Deviation between programmed and actual capsulotomy diameter in femtosecond laser–assisted cataract surgery: a clinical study of influencing factors and predictive modeling

Deviation between programmed and actual capsulotomy diameter in femtosecond laser–assisted cataract surgery: a clinical study of influencing factors and predictive modeling | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Deviation between programmed and actual capsulotomy diameter in femtosecond laser–assisted cataract surgery: a clinical study of influencing factors and predictive modeling Zhao Tan, Fei Yuan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7407175/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Dec, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 15 You are reading this latest preprint version Abstract Background Differences between actual and programmed capsulotomy diameter were found in femtosecond laser–assisted cataract surgery (FLACS). This study aimed to evaluate the deviation between the programmed capsulotomy diameter (PDC) and the actual capsulotomy diameter (ADC) in FLACS, identify the influencing factors, and establish a predictive model to improve the accuracy of capsulotomy size. Methods This prospective study included 47 eyes from 47 adult patients who underwent FLACS. The ADC was measured using Image Pro Plus version 6.0 based on intraoperative video images, and the diameter deviation of the capsulotomy (DDC) was calculated by subtracting the PDC from the ADC. Simple bivariate correlation and partial correlation analyses were performed to evaluate relationships between ADC or DDC and demographic as well as ocular biometric parameters. A stepwise multiple linear regression model was developed to predict ADC. Results The mean ADC (5.99 ± 0.34 mm) was significantly greater than the PDC (5.67 ± 0.15 mm, P < 0.001) in the overall cohort. The average DDC was 0.33 ± 0.31 mm, with 63.8% of eyes exhibiting a DDC greater than 0.20 mm. No significant difference in DDC was observed between the 5.5 mm and the 5.8 mm subgroups ( P = 0.732). Age showed a significant negative correlation with both ADC and DDC; after adjustment for ocular biometric variables, it remained the sole independent predictor of both parameters. A predictive model was constructed using age and PDC as independent variables: ADC = 2.531 − 0.011·Age + 0.741·PDC (F = 14.265, P < 0.001; adjusted R2 = 0.366, Durbin-Watson statistic = 2.294). Conclusion Significant differences were observed between PDC and ADC in adult patients. Age was found to be the most influential factor contributing to diameter deviations, possibly due to age-related changes in anterior capsule elasticity. The proposed regression model for ADC may assist surgeons in setting a more accurate and individualized capsulotomy diameter. femtosecond laser capsulotomy deviation diameter predictive model Figures Figure 1 Introduction For individuals with cataracts, surgery remains the only definitive treatment. Continuous curvilinear capsulorhexis (CCC), first introduced by Gimbel et al. ( 1 ) in 1990, has long been considered an essential procedure in cataract surgery. An ideal CCC is circular, well-centered, and slightly smaller than the intraocular lens (IOL) optic, with the anterior capsule edge completely covering the IOL optic. A well-constructed CCC facilitates subsequent surgical steps, ensures IOL centration and stability, and hinders the proliferation and migration of residual lens epithelial cells ( 2 – 4 ). In contrast, irregular, decentered, or improperly sized capsulorhexis can cause tilt, decentration, or longitudinal movement of the IOL ( 5 – 7 ) during capsular fibrosis and shrinkage. These changes may lead to refractive errors and increased higher-order aberrations ( 6 – 8 ), ultimately degrading visual quality, particularly in patients implanted with premium IOLs ( 9 ). Despite its importance, CCC remains one of the most challenging procedures in cataract surgery. Even experienced surgeons may struggle to achieve an optimal CCC every time. In 2009, the femtosecond laser technique was initially introduced into cataract surgery ( 10 ). Since then, numerous studies have demonstrated that femtosecond laser-assisted capsulotomy offers superior precision in achieving circularity and centration, and significantly reduces IOL tilt and decentration compared with manual capsulorhexis ( 11 – 16 ). Despite these advantages, clinical observations have revealed that the actual diameter of the capsulotomy (ADC) may not always match the programmed diameter of the capsulotomy (PDC) ( 17 ). This discrepancy between the ADC and PDC can affect the extent to which the anterior capsule overlaps the IOL optic. Inadequate overlap may compromise IOL stability, increasing the risk of tilt, decentration, and refractive errors, especially in patients implanted with functional IOLs. To address this issue, we aimed to identify potential factors influencing capsulotomy diameter deviation and to construct regression models that provide practical guidance for determining the target capsulotomy diameter during surgery, thereby enabling more accurate and individualized capsulotomy diameters. Methods This prospective case series was approved by the Medical Ethics Committee of Zhongshan Hospital Affiliated to Fudan University (B2023-313) and was conducted in accordance with the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants for the use of their clinical data in this study. Patient Population Patients who received femtosecond laser-assisted cataract surgery (FLACS) at the Department of Ophthalmology, Zhongshan Hospital, between March 2023 and October 2023 were consecutively enrolled. Inclusion criteria included a diagnosis of age-related cataract. Exclusion criteria included a history of intraocular surgery or ocular trauma. Patients with intraoperative complications such as anterior capsule tear, posterior capsule rupture, or significant intraoperative miosis that impaired visualization of the anterior capsule opening and IOL optic were also excluded. All participants received a comprehensive preoperative ophthalmic examination, including slit-lamp examination; dilated fundus examination; measurement of visual acuity; measurement of intraocular pressure (TX-20, Canon); endothelial cell density assessment (SP-1P, Topcon Medical Systems); optical biometry (IOL Master 700, Carl Zeiss Meditec AG); optical coherence tomography (OCT) (CIRRUS 5000, Carl Zeiss Meditec AG); and A/B-scan ultrasonography (AVISO, Quantel Medical). Surgical technique All surgical operations were conducted by an experienced cataract surgeon. Prior to surgery, patients received 0.1% pranoprofen and 0.5% levofloxacin eye drops for three consecutive days. On the day of surgery, a compound solution of 0.5% tropicamide and 0.5% phenylephrine was administered every 15 minutes until full dilation. Topical anesthesia was achieved with three applications of 0.5% proparacaine hydrochloride. A femtosecond laser platform (VICTUS Laser System, Bausch & Lomb) was used to perform the capsulotomy, lens fragmentation, and creation of clear corneal incisions. Clinically, the capsulotomy diameter is set slightly smaller than that of the IOL optic to ensure 360° overlap. For most commonly used IOLs with a 6.0 mm optic, a diameter of 5.0–5.5 mm is typically selected to achieve complete coverage. However, in certain situations, such as hard nuclear cataracts, cataracts coexisting with retinal disease, or the implantation of accommodating IOLs, a larger diameter may be preferred. In this study, capsulotomy diameters were set at 5.5 mm or 5.8 mm, based on the patients’ individual characteristics and the surgeon’s experience, to reflect real-world surgical decision-making. An eight-piece cross pattern was used for lens fragmentation. A 3.2-mm biplanar clear corneal main incision was created at 135°, and a 1.5-mm single-plane side-port incision was made at 15°. After completion of the laser treatment, patients were transferred to a sterile operating room for phacoemulsification (Centurion, Alcon Laboratories). All patients were implanted with a foldable posterior chamber IOL. All surgical procedures were video-recorded for subsequent analysis. Measurement Images in which the IOL optic and anterior capsule edge were clearly visible were extracted from the surgical videos. Image Pro Plus software, version 6.0, was used to measure ADC values, using the IOL optic diameter as a reference scale (Fig. 1 ). The diameter deviation of the capsulotomy (DDC) was calculated by subtracting the PDC from the ADC. