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Posterior continuous curvilinear capsulorhexis with hydrogel and silicone intraocular lens implantation: development of capsulorhexis size and capsule opacification.

PURPOSE: To evaluate the influence of primary posterior continuous curvilinear capsulorhexis (PCCC) on capsule opacification development and capsular bag changes within the first year after cataract surgery with 2 intraocular lenses (IOLs) of comparable design but different material. SETTING: Department of Ophthalmology, University of Vienna, Medical School, Vienna, Austria. METHODS: Thirty-seven patients with age-related cataract had bilateral small incision cataract surgery with a PCCC performed after capsular tension ring insertion. One eye was randomly assigned to receive a hydrogel IOL and the other eye, a silicone IOL. Standardized digital retroillumination photographs were taken 1 day, 1 week, and 1, 3, 6, and 12 months after surgery to evaluate changes in the dimensions of the anterior and posterior capsulorhexis opening area and the presence of anterior and posterior capsule opacification. RESULTS: The area of the anterior continuous curvilinear capsulorhexis (ACCC) opening was significantly reduced during the first 6 postoperative months. The shrinkage was more pronounced (-25%) in the silicone IOL group than in the hydrogel IOL group. Ten percent of eyes with a silicone IOL had marked shrinkage of the ACCC. The area of the PCCC did not change in eyes with a hydrogel IOL but was larger (+20%) in eyes with a silicone IOL. Anterior ongrowth was observed in 60% in the hydrogel group and in no eye in the silicone group. Anterior capsule fibrosis was observed in 90% in the silicone group and in 20% in the hydrogel group. Total closure of the PCCC was not observed within the first year, but posterior ongrowth was observed in 40% in the hydrogel group and 10% in the silicone group. CONCLUSIONS: Anterior capsulorhexis shrinkage with concomitant posterior capsulorhexis enlargement was observed in eyes with a silicone IOL. The hydrogel IOL induced more ongrowth on the anterior and posterior IOL surfaces, whereas the silicone IOL induced more anterior capsule fibrosis. Total closure of the PCCC was not observed within the first year after surgery.

Aged↗

A comparative study of the elastic properties of continuous tear curvilinear capsulorhexis versus capsulorhexis produced by radiofrequency endodiathermy.

Capsulorhexis using radio-frequency endodiathermy may confer some advantages over continuous tear curvilinear capsulorhexis (CTCC) in certain clinical situations. It is unclear whether a capsulorhexis produced in this fashion has the clinically advantageous elasticity and resistance to tearing that a CTCC has been demonstrated to have. To investigate this, a test of capsular elasticity was carried out on pairs of eyes obtained from an eye bank, 42 eyes of 21 patients in total, using modified digital vernier calipers. One eye of each pair had a CTCC, the other a diathermy capsulorhexis (DC). The elasticity of the capsule in both groups was expressed by comparing the circumference of the capsulotomy at rest with its circumference at rupture. The mean capsular elasticity of the CTCC group was significantly greater than that of the DC group (p << 0.001). The capsular edge in both groups was examined using scanning electron microscopy, and the difference in morphology appears to be the source of the difference in elasticity.

Adolescent↗

The relationship between capsulorhexis size and anterior chamber depth relation.

BACKGROUND AND OBJECTIVE: To determine whether the diameter of the capsulorhexis has an effect on anterior chamber depth (ACD) following phacoemulsification surgery. PATIENTS AND METHODS: Fifty-one consecutive patients were selected for cataract extraction by phacoemulsification with intraocular lens (IOL) implantation. Twenty-two of 51 patients underwent 4 mm capsulorhexis, while the rest underwent 6 mm. All were implanted with a multi-piece polymethyl methacrylate posterior chamber IOL with 5.0 mm diameter biconvex optic and flexible haptic. They were followed 3 months postoperatively. The width of the capsulorhexis was assured according to the IOL optic implanted intraoperatively, and by the help of slit-lamp measurement after dilatation of the pupil on the first postoperative day. ACD and axial length (AL) of patients was obtained by ultrasonography on both the days before surgery, and the first and seventh postoperative days, and after 30, 60 and 90 days. RESULTS: Early significant increase of ACD and ACD/AL ratios were observed in only the 6 mm capsulorhexis group on the first day postoperatively (P = .012, and P = .018). On the 90th postoperative day, ACD increased significantly both in the 4 mm (P = .002) and the 6 mm capsulorhexis groups (P = .049) when compared to preoperative values. For the same period, meaningful increase in ACD/AL ratio in the eyes with both 4 mm and 6 mm capsulorhexis groups was also noted compared with preoperatively (P = .002 and P = .019). There was a statistical difference between the 90th day ACD values of 4 mm (3.73 +/- 0.32 mm, mean +/- standard deviation) and 6 mm capsulorhexis groups (3.50 +/- 0.33 mm) (P = .028). For the same period, ACD/AL ratio was also significantly different for both groups (0.152 +/- 0.01, and 0.142 +/- 0.01 respectively) (P = .004). The refractive error changes followed the ACD changes and showed meaningful differences between 1st and 90th days postoperative values of each group (P = .029, and P = .014, respectively). CONCLUSION: A 4 mm capsulorhexis results in a longer postoperative ACD than does a 6 mm capsulorhexis for the IOL type used in this study.

