha character.

I agree that there is far less torsional stress on the zonules during CTR insertion with this technique. Once the technique is mastered, beginning surgeons under my supervision have found it easier to use than the CTR injector to place the ring into position. Additionally, I have never seen the CTR broken or even kinked into a poor shape as a result of this technique. The polymethyl methacrylate in the ring appears to withstand it quite well, even through my usual clear-corneal incision size of 2.6 mm.

I prefer to place the trailing end of the CTR with a smooth forceps by slight pronation of the wrist. This positions the ring's end inferior to the capsular edge; it is then released and slides easily into the peripheral bag. The use of a smooth forceps as the sole delivery tool decreases the amount of manipulation and the use of other secondary instruments that may encumber the novice surgeon.