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics version 26.0, and GraphPad Prism version 9 was used for graphical visualization. Continuous variables were expressed as mean ± standard deviation, and categorical variables as percentages. For normally distributed continuous data, paired t -tests were employed to compare PDC and ADC, whereas the Wilcoxon signed-rank test was applied for non-normally distributed data. Comparisons between the two PDC subgroups were conducted using independent-samples t-tests for normally distributed variables or the Mann–Whitney U test for non-normally distributed variables. Analysis of variance was used for comparisons among three or more groups, with post hoc pairwise comparisons adjusted by the Bonferroni method. Bivariate correlation analyses (Pearson or Spearman correlation tests, as appropriate) were used to assess the relationships between ocular biometric parameters and ADC or DDC. Partial correlation analyses were also conducted to adjust for potential confounding variables. Stepwise multiple linear regression analyses were performed, with ADC as the dependent variable and demographic or ocular biometric parameters as independent variables. A two-tailed P -value of < 0.05 was considered statistically significant. Results Characteristics Table 1 summarizes the demographic and ocular characteristics of the study population. A total of 47 participants (47 eyes) were enrolled, whose ages ranged from 32 to 92 years. Patients were classified into two subgroups according to PDC: 5.5 mm and 5.8 mm groups. Comparisons revealed no significant differences in age, axial length (AL), flat keratometry (K1), steep keratometry (K2), lens thickness (LT), anterior chamber depth (ACD), or white-to-white (WTW) measurements between the two groups (all P > 0.05; Table 2 ). Table 1 Study population characteristics Classification N = 47 Sex (F/M) 27/20 Eye (R/L) 23/24 Age (y) 72(60,83) AL (mm) 24.76(23.78,25.84) K1 43.68(42.44,44.18) K2 44.49(43.54,45.15) ACD (mm) 3.10 ± 0.48 LT (mm) 4.55 ± 0.51 WTW (mm) 11.69 ± 0.41 AL = axial length; ACD = anterior chamber depth; LT = lens thickness; WTW = white-to-white. Table 2 Characteristics of different PDC groups Classification 5.5 mm 5.8 mm statistics P Age (y) 70.48 ± 15.98 67.04 ± 15.35 t = 0.75 0.457 ACD (mm)(mm) 3.11 ± 0.43 3.09 ± 0.53 t = 0.19 0.849 LT (mm) 4.65 ± 0.47 4.47 ± 0.53 t = 1.24 0.222 WTW (mm)(mm) 11.73 ± 0.39 11.65 ± 0.44 t = 0.67 0.509 AL (mm) 25.99 ± 2.43 24.55 ± 1.80 Z = -1.94 0.053 K1 42.83 ± 2.21 43.50 ± 1.74 Z = -1.12 0.261 K2 43.86 ± 2.55 44.53 ± 1.96 Z = -1.13 0.257 ACD = anterior chamber depth; LT = lens thickness; WTW = white-to-white; AL = axial length. ADC Statistical analysis showed that ADC was significantly greater than PDC. In the overall cohort, the mean ADC was 5.99 ± 0.34 mm, compared with a mean PDC of 5.67 ± 0.15 mm ( Z = − 5.622, P < 0.001). A similar trend was observed in both subgroups: in the 5.5 mm group, the mean ADC was 5.85 ± 0.32 mm ( Z = − 3.945, P < 0.001), and in the 5.8 mm group, it was 6.11 ± 0.31 mm ( Z = − 4.078, P < 0.001). DDC The average DDC in the overall cohort was 0.33 ± 0.31 mm, with a range from − 0.25 mm to 1.22 mm. No statistically significant difference in DDC was found between the 5.5 mm and 5.8 mm subgroups (0.35 ± 0.32 mm vs. 0.31 ± 0.31 mm; Z = − 0.343, P = 0.732). Among all cases, 63.8% had a DDC greater than 0.20 mm, 29.8% had a DDC between 0 and 0.20 mm, and 6.4% had a DDC ≤ 0 mm. Influencing factors Simple bivariate correlation analyses showed that ADC was negatively correlated with age ( r s = -0.460, P = 0.001) and LT ( r = -0.402, P = 0.005). Similarly, DDC was negatively associated with age ( r s = -0.416, P = 0.004) and LT ( r s = -0.378, P = 0.009), but positively associated with AL ( r s = 0.475, P = 0.001) and ACD ( r s = 0.377, P = 0.009) (Table 3 ). Table 3 Correlation analysis of variables with ADC and DDC Variables ADC DDC r s P r s P AL (mm) 0.247 0.094 0.475 0.001* K1 0.154 0.301 0.120 0.421 K2 0.181 0.224 0.148 0.322 ACD (mm) 0.277 # 0.059 0.377 0.009* LT (mm) -0.402 # 0.005* -0.378 0.009* WTW (mm) -0.010 # 0.949 0.071 0.634 Age (y) -0.460 0.001* -0.416 0.004* # Pearson correlation analysis; *statistical significance. ACD = anterior chamber depth; AL = axial length; DDC = deviation of the diameter of the capsulotomy; LT = lens thickness; PDC = predicted diameter of capsulotomy; WTW = white-to-white. Partial correlation analyses further revealed that age remained the only independent factor significantly associated with both ADC ( r = -0.420, P = 0.003) and DDC ( r = -0.362, P = 0.012) after adjusting for AL, ACD, and LT. Table 4 summarizes the mean DDC across different age subgroups. Table 4 DDC in different age groups Age (y) N DDC (mm) 30–59 10 0.58 ± 0.39 60–69 13 0.35 ± 0.31 70–79 11 0.25 ± 0.18 ≥ 80 13 0.18 ± 0.21 statistics F = 4.324 P 0.009 DDC = diameter deviation of the capsulotomy. To predict ADC, a stepwise multiple linear regression model was developed. Age and PDC were identified as independent predictors of ADC, yielding the following equation: ADC = 2.531 − 0.011·Age + 0.741·PDC ( F = 14.265, P < 0.001; adjusted R 2 = 0.366, Durbin-Watson statistic = 2.294). Discussion Capsulorhexis is a critical step in cataract surgery since it influences the effective lens position (ELP) and the risk of posterior capsular opacification (PCO) ( 4 , 18 , 19 ). A 360° overlap of the anterior capsule edge over the IOL optic is associated with a reduced incidence of PCO and improved IOL centration and long-term stability ( 20 – 22 ). Hollick et al. ( 2 ) reported that large capsulorhexis (6.0–7.0 mm) without optic overlap resulted in a 66.2% incidence of PCO one year postoperatively, whereas smaller capsulorhexis (4.5–5.0 mm) with complete coverage of the IOL optic led to only 32.7%. Similarly, a significant correlation between ELP and the extent of anterior capsule coverage over the IOL optic was reported by Li et al ( 4 ). However, a capsulorhexis that is too small may result in excessive lens epithelial cell proliferation and anterior capsule shrinkage, thereby increasing the risk of anterior capsule contraction syndrome (ACCS) and potential IOL dislocation ( 23 ). To mitigate this risk, Joo et al. ( 24 ) suggested a capsulorhexis diameter of 5.5–6.0 mm. Conversely, an oversized capsulorhexis may fail to provide adequate overlap of the IOL optic, thereby diminishing the preventive effect against PCO ( 2 , 18 , 22 , 25 ). Furthermore, a capsulorhexis exceeding 