Adult↗

Capsulorhexis size and posterior capsule opacification.

PURPOSE: Posterior capsule opacification (PCO) after intraocular lens (IOL) implantation has a multifactored pathogenesis. Capsulorhexis and capsular bag implantation of a one-piece, biconvex poly(methyl methacrylate) (PMMA) IOL are likely to reduce the PCO incidence. This study was performed to determine whether an ideal capsulorhexis size able to reduce PCO incidence exists. METHODS: A retrospective study of 107 patients who had extracapsular cataract extraction with capsulorhexis and capsular bag IOL implantation was carried out. The PCO site (central, paracentral, and peripheral) and degree (mild, moderate, and severe) were evaluated in relation to the capsulorhexis edge location relative to the IOL optic. Slitlamp biomicroscopy and photography and examination with a three-mirror Goldmann lens were performed. Patients were divided into three groups. Group 1: capsulorhexis free edge located on the IOL optic for 360 degrees; Group 2: capsulorhexis free edge located asymmetrically on and peripherally to the IOL optic; Group 3: capsulorhexis free edge located peripherally to IOL optic for 360 degrees. Each group was divided into two subgroups; one received polyHema IOLs and the second, PMMA IOLs. RESULTS: In Groups 1 and 2, the capsular transparency was higher than in Group 3 (P < .04). Central opacification percentage was lower in Group 1 than in Groups 2 and 3 (P < .04). No statistically significant differences between the polyHema and the PMMA subgroups were seen. CONCLUSIONS: Capsulorhexis with a slightly smaller diameter than the IOL optic appears to be better than a large-size capsulorhexis in reducing the incidence of PCO.

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The effect of capsulorhexis size on development of posterior capsule opacification: small (4.5 to 5.0 mm) versus large (6.0 to 7.0 mm).

PURPOSE: The most common surgically related cause of reduced vision after extracapsular cataract extraction is posterior capsule opacification (PCO), which occurs in up to 50% of eyes following cataract extraction. This study examined whether small capsulorhexes of 4.5 to 5.0 mm, which lie completely on the 5.5 mm intraocular lens (IOL), and large capsulorhexes of 6.0 to 7.0 mm, which lie completely off the lens optic, are effective in preventing PCO development. METHODS: In this prospective study, 496 eyes of 367 patients underwent standardized phacoemulsification with capsulorhexis and capsular bag foldable acrylic IOL implantation. The patients were randomly assigned to receive either a small capsulorhexis of 4.5 to 5 mm to lie completely on the IOL optic or a large capsulorhexis of 6 to 7 mm to lie completely off the lens optic. Retroillumination photographs were taken at 6 months and then yearly. RESULTS: Throughout the follow-up, there was less PCO in the small capsulorhexis group than in the large capsulorhexis group. CONCLUSIONS.:Small capsulorhexes were associated with less wrinkling of the posterior capsule and less PCO than were large capsulorhexes. PCO after IOL implantation has a multifactored pathogenesis. Small (4.5 to 5.0 mm) capsulorhexis and capsular bag implantation of 5.5 mm acrylic IOL are likely to reduce the PCO incidence when compared with the 6.0 to 7.0 mm capsulorhexis. The significance of the IOL optic diameter in association with the capsulorhexis size should also be documented by further studies.

