Capsular tension rings and related devices: current concepts

Khalid Hasaneea, Michael Butlerb and Iqbal Ike K. Ahmeda,c

Purpose of review Introduction

To discuss current designs, indications, contraindications The use of capsular tension rings (CTRs) and other
and controversies pertaining to capsular tension devices. endocapsular support devices has found an important
Recent findings niche in the management of zonular weakness in com-
Capsular tension rings and other newer endocapsular plicated cataract surgery. Performing cataract extraction
support devices have become increasingly important in in patients with significant zonulopathy presents many
the management of zonular weakness during cataract challenges with increased risks of intraoperative and
extraction. They have been found to improve both postoperative complications.
intraoperative support during phacoemulsification and
postoperative intraocular lens centration. Since the Numerous options exist in the management of compro-
introduction of the original capsular tension rings in 1991, mised zonules. It is helpful to categorize these
there has been a progressive evolution of this device to approaches into two broad categories: methods of catar-
help deal with profound zonular weakness. These newer act extraction and intraocular lens (IOL) fixation.
devices, which permit scleral-suture fixation, include the
modified capsular tension ring and the capsular tension
With regards to cataract removal, several options exist
segment.
including phacoemulsification, extracapsular and intra-
Summary
capsular approaches. In severe cases, a posterior
Continual advances in capsular tension device technology
approach with pars plana lensectomy and vitrectomy
have allowed for increased safety and efficacy in
may be entertained. Of course, the ability to maintain
performing cataract surgery in patients with zonular
the benefits of small-incision surgery with phacoemulsi-
weakness with newer devices being evolved to manage
fication is the preferred choice.
more profound cases.

IOL implantation options include a sulcus posterior-

Keywords
chamber IOL (PCIOL), an anterior-chamber IOL
capsular tension ring, endocapsular support device,
(ACIOL), iris-fixated IOL, or in-the-bag PCIOL with
zonular dialysis
CTR. The use of the CTR with PCIOL implantation
is the preferred course of action, however, due to the
Curr Opin Ophthalmol 17:31–41. # 2006 Lippincott Williams & Wilkins.
numerous advantages that are reviewed in this paper.
a
University of Toronto, Toronto, Ontario, Canada, bUniversity of Ottawa, Ottawa,
Ontario, Canada, and cUniversity of Utah, Salt Lake City, Utah, USA
Understanding zonular weakness
Correspondence to Iqbal Ike K. Ahmed MD, FRCSC, Credit Valley EyeCare, 3200
Erin Mills Parkway, Unit 1, Mississauga, Ontario, Canada L5L 1W8
To understand zonulopathy, it is helpful to categorize it
Tel: +905 820 3937, fax: +905 820 0111; e-mail: [email protected] according to both the extent of zonular dialysis (number
Current Opinion in Ophthalmology 2006, 17:31–41
of clock hours) and the severity of generalized zonular
instability [1–3,4••]. This distinction is very important as
Abbreviations
specific zonular cases each have their own underlying
CTR capsular tension ring pathogenesis or a combination of causes. For example,
CTS capsular tension segment
IOL intraocular lens a traumatic cataract with segmental zonular lysis (with
LEC lens epithelial cell remaining strong zonules) may need to be handled dif-
M-CTR modified capsular tension ring
PCIOL posterior chamber intraocular lens ferently from a case of pseudoexfoliation with general-
PCO posterior capsule opacification ized zonular weakness. The choice of cataract extraction
and endocapsular support device relies greatly on this
# 2006 Lippincott Williams & Wilkins
1040-8738
distinction.

