Capsular Tension Rings:

Current Indications and Outcomes

Maryam Mokhtarzadeh, MD
Jayne S. Weiss, MD
John M. Ramocki, MD
No financial conflicts to disclose
Kresge Eye Institute
Detroit, Michigan

Background
A CTR is a 270 degree open PMMA ring placed
in the capsular bag during cataract surgery in
cases with zonular instability or weakness.
CTRs were introduced in 1991, used in Europe
since 1993, but were only approved by the U.S.
FDA in late 2003.
We asked: How has the introduction of CTRs
changed the surgical experience at KEI?

Purpose
To examine the history and use of capsular
tension rings among surgeons at an academic
center, specifically determining the indications
and results.

Methods
Retrospective chart review of all complex
cataract surgeries from 1/2005 to 5/2007 at KEI,
identified by billing code (66982)
Review of operating room logs from 1/2003 to
9/2007 to account for every CTR used at KEI
and the local VA since FDA approval.
Comparison of all CTR cases to a control group
consisting of all other complex cataract
surgeries.
The data was analyzed for uptake, indications,
and outcomes of CTR use.

Results
Use:
The first CTR was implanted at KEI in 10/2004
In the control group, 11 surgeons performed 254
cases coded as complex cataract surgeries.
In the experimental group, 8 of these surgeons
performed 58 cataract surgeries using CTRs.
The experimental group included every case
using CTRs that has been performed in the
history of the institutions studied.

Results
Indications:
The most commonly listed preoperative
indications for CTR placement were trauma
(22%) and pseudoexfoliation (17%).
Additional indications: prior intraocular surgery,
phacodonesis, subluxed lens, high myopia,
phacomorphic glaucoma, and phacolytic
glaucoma.
One third of patients in the experimental group
had no known preoperative indications for CTR
placement.

Results
Outcomes:
85% of control cases resulted in IOL placement
in the bag compared to 74% of CTR cases.
11% of control cases required anterior
vitrectomy compared to 27% of CTR cases.
CTRs were most frequently placed immediately
after completion of cortical removal
However, in cases where anterior vitrectomy
was performed, CTRs were more frequently
placed during phacoemulsification
There was a single incidence of posterior CTR
dislocation postoperatively which was
successfully removed by pars plana vitrectomy.

Results
Placement of IOL
Control

CTR Used

85%

74%

Results

Results (cont)
Surgical Timing of CTR Use
18
16
14

CTR+Anterior Vitrectomy
CTR+No Anterior Vitrectomy

12
10
8
6
4
2
0
Pre-Phaco

Post-Phaco
Mid-Phaco

Post-IA
Mid-IA

Unknown
Post-Lens

Discussion
Recently experience with CTRs has been
increasing rapidly; half of the cases in this study
were performed between 1/2007-9/2007.
In our patient population there are many
preoperative indications for CTR placement,
most common being trauma.
CTRs are often implanted in cases with no
known preoperative indications due to surgeon
preference or intraoperative discovery of zonular
instability.
Review of surgical boarding forms and consents
revealed that the decision to place CTRs is most
often made intraoperatively.

Discussion
Most CTRs are placed immediately after
removal of cortex is complete.
However, in cases requiring anterior vitrectomy,
CTRs are more often placed during
phacoemulsification.
There was a higher incidence of anterior
vitrectomy in the experimental group.
However, there was no statistically significant
difference between the percentages of cases
where an IOL could be successfully placed in
the capsular bag.
CTRs are being used effectively in difficult
cases.