Aged↗

Capsulorhexis ovaling and capsular bag stretch after rigid and foldable intraocular lens implantation: experimental study in pediatric human eyes.

PURPOSE: To compare the amount of capsulorhexis ovaling and capsular bag stretch produced by various intraocular lenses (IOLs) implanted in pediatric human eyes obtained post-mortem. SETTING: David J. Apple, MD Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, Salt Lake City, Utah, USA. METHODS: In this nonrandomized comparative study, 16 pediatric human eyes obtained postmortem were divided into 2 groups: Eight eyes were obtained from children younger than 2 years (Group A), and 8 eyes were obtained from children older than 2 years (Group B). All eyes were prepared according to the Miyake-Apple posterior video technique. Six types of rigid and foldable posterior chamber IOLs manufactured from poly(methyl methacrylate) (single-piece), silicone (plate and loop haptics), and hydrophobic acrylic (single-piece and 3-piece AcrySof, Alcon Laboratories) biomaterials were implanted. The capsulorhexis opening and capsular bag diameters were measured before IOL implantation and after in-the-bag IOL fixation with the haptics (or the main axis) at the 3 to 9 o'clock meridian. The percentage of ovaling of the capsulorhexis opening was calculated by noting the difference in the opening's horizontal diameter before and after IOL implantation. The percentage of capsular bag stretch was also calculated by noting the difference in the horizontal capsular bag diameter before and after IOL implantation. RESULTS: All IOLs produced ovaling of the capsulorhexis opening and stretching of the capsular bag parallel to the IOL haptics. There were significant differences in capsulorhexis ovaling and capsular bag stretch (P<.001, analysis of variance) between the 6 IOL types in each group of eyes. The postimplantation difference was significant only between the single-piece hydrophobic acrylic IOL (AcrySof) and the other IOLs. The single-piece hydrophobic acrylic IOL was associated with significantly less capsulorhexis ovaling and capsular bag stretch in both groups (mean 12.06% +/- 0.59% [SD] and 7.6% +/- 1.47%, respectively). CONCLUSIONS: Modern rigid and foldable IOLs designed for the adult population implanted in the capsular bag of infants and children produced variable degrees of capsulorhexis ovaling and capsular bag stretch. The Miyake-Apple posterior video technique confirmed the well-maintained configuration of the capsular bag (with minimal ovaling) after implantation of a single-piece hydrophobic acrylic IOL because of its flexible haptic design.

Capsulorhexis↗

Effect of capsulorhexis size on postoperative intraocular pressure.

OBJECTIVE: To determine whether capsulorhexis diameter has an effect on intraocular pressure (IOP) after phacoemulsification. SETTING: SSK Ankara Eye Hospital, Ankara, Turkey. METHODS: This prospective study comprised 58 patients selected for cataract extraction by phacoemulsification using a 5.2 mm temporal, clear corneal incision. Twenty-nine of 58 patients had a 4.0 mm capsulorhexis and the rest, 6.0 mm. All patients received a multipiece poly(methyl methacrylate) posterior chamber intraocular lens with a 5.0 mm diameter bioconvex optic and flexible haptics. Follow-up was 3 months. Postoperative IOP was obtained by Goldmann applanation tonometry 1 and 2 days before surgery and 1 and 7 days and 1, 2, and 3 months postoperatively. RESULTS: A significant decrease in IOP was observed in both the 4.0 and 6.0 mm capsulorhexis groups 1 day postoperatively (P < .0001 and P < .0001, respectively). At 3 months postoperatively, IOP decreased significantly over preoperative values both in the 4.0 mm (P < .0001) and 6.0 mm capsulorhexis (P = .0014) groups. There was a statistical difference between the mean 1 month IOP values in the 4.0 mm (11.34 +/- 2.18 mm Hg [SD]) and 6.0 mm capsulorhexis (13.00 +/- 2.30 mm Hg) groups (P = .0059). A statistical difference between the groups also existed at 3 months postoperatively (P = .0028). CONCLUSION: A 4.0 mm capsulorhexis resulted in lower postoperative IOP than a 6.0 mm capsulorhexis 1 month postoperatively.

Adult↗

Closed chamber globe stabilization and needle capsulorhexis using irrigation hand piece of bimanual irrigation and aspiration system.