Mechanics of the capsular tension ring

The mechanics of the CTR are detailed in Table 1. A
CTR may serve a dual purpose, both as a tool providing
intraoperative support during cataract removal and as an
implant for long-term IOL stabilization. As the diameter
of the CTR is larger than that of the capsule bag, the
31
32 Cataract surgery and lens implantation

Table 1 Mechanics of the CTR Figure 1 Moderate zonular dialysis

Expansion of capsular equator
Buttress areas of weak zonules
Recruit and redistribute tension from existing zonules
Recenter a mildly subluxed capsular bag

centrifugal forces inherent to the ring expand the capsu-

lar equator and buttress the weak areas, providing equal
distribution of support over the remaining zonules [5].
The CTR re-expands the capsular bag, provides coun-
ter-traction and tautens the posterior capsule during sur-
gery. After surgery, it offers the advantage of preventing
capsule shriveling and allows for Nd:YAG capsulotomy
after phaco [6••]. As the capsular bag’s circular contour is
maintained, enhanced zonular support is produced [7].
The CTR also recruits tension from existing zonules
and redistributes the forces to the remaining weaker
zonules thereby stabilizing the entire zonular apparatus.
This added support of the CTR may also help to recen-
ter a mildly subluxed capsular bag to avoid decentration
and dislocation [1]. Other advantages of the CTR on capsulorhexis, mild rhexis ovalization but without
include decreased prevalence of posterior capsule opaci- bag collapse or overt decentration [1–3,4••]. If these cri-
fication (PCO) [8], enhanced safety and efficiency dur- teria are not met, the degree of zonulopathy is likely to
ing phacoemulsification and possibly reduced incidence be moderate (Fig. 1) to advanced and a standard CTR is
of capsular contraction syndrome. Standard CTRs how- considered to be insufficient.
ever, do not recenter a severely subluxed capsular bag
nor prevent progressive zonular loss. To deal with these
There are certain situations where CTR implantation is
problems, scleral-fixated devices such as the modified
absolutely contraindicated. Anterior radial or posterior
CTR (M-CTR) or the capsular tension segment (CTS)
tears in the capsule are situations where CTR insertion
must be used.
can be detrimental [12,13]. In cases of noncontinuous
capsulorhexis, the centrifugal forces generated by the
Indications and contraindications to capsular CTR may provoke further extension of the capsular
tension rings tear towards the posterior direction. In cases such as
The most frequent causes of zonular insufficiency that these, the CTR is at risk of falling into the posterior
benefit from CTR implantation include pseudoexfolia- segment [12–14].
tion, traumatic lens displacement, iatrogenic zonular
damage, Marfan’s syndrome [9], homocystinuria, hyper-
mature cataracts, and post-vitrectomy and filtration Current endocapsular devices
patients [6••]. Other less-frequent situations include In this section we describe current endocapsular
aniridia, retinitis pigmentosa [10], intraocular neoplasms, devices.
Weil–Marchesani syndrome and microspherophakia
[6••]. CTR implantation has also been successfully per- Standard capsular tension ring
formed in cases of congenital lens coloboma; however, In 1991, Hara et al. [15] and Nagamoto and Bissen-
there have been no long-term studies [11]. Miyajima [16] introduced the first endocapsular devices.
This was later popularized and further developed by
Clinical situations where a standard CTR would be U.F.C. Legler and B.M. Witschel (The capsular ring:
indicated (authors’ preferences) include the following: a new device for complicated cataract surgery. Presented
(a) evidence of mild zonular instability based on either at American Society of Cataract and Refractive Surgery
localization of zonulysis (less than 4 clock hours); or (b) [ASCRS] Symposium on Cataract, IOL, and Refractive
degree of generalized zonular weakness, for example, Surgery, May 1993; Seattle, Washington). Known as the
mild pseudoexfoliation characterized with a ‘floppy cap- standard CTR, this open-ring structure (Fig. 2) is made
sular bag’. Certain clinical signs that may indicate ‘mild’ of polymethylmethacrylate (PMMA) material and has an
generalized weakness including slight lens movement oval-shaped cross section with eyelets at both free ends.
 Capsular tension rings and related devices Hasanee et al. 33

Figure 2 Standard CTR that phacoemulsification with in-the-bag PCIOL and

CTR implantation had a 90.47% success rate. Capsular
collapse did not occur in any eye, but two eyes devel-
oped intraoperative extension of dialysis. Fifteen eyes
(71.42%) had a final visual acuity of 20/40 or better. All
patients with successful implantation remained well
centered at 6 months.