6.5 mm may jeopardize the zonular attachment, threatening IOL stability. Irregular or decentered capsulorhexis may exert asymmetric forces on the IOL during anterior capsule contraction, resulting in IOL tilt and decentration ( 26 , 27 ). Therefore, an ideal capsulorhexis should be well-centered, circular, and appropriately sized. Taking into account various clinical factors, a diameter slightly smaller than the IOL optic is often preferred to ensure sufficient overlap and minimize capsular complications. For IOLs with a 6.0 mm optic, a capsulorhexis diameter of 5.0–5.5 mm is generally considered optimal to achieve an overlap of 0.25–0.5 mm between the edge of the anterior capsule opening and the IOL optic edge ( 28 ). However, in clinical practice, the capsulorhexis diameter may need to be adjusted based on individual patient characteristics. For instance, in cases of dense nuclear cataract, a slightly larger capsulorhexis may facilitate more efficient nucleus removal ( 29 ). In patients with coexisting retinal comorbidities, an enlarged capsulorhexis allows for better postoperative fundus examination. Additionally, for eyes receiving premium IOLs (e.g., multifocal or accommodating types), a larger capsulorhexis may be beneficial for optimal lens performance ( 30 ). In the era of refractive cataract surgery, both surgeons and patients are placing greater emphasis on achieving superior postoperative refractive outcomes. With the growing use of premium IOLs, which are more susceptible to tilt and decentration ( 5 , 9 , 31 ), increasing attention is directed toward the accuracy of capsulorhexis, particularly its diameter, to ensure optimal IOL positioning and performance. The femtosecond laser technique, characterized by high precision and reproducibility, significantly improves the accuracy of capsulotomy size compared with manual capsulorhexis ( 14 , 32 , 33 ). Schultz et al. ( 33 ) reported a minimal deviation (0.06 ± 0.03 mm) between the diameter of the capsule disk and the PDC. Nevertheless, the actual anterior opening size was found to be significantly larger than the PDC in pediatric patients undergoing FLACS ( 17 ), with a maximum DDC of 1.99 mm. Similarly, Luo et al. ( 34 ) demonstrated that ADC values were significantly greater than PDC in patients under 20 years of age; in their study, the DDC was 0.67 ± 0.04 mm in the 0–20-year-old group. Although the numerical differences between ADC and PDC are small, they may still affect IOL positioning and postoperative visual quality. Thus, achieving a predictable and stable capsulotomy diameter is essential for optimizing visual outcomes. In our study, we found a significant difference between ADC and PDC in adults, with a mean DDC of 0.33 ± 0.31 mm. This finding is inconsistent with the study by Luo et al. ( 34 ), who reported a high level of agreement between ADC and PDC in patients older than 20 years. Similarly, Akaishi et al. ( 35 ) reported minimal diameter deviations in adult patients, with an ADC of 5.30 ± 0.16 mm when the PDC was 5.30 mm. The discrepancy between studies may be attributable to differences in the preset PDC values: Luo et al. set the PDC at 5.2 mm, and Akaishi et al. set it at 5.3 mm, corresponding to the thickest region of the anterior capsule. Previous studies have shown that the thickest part of the anterior capsule lies in the midperipheral region ( 36 ), typically measuring around 5.25 mm in diameter ( 3 ). Performing the capsulotomy in this region may provide greater mechanical resistance and structural stability, potentially contributing to the reduced variation in the ADC. This may explain why no significant difference between ADC and PDC was observed when PDC was set around 5.25 mm. Correlation analysis revealed that age was significantly negatively associated with DDC, consistent with previous reports ( 17 , 34 ). Younger patients tended to exhibit greater deviation between the actual and programmed capsulotomy diameter, which may be explained by age-related changes in the biomechanical properties of the anterior capsule. The lens capsule, secreted by lens epithelial cells and composed primarily of hyaluronic acid and type IV collagen, becomes thicker and less elastic with age ( 36 ). This reduced elasticity may limit capsular distension after laser cutting and thus lead to smaller DDC in older individuals. Regarding ocular biometric parameters, Liao et al. ( 37 ) reported that, in pediatric cataract patients aged 2–6 years, AL was positively associated with the anterior capsulotomy enlargement index, whereas ACD was negatively associated with it. They proposed that a shallow anterior chamber may increase intracapsular pressure and anterior capsule tension, thereby contributing to capsulotomy enlargement. They further suggested that the influence of AL on the anterior capsulotomy diameter may be related to the laxity of the lens zonular fibers ( 37 ). Additionally, Luo et al. ( 34 ) reported a negative correlation between LT and DDC. In our study, AL, ACD, and LT were significantly correlated with DDC in simple bivariate analyses. However, after adjusting for age, none of these biometric parameters remained significantly associated with DDC, which highlights age as the dominant factor influencing capsulotomy diameter deviation. These findings suggest that ocular biometrics may interact with age to exert a combined moderate effect on capsulotomy diameter, but their individual influence diminishes once age is accounted for. Currently, the determination of PDC in clinical practice is largely empirical, and there are no established guidelines to ensure precise capsulotomy sizing. To support clinical decision-making in setting an appropriate PDC, we developed a multiple linear regression model that incorporates PDC and age as predictors for estimating ADC. This model provides a practical tool for preoperative planning, with the potential to minimize deviations in capsulotomy diameter. By improving the predictability of ADC, it may help ensure adequate anterior capsule–IOL overlap, thereby enhancing IOL stability and optimizing visual outcomes, particularly in patients receiving premium IOLs. Nonetheless, the current model is limited to adult populations, and external validation in larger, more diverse cohorts is warranted prior to widespread clinical implementation. In the present study, although most cases demonstrated an enlarged anterior capsulotomy opening, a small subset exhibited a reduced diameter. This finding indicates that factors beyond those captured in our regression model may influence ADC. One possible explanation is intraoperative repositioning of the anterior capsule: after lens extraction, the loss of lenticular support may cause the anterior capsule to shift toward the equatorial plane, moving the capsulotomy edge centripetally and thereby reducing the ADC. In addition, IOL implantation may stretch the capsular bag via its haptics, further modifying the final capsulotomy size. These biomechanical and intraoperative factors warrant further investigation to clarify their role in capsulotomy stability and predictability. In summary, while age and PDC emerged as primary predictors in our model, they may not fully account for all intraoperative influences on capsulotomy diameter. Future studies incorporating real-time anterior capsule dynamics and postoperative follow-up measurements could help refine predictive models and improve the accuracy and stability of femtosecond laser–assisted capsulotomy. This study has several limitations. First, the