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The capsular tension ring (CTR) was first described in by Hara and coauthors (). They named it an “equator ring”, designed to maintain the circular.
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Fine has a long list of indications for CTRs: When there are more than eight incisions, the surgeon was trying to achieve maximal effect, and the zonules are now weak in many of those eyes. So we use CTRs in all cases just to be sure. We also use CTRs in all eyes longer than 27 mm, where there is a tendency to weaken the zonules with cataract surgery.

Otherwise we would have implanted thousands of rings for naught.

Primochill CTR Phase II Product Overview/How To

He recalled cases where a ring was accidentally placed into the anterior chamber, another ring fractured, and another went through the capsular bag. Osher did stress that while not every case of weak zonules requires a CTR, having the CTR available is imperative when performing any phaco procedure because one never knows when a zonular problem will be encountered.

Surgeons should always hold off until you have to put it in. Rosenthal has developed a technique that obviates the risk of cortex entrapment. A retentive viscoelastic is then placed within the capsular bag, which displaces the nucleus and any leftover cortical fibers posteriorly. Fine, on the other hand, maintains that a ring should be placed right away, before doing phacoemulsification and as soon as hydrodissection is completed.

We use a Lester hook and a second hook 90 degrees away, which allows us to neutralize the forces on the capsule during implantation of the ring. We can then inject the ring toward the zonular weakness. While contention swirls around CTRs, all of these surgeons stressed the value of having this device available in their practice.


Henderson CTR

Fine, who cited statistics in which 17 percent of patients with compromised zonular integrity who underwent surgery without a ring required reintervention. Yet they are a very valuable tool. Masket reports no related financial interests. Fine is a medical monitor for Morcher. Osher is a consultant with Alcon and AMO. Rosenthal has received travel assistance from Ophtec and AMO. Cataract Innovations News in Review: Vyzulta and Rhopressa Academy Notebook: News, Tips, Resources Clinical Update: Get Ready for Chicago Morning Rounds: Richard Mills' Opinions, Lori Baker Schena, Contributing Writer.

This article is from March and may contain outdated material. Originals Followed by Innovations Two manufacturers originally introduced rings to the market. The purpose of our study was to evaluate the frequency, indications, and clinical outcome of CTR implantation in a large series of consecutive cataract surgical cases performed during the years through in our institution.

Superior, either a sclerocorneal or a clear corneal incision, was created using a diamond blade followed by a 2. For cataract surgery of mature cataracts, Trypan blue vision blue, DORC, Netherlands was used to enhance visualization of the anterior lens capsule. Capsulotomy was performed using a 25 gauge needle. After hydrodissection cataract extraction was performed using the divide and conquer technique.

We retrospectively reviewed the cataract database of the Department of Ophthalmology, Ludwig-Maximilians-University, Munich for records indicating implantation of a CTR. Since the first documented implantation of a CTR in our institution, all subsequent records were screened for indication of a CTR implantation, and subsequently clinical outcome was analyzed.


Specific indications included zonulolysis or posterior capsular rupture. In case of a zonulolysis, exogenous trauma, prior pars-plana-vitrectomy with silicone oil tamponade , or endogenous pseudoexfoliation syndrome, Marfan syndrome causes were distinguished. The decision to insert the CTR was made intraoperatively when loose zonules where apparent during capsulorhexis or phacoemulsification, or when a posterior capsular rupture occurred.

In case of a posterior capsular rupture, an anterior vitrectomy was performed. Our surgeons mainly used phacoemulsification to extract the cataract; a planned extracapsular cataract extraction was performed only twice. In all cases, the CTR was inserted with a special shooter. If accidental displacement into the vitreous occurred during the procedure, the CTR was removed. The main clinical outcome measurement was a possible PCIOL-implantation with differentiation between implantation in the capsular bag or the ciliary sulcus. In addition, the position of the intraocular lens was noted.

In case of IOL subluxation or dislocation, the clinical symptoms eg, monocular double vision were evaluated. During the period of review of 5 years, cataract surgeries were performed in our department. In 69 of these surgeries 67 patients a CTR was implanted Table 1.

EYEJET™ Capsular Tension Ring (CTR) from FCI Ophthalmics Inc.

The mean age was 62 years with a range from 22 to years. The range of follow up was between one and three years. The indications for CTR implantation were as follows: In 23 eyes, a zonular rupture occured during cataract surgery itself. In the remaining 11 eyes, no underlying predisposition could be identified before surgery. Most likely in these cases the zonulolysis occured during the procedure.

EYEJET™ Capsular Tension Ring (CTR) from FCI Ophthalmics Inc. - Product Description and Details

In one eye IOL implantation into capsular bag or ciliary sulcus was not possible due to extensive zonulolysis. Both of these eyes received an anterior chamber IOL. However none of these patients complained of any symptoms such as monocular diplopia and the decentration was stable and did not progress further during follow up.

The present study was performed to address two subjects: First, to evaluate the frequency of CTR implantation in a large consecutive series of cataract surgeries. Second, to investigate whether an anatomically reasonable outcome could be reached by the insertion of a CTR in a variety of complicated cataract surgeries. Final visual outcome was not investigated in our study as the group of patients investigated was rather heterogenous with a large spectrum of additional diseases such as macular degeneration and diabetic retinopathy that would have significantly biased any evaluation of functional outcome.

Therefore, the present study aimed at an anatomical or morphological evaluation of the surgical results and focused on the applicability of CTR implantation during cataract surgery. Since the first insertion of a CTR in our institution, cataract surgeries have been performed during the following period of 5 years. Despite the fact that predominantly severe forms of cataracts and complicated cases are relatively frequent in our tertiary care center university setting, only relatively few cases 0.

Like other authors Menapace et al ; Gimbel and Sun , our surgeons inserted the CTR as soon as zonular weekness was seen intraoperatively, for example before or after hydrodissection and prior to phacoemulsification or after complete phacoemulsification and prior to PCIOL insertion. In our series one highly myopic eye was left without IOL. The CTR helps in these cases to maintain the circular contour of the capsular bag and the shape of the continuous circular capsulorhexis Sun and Gimbel Thus, folds in the posterior capsular bag are minimized.

The only postoperative complication found in our series was minor PCIOL decentration noted biomicroscopically during follow up, but no subjective visual symptoms were noted by the patients. Because this was a retrospective chart review we were unable to determine whether the same results would have been reached without CTR implantation.

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At the moment several clinical studies are also attempting to investigate if routine CTR insertion is reasonable to prevent capsular shrinkage and posterior capsule opacification Strenn et al ; Nishi et al , ; Dick and Schwenn ; Faschinger and Eckhardt ; Sudhir and Rao ; Waheed et al Since the invention of the capsular tension ring in , many authors have reported its advantages in anterior segment surgery. Our results in this large series over a relatively long period of time confirm that CTR implantation is a useful device for cataract surgery in selected cases with difficult pre- or intraoperative conditions Figure 2.


A weakness of the present study is the retrospective nature and the lack of a control group. Obviously, only a prospective randomized study could further elucidate whether the same clincial outcome eg, possibility of PCIOL implantation could be achieved without prior implantation of a CTR. However, the following aspects should be considered in this context: First, based on our study with a frequency of CTR implantation of 0. Second, the decision whether to implant a CTR or not is usually made during surgery; this approach interferes with a prospective randomized study setting.

Third, patients would have to give their informed consent prior to surgery allowing for the randomized non- use of a CTR even in the event of complicated surgery. In the absence of such a randomized study to the best of our knowledge our experience represents the largest series of consecutive cataract surgeries that was evaluated for implantation of a CTR.