Bayraktar et al. [2] examined the effect of an endocap-

sular tension ring in preventing zonular complication
during phacoemulsification in patients with pseudo-
exfoliation without overt zonular weakness. This was a
prospective randomized study of 78 eyes with pseudo-
exfoliation cataracts that were randomly divided into
two groups. CTRs were implanted in 39 eyes and the
remaining 39 served as controls. Five eyes (12.8%) in
the control group and no eyes in the CTR group devel-
oped intraoperative zonular separation. The posterior
capsule rupture rate was 7.7% in the control and 5.2%
in the CTR groups. Capsular IOL fixation was 94.9%
and 74.3% in the CTR and control groups respectively.

In their retrospective series of 14 cases with loose or

It is a compressible circular ring with two smooth-edged broken zonules managed with capsular tension rings,
end terminals. The ‘ski tip’ design of the end terminals Gimbel et al. [3] concluded that CTRs help to avoid
aid in avoiding entrapment of the capsular equator on capsular bag collapse and vitreous presentation during
insertion and also allows for the placement of secondary surgery. No observable IOL decentration occurred in
instrumentation. their group.

The CTR is manufactured by both Morcher GmbH With regards to the issue of IOL tilt and decentration,
(Stuttgart, Germany) and Ophtec (Groningen, The Lee et al. [17] reported their findings on 40 eyes of 20
Netherlands), and are US Food and Drug Administra- patients who were followed for 2 months. Each patient
tion (FDA) approved. The Morcher ring, also known had an IOL in one eye and an IOL with a CTR in the
as the Reform ring, comes in three different sizes fellow eye. Comparatively, the IOL-CTR group had a
based on an uncompressed diameter: 12.3 mm (com- statistically lower rate of IOL decentration compared
presses to 10.0 mm), 13.0 mm (compresses to with the IOL-only group using Scheimpflug image ana-
11.0 mm) and 14.5 mm (compresses to 12.0 mm). The lysis. The mean decentration in the IOL-CTR group
Ophtec ring (which is marketed as StabilEyes in the was 0.42 ± 0.17 mm, whereas in the IOL-only group it
United States by Advanced Medical Optics, Irvine, was 0.57 ± 0.16 mm. The amount of IOL tilt at 60 days
California) is available in a 13-mm ring (compresses to was also significantly less in the IOL-CTR group (IOL-
11 mm) and a 12.0-mm ring (compresses to 10.0 mm). CTR 2.47 ± 0.40˚, IOL-only 3.06 ± 0.56˚).
The CTR may be inserted manually with forceps or
with injectors (authors’ preference), which are less trau- Selection of capsular tension ring size
matic. Both Ophtec and Geuder (Heidelberg, Germany) The selection of CTR size is based on capsular bag
manufacture injectors that may be used to implant the dimensions. A larger capsular bag usually requires a lar-
Morcher and Ophtec CTRs. It is important to note that ger ring. Many surgeons prefer to choose a slightly larger
the Ophtec CTRs are not compatible with the Geuder implant, with 13 mm being most common. At minimum,
injector. Both the Morcher and Ophtec CTRs, however, overlap of the end terminals is needed to provide com-
may be used with Ophtec injector. plete circumferential support. Vass et al. have shown that
the size of the capsular bag positively correlates with the
Currently, few studies exist examining the safety and globe’s axial length [18]. The corneal diameter is also an
efficacy of CTRs. In a prospective study of 21 eyes, indicator of capsular bag size [18]. On the basis of this
Jacob et al. [1] evaluated the safety and efficacy of the information, white-to-white corneal measurement and
CTR in patients with less than 150˚ of zonular dialysis. axial measurements can be used as a guide to CTR siz-
The mean follow-up time was 242.33 days. They found ing, although many surgeons advocate routinely using
34 Cataract surgery and lens implantation