relatively small sample size may restrict the generalizability of the findings. Second, although various biometric and demographic variables were examined, the regression model exhibited only moderate explanatory power, suggesting that additional unmeasured factors may affect capsulotomy size. Finally, ADC was measured at a single time point; dynamic assessments of the capsulotomy size could provide deeper insights into the mechanisms underlying deviations and their contributing factors. Conclusion Significant differences between the actual and programmed capsulotomy diameters were observed in adult patients undergoing FLACS. Age was identified as the primary factor influencing DDC, likely reflecting age-related changes in anterior capsule elasticity. A stepwise multiple linear regression model incorporating age and PDC was developed to predict ADC. This predictive model may assist clinicians in achieving more precise capsulotomy size, thereby contributing to superior IOL position and visual outcomes. Abbreviations PDC: Programmed capsulotomy diameter ADC: Actual capsulotomy diameter DDC: Diameter deviation of the capsulotomy FLACS: Femtosecond laser–assisted cataract surgery CCC: Continuous curvilinear capsulorhexis IOL: Intraocular lens AL: axial length K1: flat keratometry K2: steep keratometry LT: lens thickness ACD: anterior chamber depth WTW: white-to-white ELP: Effective lens position PCO: Posterior capsular opacification ACCS: anterior capsule contraction syndrome Declarations Acknowledgements Not applicable. Authors’ contributions Z.T. and F.Y. designed the study. Z.T. collected the data, performed the statistical analysis, and drafted the manuscript. F.Y. revised it for important intellectual content. All authors read and approved the final version of the manuscript. Funding No financial support or grants were received for this study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate Ethical approval was obtained from the Medical Ethics Committee of Zhongshan Hospital, Fudan University (approval No. B2023-313). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants for both participation in the study and publication of their clinical data. Consent for publication Written informed consent was obtained from the patients for publication of the data. Competing interests The authors declare that they have no competing interests. Author details 1 Changsha Center for Disease Control and Prevention, Changsha 410004, China. 2 Department of Ophthalmology, Zhongshan Hospital, Fudan University, Shanghai 200032, China. *Corresponding Author: Fei Yuan E-mail: [email protected] ; [email protected] ORCID number: 000900031474406X References Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg. 1990;16(1):31-7. Hollick EJ, Spalton DJ, Meacock WR. The effect of capsulorhexis size on posterior capsular opacification: one-year results of a randomized prospective trial. Am J Ophthalmol. 1999;128(3):271-9. Packer M, Teuma EV, Glasser A, Bott S. Defining the ideal femtosecond laser capsulotomy. Br J Ophthalmol. 2015;99(8):1137-42. Li S, Hu Y, Guo R, Shao Y, Zhao J, Zhang J, et al. 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Capsulotomy diameter mark. Journal of Cataract & Refractive Surgery. 2003;29(10):1866-8. Foster GJL, Allen QB, Ayres BD, Devgan U, Hoffman RS, Khandelwal SS, et al. Phacoemulsification of the rock-hard dense nuclear cataract: Options and recommendations. J Cataract Refract Surg. 2018;44(7):905-16. Vargas LG, Auffarth GU, Becker KA, Rabsilber TM, Holzer MP. Performance of the 1CU accommodating intraocular lens in relation to capsulorhexis size. J Cataract Refract Surg. 2005;31(2):363-8. Xu J, Zheng T, Lu Y. Effect of Decentration on the Optical Quality of Monofocal, Extended Depth of Focus, and Bifocal Intraocular Lenses. J Refract Surg. 2019;35(8):484-92. Tackman RN, Kuri JV, Nichamin LD, Edwards K. Anterior capsulotomy with an ultrashort-pulse laser. J Cataract Refract Surg. 2011;37(5):819-24. Schultz T, Joachim SC, Tischoff I, Dick HB. Histologic evaluation of in vivo femtosecond laser-generated capsulotomies reveals a potential cause for radial capsular tears. Eur J Ophthalmol. 2015;25(2):112-8. Luo WJ, Hu SQ, Wang Y, Zheng HS, Zhou SW, Ortega-Usobiaga J. Comparison of the actual diameter of capsulotomy and predicted diameter of capsulotomy after femtosecond laser-assisted capsulotomy. J Cataract Refract Surg. 2022;48(11):1264-9. Akaishi M, Teshigawara T, Hata S, Meguro A, Mizuki N. Multiple linear regression model for improving accuracy of capsulorhexis size calculation in femtosecond laser-assisted cataract surgery for adults: a retrospective single-center study. BMC Ophthalmol. 2023;23(1):19. Barraquer RI, Michael R, Abreu R, Lamarca J, Tresserra F. Human lens capsule thickness as a function of age and location along the sagittal lens perimeter. Invest Ophthalmol Vis Sci. 2006;47(5):2053-60. Liao M, Guo D, Liao S, Zhang W, Lin D, Tang Q. Study on the enlargement index of femtosecond laser-assisted capsulorhexis in 2-6-year-old patients with congenital cataract. BMC Ophthalmol. 2021;21(1):441. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Dec, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 27 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviews received at journal 28 Sep, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 20 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers invited by journal 15 Sep, 2025 Editor invited by journal 21 Aug, 2025 Editor assigned by journal 21 Aug, 2025 Submission checks completed at journal 21 Aug, 2025 First submitted to journal 19 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7407175","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":517966994,"identity":"1e7e6f8f-355a-475b-aee1-b96b96c8fdf6","order_by":0,"name":"Zhao Tan","email":"","orcid":"","institution":"Changsha Center for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Zhao","middleName":"","lastName":"Tan","suffix":""},{"id":517966995,"identity":"53adb230-fd6f-41b9-ab27-75c2809082a5","order_by":1,"name":"Fei Yuan","email":"data:image/png;base64,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","orcid":"","institution":"Zhongshan hospital of Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Fei","middleName":"","lastName":"Yuan","suffix":""}],"badges":[],"createdAt":"2025-08-19 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07:47:43","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":231415,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7407175/v1/211bb9622c5b30c30f5a8e41.png"},{"id":91960656,"identity":"1d0a17f9-2515-4bf0-acdb-de2207f74a4d","added_by":"auto","created_at":"2025-09-23 07:47:43","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99876,"visible":true,"origin":"","legend":"","description":"","filename":"df5217abafee4d79982e507895f7270a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7407175/v1/a4fb450e8417abca153641e0.xml"},{"id":91960660,"identity":"8ce5eab4-1959-4b63-a58d-ec1e3339908e","added_by":"auto","created_at":"2025-09-23 07:47:43","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108357,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7407175/v1/d35eca479506bfe838a71256.html"},{"id":91960661,"identity":"68cb92be-70c1-4e09-a599-b0f1e371673e","added_by":"auto","created_at":"2025-09-23 07:47:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5183399,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of the actual capsulotomy diameter. (a) The blue arrows indicate the edge of the anterior capsule opening, while the yellow arrows indicate the edge of the IOL optic. (b) The vertical yellow solid line represents the diameter of the IOL optic, and the horizontal red solid line represents the actual diameter of the capsulotomy.