The Essential Role of Capsule Retractors

These instruments provide temporary zonular support that can help surgeons safely remove the lens and plan for permanent capsular stabilization.

Beeran Meghpara, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Capsule retractors act as temporary artificial zonules, centering the capsular bag and preventing posterior displacement, anterior vitreous prolapse, and phaco-tip aspiration Early placement after continuous curvilinear capsulorhexis and before hydrodissection stabilizes eyes with phacodonesis, flaccid lens behavior, or significant zonular compromise Unlike iris hooks, capsule retractors provide equatorial support; after lens removal, permanent support requires a capsular tension ring or scleral-fixated segment Managing profound zonular compromise is one of the most demanding challenges in anterior segment surgery—one that tests the surgeon’s composure and technical acumen. Whether caused by pseudoexfoliation syndrome, prior ocular trauma, Marfan syndrome, or advanced age-related changes, generalized or localized zonulopathy threatens the stability of the capsular bag. The primary surgical goal in these cases is to remove the lens without damaging the capsule or allowing lens fragments to become posteriorly displaced into the vitreous. One useful tool in this setting is the capsule retractor; it is designed to provide atraumatic support and centration of the capsular bag throughout cataract extraction. These instruments feature an elongated nylon shaft and a broad, blunt terminal paddle or loop that cradles the capsular equator without causing iatrogenic trauma. A sliding silicone element on the shaft rests externally against the limbus and allows the surgeon to adjust the amount of tension required. Although retractors can be placed as a rescue maneuver when unexpected zonular dialysis becomes apparent during phacoemulsification or cortical aspiration, the instruments are most effective when used prophylactically. WHEN TO DEPLOY CAPSULE RETRACTORS The timing of capsule retractor deployment is critical to preventing progressive capsular instability. If significant phacodonesis is observed at the slit lamp preoperatively or if the lens appears flaccid during initial capsulorhexis creation, early intervention is warranted. Ideally, capsule retractors are inserted immediately after completion of the continuous curvilinear capsulorhexis and before hydrodissection or any manipulation of the nucleus.

Examining Meibomian Gland Structure and Function in Patients With Demodex Blepharitis

Findings from a retrospective analysis highlight the association between Demodex blepharitis and meibomian gland structure and function.

Cecelia Koetting, OD, FAAO, DipABO and Elizabeth Yeu, MD

Cataract and Refractive Surgery Today

Meibomian gland disease (MGD) is defined as dysfunction of meibomian glands (e.g. obstruction, atrophy, or poor-quality meibum) that leads to tear film disruption, visual disturbance, and ocular discomfort.1 Inflammation from Demodex mites may cause serious consequences, like Demodex blepharitis and MGD. When discussing MGD, it’s important to include consideration of concurrent Demodex blepharitis. According to a study published in 2022, 58% of US patients (n = 595/1032) who visited an eye care clinic and underwent a slit-lamp examination, regardless of chief complaint, had Demodex blepharitis, including consultations for cataract or refractive surgery.2 A retrospective study by Cheng et al reported a positive rate of Demodex infestation in MGD patients (89%; n = 103 eyes of 52 patients) compared to control (43%; n = 62 eyes of 31 non-MGD patients).3 In a separate single-center study, Bhandari et al concluded that the incidence of Demodex infestation was 60% for patients with MGD (n = 60) and 18% for control (n = 50).4 Finally, Lim Bon Siong et al reported that the overall incidence of Demodex blepharitis was 85% for MGD patients (n = 65) and 34% for control patients (n = 50).5 Although Demodex blepharitis may be asymptomatic in a small proportion of patients (≤1% in one prospective observational study of 515 patients; n = 4), most patients (98.3%) reported two or more symptoms.6 Symptoms can stem from Demodex mites triggering inflammation leading to swollen eyelid margins, reduced gland openings, and compromised meibum flow.7,8 Additionally, Demodex infestation may be an important contributor to inflammatory MGD and can lead to structural and functional changes in the meibomian glands.8 Symptoms from Demodex blepharitis and MGD can impact tear film stability and ocular surface integrity, and may also lead to altered biometry and abnormal corneal topography measurements, which can potentially affect cataract or refractive surgery planning and increase the risk of postoperative dissatisfaction.9-12 Therefore, evaluation for Demodex blepharitis should be considered when managing MGD, particularly in patients undergoing such procedures. Study Rationale and Design In early 2025, we published a study in the Journal of Cataract and Refractive Surgery to answer one primary question: How do structural and functional measures of MGD compare in eyes with moderate-to-severe Demodex blepharitis (collarette grades 2–4) versus those with collarette grade 0? For this retrospective, single-center, observational study, we examined case records of 438 patients ≥18 years with available data for collarettes and MGD signs (e.g., telangiectasia, meibum expressibility, meibum quality, meibography).8 Collarettes were graded per eyelid on a 0 to 4 scale: Grade 0: 0 to 2 lashes/eyelid with collarettes. Grade 1: 3 to 10 lashes/eyelid with collarettes. Grade 2: >10 to <1/3 (~50) lashes/eyelid with collarettes. Grade 3: ≥1/3 to <2/3 (~100) lashes/eyelid with collarettes. Grade 4: ≥2/3 (~150) lashes/eyelid with collarettes.

Observation vs. Vitrectomy for Floaters

Kyle Kovacs, MD; Matthew Starr, MD; and Nita Valikodath, MD

Eyetube

In this episode of New Retina Radio Journal Club with VBS, host Kyle Kovacs, MD, joins Matthew Starr, MD, and Nita Valikodath, MD, to review a major study on vision-degrading myodesopsias from vitreous floaters. They then debate the risks and value of limited refractive vitrectomy for select patients in real-world settings, and review their protocols for patients who present with floaters.