larger sizes (authors’ preference) to ensure adequate Table 2 Key points about the CTR
overlap of end terminals. Furthermore, it would be
When to use a CTR When not to use a CTR
appropriate to use a larger CTR in cataract surgery
involving highly myopic eyes [18]. Mild zonular weakness: Anterior capsule tear.
less than 4 clock hours of dia- Posterior capsule rent.
lysis; Incomplete rhexis.
Modified capsular tension ring mild generalized instability. Severely subluxed capsular bag.
All pseudoexfoliation patients (de-
Prior to the advent of the M-CTR, management of pro- bated): does improve centration
found lens subluxation required more invasive and com- and tilt.
plicated surgery as the standard CTR is unable to pro-
vide adequate intraoperative support and center the
capsule bag in these cases. Some surgeons sutured the
standard CTR through the capsule bag with or without a 1-L or 1-R) or two (model 2-L) fixation eyelets attached
peripheral capsulorhexis and then lassoed the CTR to the central ring. The eyelets, which allow the ring to
along with the peripheral capsule [19]. To avoid the be sutured to the sclera, protrude 0.25 mm forward from
risk of creating capsular tears with this technique, the body of the CTR and thus sit anterior to the anterior
Cionni developed the M-CTR (Morcher GmbH) in capsule, thereby conserving the capsular bag’s integrity
1998 (Fig. 3, Table 2). This implant provides a solution on suturing [6].
to extensive and/or progressive zonular damage by
allowing the surgeon to anchor the capsule bag to the Moreover, an adequately sized capsulorhexis (that is,
eye wall. It is an open-ring design with one (model 5.5 mm) is of utmost importance when working with
the M-CTR. In cases of a small capsulorhexis margin,
the hook may drag on the capsulorhexis edge and result
Figure 3 Cionni M-CTR for suture scleral fixation
in iris chafing and related pigment dispersion and
chronic uveitis.

Cionni et al. [20] studied the effect of the M-CTR in 90

eyes with congenital loss of zonular support. In 94% of
cases, the M-CTR provided good centration of the cap-
sular bag and PCIOL. In 80% of eyes, the best-corrected
visual acuity was 20/40 or better. The suture breakage
incidence was 10%. Hence, recommendations were
made to use 9–0 rather than 10–0 sutures to address
this concern.

Ahmed et al. [21•] reported their series of 68 consecutive

patients with profound zonulopathy due to a variety of
causes in which the M-CTR was scleral-fixated. The
double-eyelet M-CTR was implanted in 10 cases with
the remainder receiving the single-eyelet M-CTR. Vary-
ing causes for zonular weakness included Marfan’s syn-
drome (22 cases), trauma (19 cases), ectopia lentis (10
cases), pseudoexfoliation (six cases) and other (12
cases). The average follow-up time was 12.4 months
with all cases achieving adequate centration. Complica-
tions included elevated intraocular pressure (six cases),
mild PCO tilt (five cases), pigment dispersion (two
cases), mild iritis (five cases) and cystoid macular
edema (four cases). These results demonstrated the
wide range of clinical situations where a M-CTR may
be utilized. One of the major findings of these studies
is that the need for vitrectomy, which would have been
(a) single eyelet. (b) double eyelet. routinely required with many of these cases, is often
obviated with the use of capsular tension devices.
 Capsular tension rings and related devices Hasanee et al. 35

In their case series of seven eyes (five patients), Capsular tension segment
Moreno-Montanes et al. [22] demonstrated that The CTS, designed by Ahmed in 2002 (Figs 4a–d) and
M-CTR implantation was an acceptable procedure to manufactured by Morcher GmbH, is also intended for
correct limited lens subluxation, with preservation of patients with profound zonular insufficiency. It is
the capsular bag and relatively few complications. designed for cases requiring optimal intraoperative sup-
port (Figs 4b, 4c) for significant zonular weakness, or for
patients in need of long-term postoperative centration of
an IOL within the capsular bag. This partial PMMA ring
Figure 4a CTS segment (Fig. 5) is 120˚ with a radius of 5 mm and, like
the M-CTR, the CTS also possesses an anteriorly posi-
tioned fixation eyelet.