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7407175/v1/a9b87baf6c3e1c53d41ce79d.png"},{"id":99172949,"identity":"2aa4b04f-9f21-40f1-a679-952fd556e331","added_by":"auto","created_at":"2025-12-29 16:12:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5514759,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7407175/v1/0ad5b3e4-0815-44f9-9ee6-1b0c7bde2fa4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Deviation between programmed and actual capsulotomy diameter in femtosecond laser–assisted cataract surgery: a clinical study of influencing factors and predictive modeling","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFor individuals with cataracts, surgery remains the only definitive treatment. Continuous curvilinear capsulorhexis (CCC), first introduced by Gimbel et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) in 1990, has long been considered an essential procedure in cataract surgery. An ideal CCC is circular, well-centered, and slightly smaller than the intraocular lens (IOL) optic, with the anterior capsule edge completely covering the IOL optic. A well-constructed CCC facilitates subsequent surgical steps, ensures IOL centration and stability, and hinders the proliferation and migration of residual lens epithelial cells (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In contrast, irregular, decentered, or improperly sized capsulorhexis can cause tilt, decentration, or longitudinal movement of the IOL (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) during capsular fibrosis and shrinkage. These changes may lead to refractive errors and increased higher-order aberrations (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), ultimately degrading visual quality, particularly in patients implanted with premium IOLs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite its importance, CCC remains one of the most challenging procedures in cataract surgery. Even experienced surgeons may struggle to achieve an optimal CCC every time.\u003c/p\u003e\u003cp\u003eIn 2009, the femtosecond laser technique was initially introduced into cataract surgery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Since then, numerous studies have demonstrated that femtosecond laser-assisted capsulotomy offers superior precision in achieving circularity and centration, and significantly reduces IOL tilt and decentration compared with manual capsulorhexis (\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Despite these advantages, clinical observations have revealed that the actual diameter of the capsulotomy (ADC) may not always match the programmed diameter of the capsulotomy (PDC) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This discrepancy between the ADC and PDC can affect the extent to which the anterior capsule overlaps the IOL optic. Inadequate overlap may compromise IOL stability, increasing the risk of tilt, decentration, and refractive errors, especially in patients implanted with functional IOLs.\u003c/p\u003e\u003cp\u003eTo address this issue, we aimed to identify potential factors influencing capsulotomy diameter deviation and to construct regression models that provide practical guidance for determining the target capsulotomy diameter during surgery, thereby enabling more accurate and individualized capsulotomy diameters.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This prospective case series was approved by the Medical Ethics Committee of Zhongshan Hospital Affiliated to Fudan University (B2023-313) and was conducted in accordance with the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants for the use of their clinical data in this study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient Population\u003c/h2\u003e\u003cp\u003ePatients who received femtosecond laser-assisted cataract surgery (FLACS) at the Department of Ophthalmology, Zhongshan Hospital, between March 2023 and October 2023 were consecutively enrolled. Inclusion criteria included a diagnosis of age-related cataract. Exclusion criteria included a history of intraocular surgery or ocular trauma. Patients with intraoperative complications such as anterior capsule tear, posterior capsule rupture, or significant intraoperative miosis that impaired visualization of the anterior capsule opening and IOL optic were also excluded.\u003c/p\u003e\u003cp\u003eAll participants received a comprehensive preoperative ophthalmic examination, including slit-lamp examination; dilated fundus examination; measurement of visual acuity; measurement of intraocular pressure (TX-20, Canon); endothelial cell density assessment (SP-1P, Topcon Medical Systems); optical biometry (IOL Master 700, Carl Zeiss Meditec AG); optical coherence tomography (OCT) (CIRRUS 5000, Carl Zeiss Meditec AG); and A/B-scan ultrasonography (AVISO, Quantel Medical).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eAll surgical operations were conducted by an experienced cataract surgeon. Prior to surgery, patients received 0.1% pranoprofen and 0.5% levofloxacin eye drops for three consecutive days. On the day of surgery, a compound solution of 0.5% tropicamide and 0.5% phenylephrine was administered every 15 minutes until full dilation. Topical anesthesia was achieved with three applications of 0.5% proparacaine hydrochloride.\u003c/p\u003e\u003cp\u003eA femtosecond laser platform (VICTUS Laser System, Bausch \u0026amp; Lomb) was used to perform the capsulotomy, lens fragmentation, and creation of clear corneal incisions. Clinically, the capsulotomy diameter is set slightly smaller than that of the IOL optic to ensure 360\u0026deg; overlap. For most commonly used IOLs with a 6.0 mm optic, a diameter of 5.0\u0026ndash;5.5 mm is typically selected to achieve complete coverage. However, in certain situations, such as hard nuclear cataracts, cataracts coexisting with retinal disease, or the implantation of accommodating IOLs, a larger diameter may be preferred. In this study, capsulotomy diameters were set at 5.5 mm or 5.8 mm, based on the patients\u0026rsquo; individual characteristics and the surgeon\u0026rsquo;s experience, to reflect real-world surgical decision-making. An eight-piece cross pattern was used for lens fragmentation. A 3.2-mm biplanar clear corneal main incision was created at 135\u0026deg;, and a 1.5-mm single-plane side-port incision was made at 15\u0026deg;. After completion of the laser treatment, patients were transferred to a sterile operating room for phacoemulsification (Centurion, Alcon Laboratories). All patients were implanted with a foldable posterior chamber IOL. All surgical procedures were video-recorded for subsequent analysis.\u003c/p\u003e\n\u003ch3\u003eMeasurement\u003c/h3\u003e\n\u003cp\u003eImages in which the IOL optic and anterior capsule edge were clearly visible were extracted from the surgical videos. Image Pro Plus software, version 6.0, was used to measure ADC values, using the IOL optic diameter as a reference scale (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The diameter deviation of the capsulotomy (DDC) was calculated by subtracting the PDC from the ADC.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 26.0, and GraphPad Prism version 9 was used for graphical visualization. