Using automated capsulotomy in complicated cataract surgeries


Automated capsulotomy is a new option that surgeons can choose for patients with opaque corneas, as well as when performing an open sky rhexis during the triple procedure and during surgery that requires the use of premium or multifocal lenses.

Performing a manual capsulorhexis, although requiring skill, does not always result in a perfectly round opening in the capsule. Often, a slightly oval capsulotomy is not a major issue. However, there are instances where this is not the case and a perfectly circular capsulorhexis is required.


Indeed, the use of multifocal and toric lenses necessitates a perfectly round and well centred capsulotomy. In other incidences, such as opaque corneas or white milky hypermature cataracts, creating a rhexis can become challenging due to poor visibility or high intracapsular pressure.


Handheld procedure

A new option available to surgeons is automated capsulotomy. In my practice, we use a handheld device specifically designed for automated, rapid and precise capsulotomies during cataract surgery (Zepto; Mynosys Cellular Devices Inc.).1


It is important to try to adapt the surgical techniques according to the patient’s needs. I am often asked in what situation might I prefer to perform an automated capsulotomy, to which my answer would be for patients with opaque corneas.


An opaque cornea presents several challenges to the surgeon with regards to cataract surgery. For example, in such cases, patients cannot be safely and predictably treated either manually or by femtosecond laser-assisted cataract surgery, which requires a transparent cornea.


Instead, this device can be placed beneath the cornea almost by feeling, which is especially beneficial when visibility is impaired. Using precision pulse technology also ensures the tear strength of the capsulotomy edge is high. This, in turn, is quite beneficial for white intumescent cataracts.


The automated rhexis is performed in such a fast manner that there is virtually no risk of an Argentinian flag sign, while neither high viscosity ocular viscoelastic devices nor capsular staining is required. In fact, it has been shown to be up to four times stronger than if the capsulotomy was performed manually or by laser.1


I also found automated capsulotomy to be an asset when performing an open sky rhexis during the triple procedure (combined keratoplasty, cataract extraction and IOL implantation).


Surgery which requires the use of premium or multifocal lenses is another candidate for automated capsulotomy. Particularly as a poorly created capsulotomy can lead to the lens decentration with debilitating visual symptoms.


Around 10% of the work carried out in my surgery equates to premium lenses and integrating an automated capsulotomy device means I can offer premium surgery with a minimal expense compared with a femtosecond laser. In terms of space, the console can be very compact so there is also no added commitment for space.


Finally, the ease of use of an automated capsulotomy device is particularly appealing to less experienced or novel surgeons, as well as those who thrive for perfectionism in every single case performed.




1. Waltz K, Thompson VM and Quesada G. Precision pulse capsulotomy: Initial clinical experience in simple and challenging cataract surgery cases. J Cataract Refract Sur. 2017;43:606-614.


Professor Walter Sekundo, MD, PhD


Professor Sekundo is the chairman of the Department of Ophthalmology of the University Eye Clinic Marburg. He is also a university professor of Ophthalmology at the Philipps University of Marburg. Prof. Sekundo has no financial interest in the products cited in the article.



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