Placing a CTR into an eye with a dense cataract or sig-

nificant zonular weakness prior to phacoemulsification

Figure 4c Phacoemulsification with CTS and iris retractor in

place

Figure 4b CTS with iris retractor through eyelet for intra- Figure 4d Sutured CTS in place after surgery with well cen-
operative stabilization tered IOL
36 Cataract surgery and lens implantation

Figure 5 Dimensions of CTS can be challenging and may create further zonular
damage [23••]. As the CTS can be implanted without a
dialing technique and thus with much less force trans-
mitted to the zonular apparatus, it has a distinct advan-
tage over the CTR and M-CTR in these situations. The
CTS is designed to slide into the capsule bag with mini-
mal trauma, and thus may be used in cases of a discon-
tinuous capsulorhexis or anterior capsule tear, or a pos-
terior capsule rent. It is inserted into the capsule bag
after capsulorhexis and placed over the area of zonular
weakness. The main body of the device sits inside the
capsule bag supporting and extending the capsule equa-
tor. The central eyelet remains anterior to the capsule.
When used for intraoperative support, an inverted iris
retractor, via a paracentesis, is placed through the eyelet
acting as a coat hanger to support the capsule in the area
of zonular weakness (Figs 4b, 4c). For global weakness,
multiple CTS devices may be used in a similar fashion
[24••] (Fig. 6). Unlike other endocapsular devices, the
CTS may be used only as an intraoperative device and
can be easily removed once lens extraction is complete
or, as most surgeons do, it can be permanently suture-
fixated to the sclera, much like the M-CTR for long-
term capsular bag support and centration. It should be
distinguished that the CTS provides support in the
transverse plane when sutured to the scleral wall.
When circumferential support is also required, a CTR
may be implanted in conjunction with an already posi-
tioned CTS (authors’ preference).

Figure 6 Postoperative photos of dual CTS. Close-up view (top left)

 Capsular tension rings and related devices Hasanee et al. 37

The CTS is available in three different radii of curva- zonular weakness (nonprogressive compared with pro-
ture: 4.5 mm (model 6E), 5.0 mm (model 6D) and gressive) [24••]. It would perhaps be more useful to
5.5 mm (model 6C). also take into consideration the degree of zonular loss
and/or extent of generalized zonular instability.
In a consecutive series of 35 patients in which a CTS
was implanted with or without another support device, Nonprogressive zonulopathy such as traumatic or iatro-
IOL centration was achieved in all cases with no signif- genic zonular dialysis or zonular coloboma are well
icant IOL tilt [25]. Several combinations of devices were suited for standard CTRs as the remaining zonular fibers
used including the following: one CTS (nine patients), are usually quite strong and, with redistribution of these
two CTSs (eight patients), CTS + CTR (nine patients), forces with the CTR, can support the capsular bag
CTS + M-CTR (four patients), CTS + Iris coloboma [24••]. In progressive cases such as advanced pseudoex-
ring (one patient) and CTS + Iris diaphragm rings foliation syndrome or Marfan’s syndrome, however, a
(four patients). Two patients developed an intraopera- suturable M-CTR or CTS may be of optimal value as
tive anterior capsule tear and one patient develop a pos- it can be secured to the sclera. Further support can be
terior capsule rent, but the CTS was still successfully achieved as necessary by combining devices depending
implanted in these cases. Three patients developed on the amount of scleral-fixation needed. Moreover,
PCO. Initial outcomes have demonstrated the versatility endocapsular ring implantation does not eliminate the
of the CTS both as an intraoperative tool and implant underlying cause of zonular weakness and in severe
support device. cases of progressive dialysis it may be unavoidable
with a conventional CTR to prevent pseudophacodin-
Closed foldable capsular folding ring esis, further luxation or dislocation of the capsular bag
Dick [26] has recently introduced a new device, the complex into the vitreous [4••].
closed foldable capsular ring (CFCR), which is a fold-
able capsular tension and bending ring system with a CTRs are indicated in cases of mild, generalized zonular
sharp-edged design. The CFCR has eight hydrophobic weakness or small, localized zonular dialysis (less than
and eight hydrophilic ring segments. The minimum 3–4 clock hours). In cases of profound zonular insuffi-
overall diameter is 9.2 mm. This implant device can be ciency, a standard CTR may not supply enough intra-
inserted either manually with forceps and a two-folded operative and postoperative support to maintain the
technique or through an injector cartridge system. In desired orientation of the capsular bag.
their series of 104 eyes, this implant was inserted
through a small incision (1.6–3.2 mm) with no significant In more advanced or progressive cases of zonular
complications over 6-months follow-up. PCO was mini- instability, the Cionni M-CTR or the CTS(s) is indi-
mal or absent in all cases. cated. A 9.0 Prolene suture with double-armed CTC-6
needles (Ethicon Inc, Somerville, New Jersey) is passed
Current issues concerning capsular tension through the eyelet of the fixation hook of the CTS or
rings MCTR prior to implantation and fixated to sclera [27].
In this section we describe current issues concerning An ab-externo approach through a scleral groove to
CTR. suture the CTS or MCTR has been proposed, which
can be performed under topical anesthesia [28].
What device to use
A comparison of CTR, M-CTR and CTS is given in When to place the capsular tension ring
Table 3. Some surgeons feel that the choice of endocap- Issues concerning the timing of insertion are given in
sular support devices depends mainly on the nature of Table 4. The CTR can be inserted into the capsule