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables as percentages. For normally distributed continuous data, paired \u003cem\u003et\u003c/em\u003e-tests were employed to compare PDC and ADC, whereas the Wilcoxon signed-rank test was applied for non-normally distributed data. Comparisons between the two PDC subgroups were conducted using independent-samples t-tests for normally distributed variables or the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for non-normally distributed variables. Analysis of variance was used for comparisons among three or more groups, with post hoc pairwise comparisons adjusted by the Bonferroni method. Bivariate correlation analyses (Pearson or Spearman correlation tests, as appropriate) were used to assess the relationships between ocular biometric parameters and ADC or DDC. Partial correlation analyses were also conducted to adjust for potential confounding variables. Stepwise multiple linear regression analyses were performed, with ADC as the dependent variable and demographic or ocular biometric parameters as independent variables. A two-tailed \u003cem\u003eP\u003c/em\u003e-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the demographic and ocular characteristics of the study population. A total of 47 participants (47 eyes) were enrolled, whose ages ranged from 32 to 92 years. Patients were classified into two subgroups according to PDC: 5.5 mm and 5.8 mm groups. Comparisons revealed no significant differences in age, axial length (AL), flat keratometry (K1), steep keratometry (K2), lens thickness (LT), anterior chamber depth (ACD), or white-to-white (WTW) measurements between the two groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy population characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClassification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (F/M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27/20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEye (R/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23/24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (y)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72(60,83)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAL (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.76(23.78,25.84)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.68(42.44,44.18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.49(43.54,45.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACD (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLT (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWTW (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eAL\u0026thinsp;=\u0026thinsp;axial length; ACD\u0026thinsp;=\u0026thinsp;anterior chamber depth; LT\u0026thinsp;=\u0026thinsp;lens thickness; WTW\u0026thinsp;=\u0026thinsp;white-to-white.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of different PDC groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClassification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.5 mm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.8 mm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003estatistics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (y)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e70.48\u0026thinsp;\u0026plusmn;\u0026thinsp;15.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e67.04\u0026thinsp;\u0026plusmn;\u0026thinsp;15.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.457\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACD (mm)(mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLT (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.222\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWTW (mm)(mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.509\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAL (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e25.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e24.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e = -1.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e42.83\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e43.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e = -1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.261\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e43.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e44.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e = -1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.257\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eACD\u0026thinsp;=\u0026thinsp;anterior chamber depth; LT\u0026thinsp;=\u0026thinsp;lens thickness; WTW\u0026thinsp;=\u0026thinsp;white-to-white; AL\u0026thinsp;=\u0026thinsp;axial length.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eADC\u003c/h3\u003e\n\u003cp\u003eStatistical analysis showed that ADC was significantly greater than PDC. In the overall cohort, the mean ADC was 5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34 mm, compared with a mean PDC of 5.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15 mm (\u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;5.622, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A similar trend was observed in both subgroups: in the 5.5 mm group, the mean ADC was 5.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32 mm (\u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;3.945, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and in the 5.8 mm group, it was 6.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 mm (\u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;4.078, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003ch3\u003eDDC\u003c/h3\u003e\n\u003cp\u003eThe average DDC in the overall cohort was 0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 mm, with a range from \u0026minus;\u0026thinsp;0.25 mm to 1.22 mm. No statistically significant difference in DDC was found between the 5.5 mm and 5.8 mm subgroups (0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32 mm vs. 0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 mm; \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.343, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.732). Among all cases, 63.8% had a DDC greater than 0.20 mm, 29.8% had a DDC between 0 and 0.20 mm, and 6.4% had a DDC\u0026thinsp;\u0026le;\u0026thinsp;0 mm.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInfluencing factors\u003c/h2\u003e\u003cp\u003eSimple bivariate correlation analyses showed that ADC was negatively correlated with age (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = -0.460, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and LT (\u003cem\u003er\u003c/em\u003e = -0.402, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). Similarly, DDC was negatively associated with age (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = -0.416, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) and LT (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = -0.378, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009), but positively associated with AL (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = 0.475, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and ACD (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e = 0.377, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation analysis of variables with ADC and DDC\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eADC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eDDC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003es\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAL (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eK2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.322\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACD (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.277\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.009*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLT (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.402\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.005*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.009*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWTW (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.010\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.949\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.634\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (y)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.460\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e Pearson correlation analysis; *statistical significance.