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.

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Retina Then and Now: May/June Spotlight

As part of our 20th anniversary, Retina Today is digging into the archives to reflect on how much the profession has changed.

Michael S. Ip, MD

Retina Today

May/June Spotlight: CRVO, BRVO, and DME In 2006, Michael S. Ip, MD, contributed an article on The Future of CRVO, BRVO, and DME Therapies (click here to read the original article). He noted that “not many existing treatments produce profound improvements in visual acuity,” and the only effective therapy for diabetic macular edema (DME) was laser photocoagulation. Here, he reflects on the advances in our armamentarium for macular edema due to central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), and diabetic retinopathy over the last 20 years, and the innovations poised to change the treatment paradigm once again. RETINA TODAY (RT): How were you treating RVOs and DME in 2006? Dr. Ip: We were treating RVO and DME primarily with laser photocoagulation, or observation in the case of CRVO. Intravitreal corticosteroids were also an option, and level 1 evidence regarding their use came out following the release of the DRCR Retina Network’s Protocol B dataset and the original SCORE dataset.1,2 RT: How has the therapeutic landscape evolved over the last 2 decades? Dr. Ip: The introduction of anti-VEGF therapy came with the release of the BRAVO, CRUISE, RIDE, and RISE data for ranibizumab (Lucentis, Genentech/Roche) for RVO and DME, as well as the release of DRCR Retina Network’s Protocol I.3-6 The Copernicus, Galileo, VIVID, and VISTA trials for 2 mg aflibercept (Eylea, Regeneron) soon followed.7-9 These trials established anti-VEGF therapy as a standard of care for RVO and DME, which provides excellent results with overall excellent safety (Figure).