Table 3 Comparison of CTR, M-CTR and CTS

CTR M-CTR CTS

Requires continuous curvilinear capsulorhexis Yes Yes No

May be placed prior to lens removal With difficulty With difficulty Yes
Use with anterior capsule tear No No Yes
Use with posterior capsule rent No No Yes
Use with large zonular dialysis (more than 4 clock hours) No Yes Yes (± multiple segments)
Use in progressive zonulysis No Yes Yes
Allows for suture fixation to sclera No Yes Yes
May be easily removed from eye if needed No No Yes
Cortical removal difficulty Yes Yes No
38 Cataract surgery and lens implantation

Table 4 Timing of CTR insertion Figure 7 Iris retractors placed at capsulorhexis edge to
stabilize loose capsular-zonular complex. They run the risk of
When to place a CTRa inadvertent dislodgement or anterior capsular tear

Prior to phaco
• Offers better nuclear stability for phacoemulsification
• More difficult with dense lens (higher risk of iatrogenic zonular
damage)
• Difficult to remove cortex
After phaco/cortical removal
• Use iris hooks during phaco/cortical irrigation and aspiration
• Risk of iris hook dislodgement (subsequent tears)
a
CTS may be inserted at any time due to atraumatic entry.

bag at any time following capsulorhexis, viscodissection

and hydrodissection. There has been debate as to the
optimal timing of CTR insertion. CTR implantation
after capsulorhexis and hydrodissection, but before
nucleus extraction (early implantation) has been hailed
as a safe alternative in cases of pseudoexfoliation. By
using this early implantation technique, reduced intra-
operative complications caused by zonular separation
have been reported [2]. During phacoemulsification
and cortical aspiration, the distended capsular orienta- without the support of CTS or iris/capsular retractors
tion decreases the risk of it being aspirated by the risks capsule bag dislocation and lens subluxation, even
phaco or irrigation/aspiration tips [3,29]. if a CTR has been implanted.