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eACD\u0026thinsp;=\u0026thinsp;anterior chamber depth; AL\u0026thinsp;=\u0026thinsp;axial length; DDC\u0026thinsp;=\u0026thinsp;deviation of the diameter of the capsulotomy; LT\u0026thinsp;=\u0026thinsp;lens thickness; PDC\u0026thinsp;=\u0026thinsp;predicted diameter of capsulotomy; WTW\u0026thinsp;=\u0026thinsp;white-to-white.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePartial correlation analyses further revealed that age remained the only independent factor significantly associated with both ADC (\u003cem\u003er\u003c/em\u003e = -0.420, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) and DDC (\u003cem\u003er\u003c/em\u003e = -0.362, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012) after adjusting for AL, ACD, and LT. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the mean DDC across different age subgroups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDDC in different age groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (y)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDDC (mm)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026ndash;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003estatistics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.324\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eDDC\u0026thinsp;=\u0026thinsp;diameter deviation of the capsulotomy.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo predict ADC, a stepwise multiple linear regression model was developed. Age and PDC were identified as independent predictors of ADC, yielding the following equation: ADC\u0026thinsp;=\u0026thinsp;2.531\u0026thinsp;\u0026minus;\u0026thinsp;0.011\u0026middot;Age\u0026thinsp;+\u0026thinsp;0.741\u0026middot;PDC (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14.265, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; adjusted R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.366, Durbin-Watson statistic\u0026thinsp;=\u0026thinsp;2.294).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eCapsulorhexis is a critical step in cataract surgery since it influences the effective lens position (ELP) and the risk of posterior capsular opacification (PCO) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A 360\u0026deg; overlap of the anterior capsule edge over the IOL optic is associated with a reduced incidence of PCO and improved IOL centration and long-term stability (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Hollick et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) reported that large capsulorhexis (6.0\u0026ndash;7.0 mm) without optic overlap resulted in a 66.2% incidence of PCO one year postoperatively, whereas smaller capsulorhexis (4.5\u0026ndash;5.0 mm) with complete coverage of the IOL optic led to only 32.7%. Similarly, a significant correlation between ELP and the extent of anterior capsule coverage over the IOL optic was reported by Li et al (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, a capsulorhexis that is too small may result in excessive lens epithelial cell proliferation and anterior capsule shrinkage, thereby increasing the risk of anterior capsule contraction syndrome (ACCS) and potential IOL dislocation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). To mitigate this risk, Joo et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) suggested a capsulorhexis diameter of 5.5\u0026ndash;6.0 mm. Conversely, an oversized capsulorhexis may fail to provide adequate overlap of the IOL optic, thereby diminishing the preventive effect against PCO (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Furthermore, a capsulorhexis exceeding 6.5 mm may jeopardize the zonular attachment, threatening IOL stability. Irregular or decentered capsulorhexis may exert asymmetric forces on the IOL during anterior capsule contraction, resulting in IOL tilt and decentration (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTherefore, an ideal capsulorhexis should be well-centered, circular, and appropriately sized. Taking into account various clinical factors, a diameter slightly smaller than the IOL optic is often preferred to ensure sufficient overlap and minimize capsular complications. For IOLs with a 6.0 mm optic, a capsulorhexis diameter of 5.0\u0026ndash;5.5 mm is generally considered optimal to achieve an overlap of 0.25\u0026ndash;0.5 mm between the edge of the anterior capsule opening and the IOL optic edge (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, in clinical practice, the capsulorhexis diameter may need to be adjusted based on individual patient characteristics. For instance, in cases of dense nuclear cataract, a slightly larger capsulorhexis may facilitate more efficient nucleus removal (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In patients with coexisting retinal comorbidities, an enlarged capsulorhexis allows for better postoperative fundus examination. Additionally, for eyes receiving premium IOLs (e.g., multifocal or accommodating types), a larger capsulorhexis may be beneficial for optimal lens performance (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the era of refractive cataract surgery, both surgeons and patients are placing greater emphasis on achieving superior postoperative refractive outcomes. With the growing use of premium IOLs, which are more susceptible to tilt and decentration (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), increasing attention is directed toward the accuracy of capsulorhexis, particularly its diameter, to ensure optimal IOL positioning and performance.\u003c/p\u003e\u003cp\u003eThe femtosecond laser technique, characterized by high precision and reproducibility, significantly improves the accuracy of capsulotomy size compared with manual capsulorhexis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Schultz et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) reported a minimal deviation (0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 mm) between the diameter of the capsule disk and the PDC. Nevertheless, the actual anterior opening size was found to be significantly larger than the PDC in pediatric patients undergoing FLACS (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), with a maximum DDC of 1.99 mm. Similarly, Luo et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) demonstrated that ADC values were significantly greater than PDC in patients under 20 years of age; in their study, the DDC was 0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04 mm in the 0\u0026ndash;20-year-old group. Although the numerical differences between ADC and PDC are small, they may still affect IOL positioning and postoperative visual quality. Thus, achieving a predictable and stable capsulotomy diameter is essential for optimizing visual outcomes.