BACKGROUND: The prerequisites for a good capsulorhexis include a deep, well maintained anterior chamber, globe stabilization and globe manipulation. This helps to achieve a capsulorhexis of optimal size, shape and obtain the best possible position for a red glow under retroillumination. We report the use of irrigation handpiece of bimanual irrigation aspiration system to stabilize the globe, maintain a deep anterior chamber and manipulate the globe to a position of optimal red reflex during needle capsulorhexis in phacoemulsification. METHODS: Two side ports are made with 20 G MVR 'V' lance knife (Alcon, USA). The irrigation handpiece with irrigation on is introduced into the anterior chamber through one side port and the 26-G cystitome (made from 26-G needle) is introduced through the other. The capsolurhexis is completed with the needle. RESULTS: Needle capsulorhexis with this technique was used in 30 cases of uncomplicated immature senile cataracts. 10 cases were done under peribulbar anaesthesia and 20 under topical anaesthesia. A complete capsulorhexis was achieved in all cases. CONCLUSION: The irrigating handpiece maintains deep anterior chamber, stabilizes the globe, facilitates pupillary dilatation, and helps in maintaining the eye in the position with optimal red reflex during needle capsulorhexis. This technique is a safe and effective way to perform needle capsulorhexis.

Capsulorhexis↗

[Original technique of double capsulorhexis].

The current endophako technique with posterior scleral tunnel incision requires perfect continuous curvi-linear capsulorhexis. A rupture in the capsulorhexis ring may produce a posterior capsular tear. An excessively large anterior capsular residue will lead to purse-string fibrosis. The original surgical technique of double circular capsulorhexis resolve these two points. This technique allows a small capsulorhexis (diameter about 4 millimeters), reproductibility in spite of difficult surgical cases (hypertonia, poor visibility); it avoids tearing the anterior capsular edge to the zonula. A second capsulorhexis at the end of the operation, exactly following the optic zone of the intra-ocular implant, helps to guide healing of the anterior capsular edge, reducing fibrosis and avoiding purse-string fibrosis. The double capsulorhexis technique allows a double security: during surgery: it ensures a safe reproducible capsulorhexis; after surgery: the guided ablation of the large anterior capsular residue allows better long-term retinal follow up.

Humans↗

Removal of lens epithelial cells and the effect on capsulorhexis size.

PURPOSE: To assess the long-term effects of lens epithelial cell (LEC) removal on capsulorhexis opening size. SETTING: Dorset County Hospital, Dorchester, United Kingdom. METHODS: This prospective randomized control study included 39 eyes of 38 patients. Twenty eyes were selected randomly for removal of LECs from the anterior capsule as part of routine cataract operation comprising phacoemulsification with intraocular lens (IOL) implantation. The other 19 eyes were used as controls in which the LECs were not removed. All surgeries were performed by 1 surgeon (A.T.). All patients had silicone IOL (Allergan SI-40) implantation. The capsulorhexis opening size was determined immediately after surgery and 2 weeks and 6 months after surgery. Data on treatment outcome of the cataract surgery were analyzed statistically. RESULTS: Six months postoperatively, the size of the capsulorhexis had statistically significant increased in the study group that had LECs removed (mean increase 1.07 +/- 1.70 mm(2); paired Student t test P=.01), whereas the capsulorhexis size had statistically significant decreased in the control group (mean decrease -3.38 +/- 2.37 mm(2); paired Student t test, P<.0001). The difference in changes in the capsulorhexis areas between the 2 groups was also highly statistically significant (independent-sample Student t test, P<.0001). CONCLUSION: Removal of anterior subcapsular LECs by aspiration helped maintain the size of the capsulorhexis opening and thus can help prevent capsule contraction syndrome.

Aged↗

Effect of lens epithelial cell aspiration on postoperative capsulorhexis contraction with the use of the AcrySof intraocular lens: randomized clinical trial.