There are drawbacks to CTR implantation prior to Pseudoexfoliation and capsular tension devices
nuclear extraction. Entrapment of cortical material by Patients with pseudoexfoliation are excellent candidates
the CTR against the capsular bag may hinder removal for CTR implantation, due to associated progressive
[12]. Placing the CTS as an intraoperative device during zonular deterioration [2]. There is a debate, however,
phaco and cortex removal, however, helps solve this as to whether all pseudoexfoliation patients should
problem as it is much easier to strip cortex around the receive CTRs. These patients are at an increased risk
partial segment as opposed to the full ring structure. for intraoperative complications, as well as postoperative
IOL dislocation especially from superior zonular dialysis
CTR implantation prior to cataract removal may result [30,31]. Postoperative capsular phimosis is also an
in further iatrogenic zonular damage. Ahmed et al. [23••] impending risk in pseudoexfoliation syndrome.
using Miyake-Apple video analysis, have demonstrated Moreno-Montanes and Rodriguez-Conde [32] have
that early CTR implantation in cases with moderate recommended that CTR placement should be manda-
zonulysis results in significant zonular elongation and tory when operating on all patients with pseudoexfolia-
capsular displacement of up to 4 mm compared with tion. There is currently no evidence, however, demon-
later CTR implantation. Furthermore, if a capsular tear strating that pseudoexfoliation patients without any
ensues there is risk of CTR subluxation into the vitreous zonulopathy require an insertion of a CTR prophylacti-
body [12,14]. It is therefore recommended (authors’ pre- cally. Furthermore, even with CTR implantation, cer-
ference) that the optimal timing of CTR or M-CTR tain progressive cases may still dislocate years later
insertion into the capsular bag be as late as safely possi- [4••].
ble (CTS may be implanted early due to its atraumatic
insertion). For cases of serious zonular weakness, the Capsule phimosis
CTS may be used in conjunction with an iris retractor Due to weakened zonules exerting decreased centrifu-
for intraoperative support as described earlier. Alterna- gal forces, the contractile forces of an anterior fibrosing
tively, iris retractors or modified capsule retractors capsule may be overwhelming, thereby leading to cap-
(Mackool Cataract Support System, Duckworth and sular phimosis. Capsular contraction forces may be sym-
Kent Ltd, Hertfordshire, UK) placed on the capsulor- metric or asymmetric. Asymmetric forces cause the IOL
hexis (Fig. 7) may provide support, but risk capsular to shift to one side (usually the stronger side), whereas
tear or dislodgement, which is less likely with the symmetric contraction is less likely to result in lens
CTS. Performing phaco in profound zonular instability decentration.
 Capsular tension rings and related devices Hasanee et al. 39

Tehrani et al. [33] showed a positive correlation between Kurz and Dick [42] demonstrated that the spring con-
capsular bag shrinkage and axial length in their study stant of a CTR is a suitable mechanical characteristic
with the capsule measuring ring (HumanOptics, Erlan- to facilitate the choice of CTR model. They found
gen, Germany). Utilizing preoperative biometric data, a that CTRs with lower spring constants were more
regression formula of moderate validity was determined advantageous for the management of zonular dialysis,
to predict the amount of capsular bag shrinkage. whereas higher spring constant CTRs were ideal for
the prevention of capsular bag shrinkage.
Although it was initially felt that anterior capsule con-
traction following cataract surgery with CTR placement How to manage capsular tension ring dislocation
might be prevented [3,34], more recent reports have Postoperative CTR subluxation or dislocation is a risk
indicated that capsular phimosis is still a postoperative for patients with severe or progressive zonulysis. In a
concern despite CTR implantation [29]. Capsular con- retrospective interventional case-series of 11 patients,
traction to the point of complete capsulorhexis opening Ahmed et al. [4••] demonstrated that CTR decentra-
occlusion has also been reported despite CTR use [34, tions, including into posterior vitreous, may be effec-
35]. Capsular contraction has occurred following CTR tively managed with scleral-suture fixation of the CTR
implantation with IOLs made from silicone, PMMA through the fibrotic capsular bag, or with the placement
and acrylic materials [34]. CTRs are still beneficial in of a CTS under the anterior capsule to reposition the
these situations, however, as the capsular contraction is displaced apparatus.
typically symmetrical as opposed to asymmetrical with-
out the use of a CTR, thus reducing the risk of IOL In cases where a CTR displaced into the vitreous cavity
cannot be repositioned, several techniques of retrieval
decentration.
have been reported. Lang et al. [14] have reported the
successful removal of an intact ring through a sclerotomy
Methods to further reduce the risk of capsule contrac-
site. Another possible approach is to cut the fallen ring
tion syndrome include creating a capsulorhexis opening
into two halves and remove each half by using two
of 5.5–6.0 mm, use of an acrylic IOL [36–39], aspiration
forceps utilizing a bimanual technique [43]. A third
of lens epithelial cells (LECs) on the undersurface of
technique proposed by Ma et al. [44] appears to be the
the anterior capsule to reduce LEC proliferation and
most viable and safest option. This approach encom-
metaplasia [40]. LEC metaplasia and fibrosis may also
passes the use of a CTR injector to withdraw the ring
be reduced by the presence of an endocapsular ring by
in one piece through the initial phaco incision.
decreasing contact between the optic and anterior cap-
sule [41]. Anterior capsule relaxing incisions either dur- Posterior capsule opacification
ing surgery with microscissors or after surgery with a Nd: Although the incidence of PCO is reduced with the use
YAG anterior capsulotomy is a critical step to prevent of CTRs [8], PCO has still been reported after surgery
decentration (Fig. 8). [24••]. To minimize the risk of PCO, Nishi et al.’s [41]
capsular bending ring (CBR) may be utilized, with the
added feature of a square edge. This model has been
Figure 8 CTS with Nd:YAG radial cuts to anterior capsule for
capsule contracture. IOL is well centered shown to significantly reduce the risk of posterior cap-
sule epithelial growth [41]. In additional, Dick et al. [45]
reported that combining a viscoadaptive viscoelastic
agent and a CBR not only enhances the safety of pri-
mary and secondary PCIOL implantation and IOL
exchange in pediatric cases, but also reduces PCO. A
square-edged IOL design used in conjunction with a
CTR may also decrease the incidence of PCO [38].

