“For right handed person which should be direction of rhexis, clockwise or anticlockwise?
I feel do have answer but still Smart members please enlighten! Which ever direction one is comfortable is “way out” answer.
dr. shekhar paranjpe
1. Please hold a pencil and draw several circles on a paper,clock and anti-clockwise. Please check which is more comfortable for your hand, and which circle is nicer. Than decide.
2. This decision is already taken by mother nature. As I have put in first post which ever direction one is more comfortable is “way out” answer. That may not be scientifically correct… but let others come out with any answer. I do have one answer which I feel is scientifically correct. But in the end I may turn out to be wrong…. but that is ok
3. Do smart incision it’s a good case to get zero cyl and excellent bifocality.
For right handed anticlockwise movement is pronation which is basically done by muscles of arm above wrist (That is the reason in our second year pharmac days we were taught to make liniment by pronation movement which is strong movement). While supination is by intrinsic muscles of hand where wrist and forearm movement is minimal. So hand is naturally more steady. Intrinsic muscles of hand are also called artists’ muscles. And supination is artistic movement.
Furthermore…..
all IOL confugeration is such that we dial (like telephone dial) iols by clockwise movement. (iol companies should manufacture iols for left handed surgeons where dialing should be anticlockwise.
Still one question remains unanswered….. why revered Professor Gimble who has pioneered capsulorhexis started doing it anticlockwise? i am ready for any explaination or accept if i am wrong in my analysis.
Amen. Dr. Shekhar Paranjpe
4. Thought of this explanation, but wanted to practically check during surgery.. however I observed my hands and most of the surgery, including CCC happened with fingers, than wrist at all..
I’m right handed, and always do rhexis anti-clockwise. Today tried doing clock-wise for the first time and didn’t find any difficulty.
All screws and screw able lids, by default are tightened by clockwise rotation.. Using the pronation motion which gives better power as the wrist pronators are stronger..
keep aside the first designer of screws….. when we drain the wet cloth by twisting by holding in both hands both hands make a pronation movement (try it)….. so this concept is eternally old
Basically CCC does not require strength. Secondly for CCC in any direction, half of the time you are pushing the flap away from you and half of the time you are pulling it towards you. The direction must be surgeon’s preference. My preference is counterclockwise. (In my previous post it was written vice versa by mistake).
There is a rule in physics, pulling is always easier than pushing!
In CCC it may be appearing to be pulling for half the circle and pushing in the other half of the circle. But the fact is the tip of the needle cystitome is always pulling on the flap while it is sliding the flap already dissected on the anterior capsule. This action has been previously described as shearing.
Physics or mechanics does not interfere with the clockwise or anticlockwise action in constructing a CCC.
I have been doing it anti-clockwise since ages! Initially I was doing it both the ways, but finally settled down to the anti clockwise action for I found that easier! Though, while writing a cipher I go clock-wise!
If there is anything regarding the embryology or the anatomy of the anterior capsule involved in this, I would request Dr. Ravindra and Rajiv to throw some light upon it.
Beginners must start rhexis with anti clock movement because the movement of rhexis will be more controlled as one is pulling rhexis towards oneself in the start unlike clock wise where movement is away from the body which has possibility of rhexis slipping to periphery due to more force.once your are an expert clock anticlockwise don’t matter
For the new players … run away rhexis must be diagnosed half a second earlier than where normal human beings will diagnose it, if you wish to play the game well. That half second and half mm separates the men from the boys.
Very practical thinking.. depressing the pars plicate area to relax zonules..
Will it work even if there is a zonule attached a little more anteriorly, as can happen while operating an young eye?
What is the best strategy if the rhexis goes beyond an anteriorly inserting zonule
RLE in a young high myope.. how many here are really comfortable. Operating a lens out of a myope in the older age group, compared to the younger lot.. Is safer. The volumetric changes due to replacement of thick crystalline lens with a thin iol causes a lot of changes in the vitreous body, base, peripheral retina area. Lesser elasticity, presence of pvd, lesser chance of pco in the older group offer the protection, not available in the youngsters. The RDs after myopic RLE are the worst to operate, due to poor visibility of the periphery, holes being very small and untracable and more than usual vitreous reaction, PVR etc..
Yes it’s a huge responsibility when one does lens exchange in young high myopes.we treat the Retina in advance and insist on yearly check ups.
If the rhexis goes beyond an anteriorly inserted zonules …prevention.i use high magnification and I always press the plicata to have complete control in these cases.
Saw the video. Very good. Very simple concept, no special instrument. Sometimes you really wonder why no one thought of this before? Similarly, after many years of extracapsular cataract extraction, two surgeons simultaneously thought of CCC (1991 I suppose). CCC again was a major revolution in cataract surgery, which can be done with a simple bent needle. Phaco got popularity only after the invention of CCC.
Guys the cornea keratoscopy concept is more important because it is used in every case. Only it is less easy to imagine.just trust me and use it learn it,and in few months each of your cases is better than any Phaco case in your region.