PURPOSE: To determine whether aspiration of lens epithelial cells (LECs) from under the anterior capsule reduces postoperative contraction of the capsulorhexis aperture. SETTING: Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, United Kingdom. METHODS: This prospective randomized observer-masked study comprised 100 patients who had routine phacoemulsification by the same surgeon at a district general hospital in the United Kingdom. The postoperative changes in capsulorhexis apertures and anterior capsule opacification (ACO) between Group A (aspiration of LECs) and Group B (control) were compared. Digital retroillumination images of the capsulorhexis aperture were taken 1 week and 3 months postoperatively. The area of capsulorhexis aperture was determined with computer software, and capsule opacification was graded subjectively. RESULTS: Three months postoperatively, the mean decrease in capsulorhexis aperture was 1.9% in Group A and 5.6% in Group B (P = .02). The ACO at 3 months was grade 2 in 44% of eyes in Group A and in 61% in Group B (P = .13). CONCLUSION: Aspiration of LECs from the anterior capsule was a safe procedure that reduced capsulorhexis aperture contraction 3 months after cataract surgery.

Acrylic Resins↗

The effect of capsulorhexis size on posterior capsular opacification: one-year results of a randomized prospective trial.

PURPOSE: Posterior capsular opacification is the most common surgically related cause of reduced vision after cataract surgery. We studied the effect of capsulorhexis size on the pattern and severity of posterior capsular opacification. METHODS: In this prospective study 75 patients underwent standardized phacoemulsification with capsulorhexis and in-the-bag placement of a 5.5-mm polymethylmethacrylate intraocular lens implant. The patients were randomly assigned to receive either a small capsulorhexis of 4.5 to 5 mm to lie completely on the intraocular lens optic or a large capsulorhexis of 6 to 7 mm to lie completely off the lens optic. Patients were examined at days 1, 14, 30, 90, and 180 and at year 1 with logMAR visual acuity assessment, Pelli-Robson contrast sensitivity testing, anterior chamber flare and cell measurement, and high-resolution digital retroillumination imaging of the posterior capsule. The pattern of posterior capsular opacification was determined, and the percentage area of posterior capsular opacification was calculated for each image with dedicated image analysis software. RESULTS: Large capsulorhexes were associated with significantly more wrinkling of the posterior capsule and worse posterior capsular opacification than small capsulorhexes. At 1 year the average percentage area of posterior capsular opacification was 32.7% for small capsulorhexes (95% confidence interval, 19.8 to 45.6) and 66.2% for large capsulorhexes (95% confidence interval, 57.7 to 74.6) (P = .0001). The patients with large capsulorhexes had significantly poorer visual acuities and a trend toward worse contrast sensitivities. CONCLUSION: This study demonstrated significantly greater wrinkling and opacification of the posterior capsule and worse visual acuity with large capsulorhexes than with small capsulorhexes. In cataract surgery with a polymethylmethacrylate intraocular lens, a small capsulorhexis with the edge completely on the surface of the implant is preferable to a large capsulorhexis in reducing posterior capsular opacification.

Aged↗

Posterior capsulorhexis in adult eyes with intact and clear capsules.

PURPOSE: To evaluate the feasibility and risks of primary posterior capsulorhexis. SETTING: Department of Ophthalmology, University Hospital of Liège, Belgium. METHODS: Retrospective analysis of 319 patients with cataracts who had phacoemulsification or manual extracapsular cataract extraction with a simultaneous circular posterior capsulorhexis between August 1993 and April 1994. The number of intraoperative complications and the number of postoperative complications that could be related to the posterior capsule opening were looked at. Fluorescein angiography was performed in a random sample of patients. RESULTS: Twelve intraoperative complications consisted of 5 irregular tears, 4 vitreous prolapses into the posterior capsulorhexis, and 3 vitreous prolapses into the anterior chamber; 11 occurred in eyes with positive posterior pressure. Postoperative complications consisted of 3 vitreous prolapses into the pupil and 1 retinal detachment. Two of the 3 late vitreous prolapses occurred in eyes in which the posterior capsulorhexis was larger than the intraocular lens (IOL) optic. The retinal detachment occurred in an eye with a 25.79 mm axial length. Fluorescein angiography of 49 cases revealed 3 with cystoid macular edema. CONCLUSIONS: Based on our results, we believe that primary posterior capsulorhexis can be a routine procedure during cataract surgery and IOL implantation in adults, except in cases of positive pressure. The diameter of the posterior capsulorhexis should be smaller than the diameter of the IOL optic.

Adult↗

[Elasticity of capsulorhexis in the animal model].