PCO was reported to be of particular concern when

using the Cionni M-CTR [22]. With the fixation hook
protruding anterior to the capsulorhexis margin, it has
been suggested that the anterior capsule may be slightly
lifted away from the optic and this may facilitate LEC
migration in this zone [22].

Conclusion
Endocapsular devices offer numerous advantages in
situations of zonular insufficiency including reestablish-
40 Cataract surgery and lens implantation

ment of the capsular bag contour, decreased risk of 15 Hara T, Hara T, Yamada Y. ‘Equator ring’ for maintenance of the completely
PCO, decreased capsular bag collapse and risk of aspira- circular contour of the capsular bag equator after cataract removal. Ophthal-
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16 Nagamoto T, Bissen-Miyajima H. A ring to support the capsular bag after
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lens decentration and tilting after cataract surgery. J Cataract Refract Surg
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18 Vass C, Menapace R, Schetterer K, et al. Prediction of pseudophakic capsu-
Over the past decade, there have been dramatic lar bag diameter based on biometric variables. J Cataract Refract Surg
advances in the management of zonular weakness. 1999; 25:1376–1381.

From the advent of the capsular tension ring to the 19 Lam DS, Young AL, Leung AT, et al. Scleral fixation of a capsular tension ring
for severe ectopia lentis. J Cataract Refract Surg 2000; 26:609–612.
more recent CTS, each device has served to play a spe-
20 Cionni RJ, Osher RH, Marques DM, et al. Modified capsular tension ring for
cific role in the management of weak zonules in cataract patients with congenital loss of zonular support. J Cataract Refract Surg
surgery. 2003; 29:1668–1673.
21 Ahmed IIK, Crandall AS, Kranemann C, Goldsmith J. Clinical Results of the
References and recommended reading
.

! Cionni Modified Capsular Tension Ring for Sever Zonular Weakness. Amer-
Papers of particular interest, published within the annual period of review, have ican Academy of Ophthalmology Meeting, New Orleans, Louisiana; October
been highlighted as: 2004. Paper Session.
• of special interest This paper demonstrates that the M-CTR can be used in a variety of clinical
•• of outstanding interest situations.
Additional references related to this topic can also be found in the Current
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