How to Insert a Capsular Tension Ring (CTR) in the Capsular Bag
In this guide, you’ll learn how to maneuver a capsular tension ring (CTR) safely and effectively. The CTR has significant memory, which can potentially damage ocular structures if not handled with precision. Therefore, controlled and deliberate movements are essential.
Step 1: Preparing the Capsular Bag
Before inserting the CTR, apply viscoelastic, preferably a cohesive viscoelastic, into the capsular bag. This step helps protect the corneal endothelium and provides the necessary space for safe manipulation.
Step 2: Positioning the Injector
- Hold the CTR injector with the correct hand positioning.
- Insert the injector into the anterior chamber at the proper angle.
- Ensure the haptic exit direction is oriented correctly—the leading edge of the CTR should be positioned for smooth delivery.
Step 3: Inserting the CTR
- Use the second hand to assist in guiding the CTR.
- Grip the CTR at the designated hole using forceps.
- Gently advance the CTR while maintaining control.
- Ensure the initial contact with the weakened zonules is soft and controlled to avoid excessive stress.
- Complete the insertion smoothly to prevent sudden pressure on the capsular bag.
Step 4: Managing the Cortex After CTR Placement
Once the CTR is in place, you need to remove the cortical material:
- Use irrigation and aspiration (I/A) at a low vacuum setting (≈200 mmHg) to minimize stress on the zonules.
- Work manually and carefully when approaching the cortex, particularly the equatorial cortex, which tends to remain attached due to the CTR.
- Use slight lateral movements to disengage the cortex without damaging the posterior capsule.
- Proceed gently and systematically, ensuring safe removal of all cortical material.
Step 5: Confirming CTR Placement
- Remove the aspirator and irrigator carefully.
- Verify that the zonules remain stable, with no unnecessary tension.
- Check for any tissue stress or injury.
- If necessary, use a hook-assisted technique to fine-tune the CTR’s position.
- Always review the time-lapse recording (if available) to confirm that the procedure was executed correctly.
Handling Special Scenarios
- One End of the CTR in the Sulcus
- Inject additional viscoelastic for protection.
- Use a Sinskey hook to gently reposition the misplaced segment into the capsular bag.
- The Entire CTR in the Sulcus
- Inject viscoelastic into the anterior chamber and capsular bag.
- Use one or two Sinskey hooks to carefully maneuver the CTR into the correct position.
- Advance the CTR partially and progressively to ensure smooth placement.
- Rotating the CTR into Position
- If necessary, apply rotational movements to guide the CTR fully into the capsular bag.
- Ensure the CTR sits securely and symmetrically within the bag to provide optimal support.
By mastering these techniques, you can effectively manage CTR insertion while preserving the integrity of the zonules and capsular bag.