 Hi, I'm Alice Epitropoulos and I'm a cataract and refractive surgeon in Columbus, Ohio. I practice at the Eye Center of Columbus and I'd like to share a few pearls performing capsulotomy and some of the challenges that can be associated with it. Each step with FACO is crucial to the next. Faculty and residents alike consider the capsular axis the most difficult and technically challenging part of FACO surgery to master. Getting it right is important because it really sets the scene for the rest of the procedure, but also for potential problems further down the line such as capsular contraction, lens decentration, and refractive errors. So three goals to keep in mind as you make your rexis. You want to make it round, centered, and slightly smaller than the optic. This is essential for maximizing IOL performance, especially in those patients with premium Presbyopic implants. So you want to try to pick patients that are really easy for your first few cases. Patients with a large pupil, a good red reflex, patients that are blocked so they don't try to make their own capsulotomy. The newer caps, the newer microscopes really have a way to maximize the red reflex. The Lumero microscope has a stereo coaxial illumination. Dr. Eutrata, who invented the Eutrata forceps is a good friend of mine, and he helped to train me on FACO surgery and performing capsular rexis. And I always remembered on Valentine's Day he would make the capsular rexis in the shape of a heart. And this is way before we knew how important it was to make a round and very symmetrical capsular rexis. So think of the capsular rexis as a series of repeating steps, perfecting your ability to perform a freehand rexis is crucial to performing successful fake almostification. As they say in the big fat Greek wedding, give me any word and the root is Greek. Well there is some truth to that and the root rexis means to tear. One of the most important pearls when doing your rexis, always maintain the depth of the interior chamber with OVD. This reduces the risk of radial tear out, which can lead to complications. You'll see different ways for doing a rexis and I'm just going to demonstrate my technique. And as you can see I'm adding more OVD after making my main incision. I use a sharp 27 gauge cystatome to puncture the central anterior capsule and this creates a linear radial tear which is extended to the desired diameter. With the needle's lateral blunt edge you're going to form the flap. Then I grasp the flap using my blunt eutrata forceps which is then dragged circumferentially. You want to avoid pulling the capsular flap vertically toward the cornea because this encourages the rexis to rip out radially towards the equator. So you want to keep the flap as flat as you can. The forceps should be repeatedly released and again re-grasped at the flap's edge and this allows you to maintain precise control in the direction of the tear. Many devices have been created to improve the accuracy of this part of the procedure including corneal and capsular markers as well as different image guided systems which can project a circular template onto the capsule. Laser assisted capsulonomy uses femtosecond technology and has been shown to create a more predictable rexis in terms of centration and diameter and possibly even improved refractive outcomes compared to a manual rexis. So if you have the opportunity to perform a handful of femtosecond cataract cases during your residency, it's going to really benefit you but it should not replace performing manual capsule rexis. So this is a pretty impressive video from Mitch Schultz creating a free floating capsulotomy and you can see this on the right with LIBO CT using the Victus Femtosecond Laser. You can really see that anterior capsule just floating upwards after that capsulotomy. The anterior capsule is then removed with uterotophore steps making sure that there's no capsular tags. With the newer technology laser platforms we really don't see tags anymore but you still have to be careful when removing that capsule remnant. I also like to use a pre-chopper to complete splitting of the nuclear fragment. This really helps to reduce the amount of faco energy that you use in the eye. Now that you've seen how things go perfectly with a rexis I'm going to show you when things don't go as well and how to fix that problem. So this video demonstrates a capsulotomy over a dense white hyper-mature cataract utilizing tripan blue under an air bubble. So this allows for maximum visibility of the capsule. So the air bubble and the excessive tripan is removed with viscoelastic. The incision is made in the center part of the nucleus and really in this case there's really not a whole lot of liquid cortex causing pressure, however it's a pretty large cataract. And again the rexis is perhaps a little bit more peripheral than we'd like to see it. You want to ideally try to keep the rexis more central in these hyper-mature cataracts. The tear is begun and again the tear is a little bit more peripheral than we'd like. And again it helps at this stage to maybe pressurize the interior chamber with a little bit more OBD when you see it going out more peripherally. And again keeping that flat as flat as possible not pulling up and again it's tending to tear out again so you're adding more OBD and then the flap is completed. So if this doesn't work and the tear goes out radially to the equator you may need to resort to using a conventional can opener capsulonomy which is the technique used routinely when we used to do extra capsular surgery. The can opener technique uses a cystotome to interconnect perforations of the anterior capsule to complete this circular opening. It's important to be familiar with this technique. Usually you won't have to resort to it very often but it can be used if the rexis extends and it cannot be rescued. So dealing with hyper-mature cataracts can be challenging. They are characterized by an opaque lens with a poor red reflex and increased intercapsular pressure. These cataracts require special precautions when performing the rexis. First we stain the capsule with trypan blue. This helps to facilitate visibility of the rexis. Generous injection of viscoelastic helps to maintain that anterior chamber and helps to reduce the risk of that tear going out radially. The most common complication in hyper-mature cataracts is when a spontaneous tear in the capsule extends into the periphery. This is when your heart sinks and sometimes you're nucleus. So the appearance of the stained capsule beside the white cataract mimits the blue white blue arrangement of the Argentinian flag and hence the Argentinian flag sign. So this is when you want to put yourself somewhere that calms you and I prefer this combination of blue and white and Santorini that much more than the Argentinian flag. So there's a few steps that you can take to avoid the Argentinian flag sign when you're operating on these hyper-mature cataracts. One method for preventing the Argentinian flag sign is by introducing a 27 gauge needle on a syringe into an intact anterior capsule. The needle is used to aspirate the liquefied cortex, reducing the pressure in the nucleus which facilitates a more controlled capsular rexis. So despite these maneuvers, the Argentinian flag sign may still occur, but try not to panic because the zonials are pretty good barriers to a stray, outgoing rexis. Whenever the tear leads towards the periphery, we should begin a new tear to correct it. We can either finish the rexis using a can opener style or create two semi-circular rexis using either a bent needle, forceps, or micro-scissors. And again, you're feeling pretty good if you can get to this point, but don't celebrate too soon. You have to use extra caution through the rest of the procedure not to extend the existing tear. So patients with small myotic pupils, as seen with pseudo-exfoliation or in patients that have a history of using alpha blockers such as Flowmax, can also make the capsular rexis much more challenging. So don't hesitate to use a pupil expansion device such as the Maluyugan ring, which really helps to improve your visibility and helps to decrease the risk of complications. We've also used FDA-proved compounded medication called Amidria that can be administered into the irrigating solution to help maintain pupil dilation throughout the procedure. To summarize a few pearls in performing challenging capsular rexis, keep the interior chamber pressurized. Use lots of OVD. You want to use tri-pan blue in patients that have hyper-mature cataracts. Never hesitate to use pupil expansion devices in patients that have small pupils. And again, as you're performing the capsulotomy, you want to stay close to the flap, keep it flap, and just really take your time. Don't hurry through the procedure. Thank you so much for your attention. Again, my name is Alice Epitopoulos from Columbus, Ohio. Thank you again.