A special caliper was designed to determine the stretching capacity of a circular capsulorhexis allowing measurements in 0.02 mm increments. A small capsulorhexis 4.5-6.0 mm in diameter could be stretched 2.7 times; a large capsulorhexis 6.5-8.0 mm in diameter was stretched 2.6 times the original diameter. A smooth circular capsulorhexis is very strong and stabile but also has significant stretching capacity. In a small capsulorhexis, there is the danger that zonular fiber defects or posterior capsular rupture may occur during manual expression, of the nucleus. A large capsulorhexis is more suitable for manual nucleus delivery.

Animals↗

[Histological observation of anterior capsular edges produced by continuous curvilinear and diathermy capsulorhexis].

Radiofrequency endodiathermy capsulorhexis (DC) is a new method for anterior capsulorhexis in cataract surgery. DC may confer some advantages over continuous curvilinear capsulorhexis(CCC) in certain clinical situations. The elasticity of capsulorhexis produced by DC and the proper diathermy time are still unclear. Histological examination of rabbit lenses, on which a variety of coagulation times (0.5 to 5.0 sec) were tested revealed that 0.5 sec was long enough to coagulate the anterior capsule and that the longer coagulation extend the tissue damage into the deeper cortex. Small capsulorhexis (3.5 mm in diameter) produced experimentally with DC showed less elasticity than that produced with CCC when the edge of the capsulorhexis was pulled. Thus the heat coagulation of the capsular edge produced by DC results in less elasticity than that produced by CCC.

Animals↗

Trypan blue capsular staining to "find" the leading edge of a "lost" capsulorhexis.

PURPOSE: To describe an effective surgical technique to visualize an obscured leading edge of a capsulorhexis. DESIGN: Prospective, interventional case series. METHODS: In six eyes of six patients in which the capsulorhexis was started but could no longer be seen during surgery, the anterior chamber was irrigated to remove all viscoelastic, and 0.3-ml trypan blue 0.06% was applied onto the anterior lens capsule to stain and visualize the leading edge of the capsulorhexis. RESULTS: In all patients, the leading edge of the capsulorhexis was quickly visualized by using the dye. No adverse reactions were observed up to 1 year after surgery. CONCLUSION: Trypan blue staining of the anterior lens capsule is an effective and apparently safe technique to "find" a "lost" capsulorhexis during surgery.

Capsulorhexis↗

Bimanual Sinskey hook technique to enlarge a preexisting capsulorhexis.

We describe a technique of enlarging a small primary capsulorhexis. Two Sinskey hooks are introduced through the side ports. One hook is placed above the anterior capsulorhexis margin with its tip pointing down, and the other is placed beneath the anterior capsulorhexis margin with its tip pointing up. A small nick is made between the tips of the 2 hooks, and the capsulorhexis is extended with a Utrata capsulorhexis forceps. This technique does not require additional instrumentation, impart zonular stress, or disturb wound architecture or integrity.

Capsulorhexis↗

Post-operative changes in the capsulorhexis aperture: a prospective, randomised comparison between loop and plate haptic silicone intraocular lenses.

PURPOSE: There is disagreement regarding whether the capsulorhexis aperture always decreases or may increase post-operatively. The aim of this study was to settle the controversy concerning loop haptic silicone lenses and to learn more of the dynamics of the capsulorhexis relating to plate haptic lenses. METHODS: We performed a prospective randomised study comparing the post-operative changes in capsulorhexis aperture in two groups of eyes implanted with either plate or loop haptic silicone intraocular lenses. All the surgery was performed, at a teaching hospital in the United Kingdom, by a single surgeon, using a standard technique of phacoemulsification. Patients were reviewed at 2 weeks and 6 months post-operatively. Digital retroillumination images of the anterior segment were captured. The area of the capsulorhexis aperture was determined by manually detecting its edge on a computer monitor. RESULTS: Forty-eight cases were randomised. The groups were comparable for demographic variables and mean initial aperture size (p > 0.05). There was an 8.4% mean decrease in aperture size for the loop haptics, contrasting with 4.5% expansion for the plate haptics (p < 0.05). Sixty-five per cent of patients with the plate haptic underwent enlargement of the aperture, contrasting with 25% for the loop haptic lens (p < 0.05). CONCLUSIONS: Silicone lenses with plate haptics undergo expansion of the capsulorhexis aperture more frequently than those with Prolene loop haptics.

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