\u003c/p\u003e\u003cp\u003eIn our study, we found a significant difference between ADC and PDC in adults, with a mean DDC of 0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 mm. This finding is inconsistent with the study by Luo et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), who reported a high level of agreement between ADC and PDC in patients older than 20 years. Similarly, Akaishi et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) reported minimal diameter deviations in adult patients, with an ADC of 5.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16 mm when the PDC was 5.30 mm. The discrepancy between studies may be attributable to differences in the preset PDC values: Luo et al. set the PDC at 5.2 mm, and Akaishi et al. set it at 5.3 mm, corresponding to the thickest region of the anterior capsule. Previous studies have shown that the thickest part of the anterior capsule lies in the midperipheral region (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), typically measuring around 5.25 mm in diameter (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Performing the capsulotomy in this region may provide greater mechanical resistance and structural stability, potentially contributing to the reduced variation in the ADC. This may explain why no significant difference between ADC and PDC was observed when PDC was set around 5.25 mm.\u003c/p\u003e\u003cp\u003eCorrelation analysis revealed that age was significantly negatively associated with DDC, consistent with previous reports (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Younger patients tended to exhibit greater deviation between the actual and programmed capsulotomy diameter, which may be explained by age-related changes in the biomechanical properties of the anterior capsule. The lens capsule, secreted by lens epithelial cells and composed primarily of hyaluronic acid and type IV collagen, becomes thicker and less elastic with age (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This reduced elasticity may limit capsular distension after laser cutting and thus lead to smaller DDC in older individuals.\u003c/p\u003e\u003cp\u003eRegarding ocular biometric parameters, Liao et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) reported that, in pediatric cataract patients aged 2\u0026ndash;6 years, AL was positively associated with the anterior capsulotomy enlargement index, whereas ACD was negatively associated with it. They proposed that a shallow anterior chamber may increase intracapsular pressure and anterior capsule tension, thereby contributing to capsulotomy enlargement. They further suggested that the influence of AL on the anterior capsulotomy diameter may be related to the laxity of the lens zonular fibers (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Additionally, Luo et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) reported a negative correlation between LT and DDC. In our study, AL, ACD, and LT were significantly correlated with DDC in simple bivariate analyses. However, after adjusting for age, none of these biometric parameters remained significantly associated with DDC, which highlights age as the dominant factor influencing capsulotomy diameter deviation. These findings suggest that ocular biometrics may interact with age to exert a combined moderate effect on capsulotomy diameter, but their individual influence diminishes once age is accounted for.\u003c/p\u003e\u003cp\u003e Currently, the determination of PDC in clinical practice is largely empirical, and there are no established guidelines to ensure precise capsulotomy sizing. To support clinical decision-making in setting an appropriate PDC, we developed a multiple linear regression model that incorporates PDC and age as predictors for estimating ADC. This model provides a practical tool for preoperative planning, with the potential to minimize deviations in capsulotomy diameter. By improving the predictability of ADC, it may help ensure adequate anterior capsule\u0026ndash;IOL overlap, thereby enhancing IOL stability and optimizing visual outcomes, particularly in patients receiving premium IOLs. Nonetheless, the current model is limited to adult populations, and external validation in larger, more diverse cohorts is warranted prior to widespread clinical implementation.\u003c/p\u003e\u003cp\u003eIn the present study, although most cases demonstrated an enlarged anterior capsulotomy opening, a small subset exhibited a reduced diameter. This finding indicates that factors beyond those captured in our regression model may influence ADC. One possible explanation is intraoperative repositioning of the anterior capsule: after lens extraction, the loss of lenticular support may cause the anterior capsule to shift toward the equatorial plane, moving the capsulotomy edge centripetally and thereby reducing the ADC. In addition, IOL implantation may stretch the capsular bag via its haptics, further modifying the final capsulotomy size. These biomechanical and intraoperative factors warrant further investigation to clarify their role in capsulotomy stability and predictability. In summary, while age and PDC emerged as primary predictors in our model, they may not fully account for all intraoperative influences on capsulotomy diameter. Future studies incorporating real-time anterior capsule dynamics and postoperative follow-up measurements could help refine predictive models and improve the accuracy and stability of femtosecond laser\u0026ndash;assisted capsulotomy.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the relatively small sample size may restrict the generalizability of the findings. Second, although various biometric and demographic variables were examined, the regression model exhibited only moderate explanatory power, suggesting that additional unmeasured factors may affect capsulotomy size. Finally, ADC was measured at a single time point; dynamic assessments of the capsulotomy size could provide deeper insights into the mechanisms underlying deviations and their contributing factors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSignificant differences between the actual and programmed capsulotomy diameters were observed in adult patients undergoing FLACS. Age was identified as the primary factor influencing DDC, likely reflecting age-related changes in anterior capsule elasticity. A stepwise multiple linear regression model incorporating age and PDC was developed to predict ADC. This predictive model may assist clinicians in achieving more precise capsulotomy size, thereby contributing to superior IOL position and visual outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePDC: Programmed capsulotomy diameter\u003c/p\u003e\n\u003cp\u003eADC: Actual capsulotomy diameter\u003c/p\u003e\n\u003cp\u003eDDC: Diameter deviation of the capsulotomy\u003c/p\u003e\n\u003cp\u003eFLACS: Femtosecond laser\u0026ndash;assisted cataract surgery\u003c/p\u003e\n\u003cp\u003eCCC: Continuous curvilinear capsulorhexis\u003c/p\u003e\n\u003cp\u003eIOL: Intraocular lens\u003c/p\u003e\n\u003cp\u003eAL: axial length\u003c/p\u003e\n\u003cp\u003eK1: flat keratometry\u003c/p\u003e\n\u003cp\u003eK2: steep keratometry\u003c/p\u003e\n\u003cp\u003eLT: lens thickness\u003c/p\u003e\n\u003cp\u003eACD: anterior chamber depth\u003c/p\u003e\n\u003cp\u003eWTW: white-to-white\u003c/p\u003e\n\u003cp\u003eELP: Effective lens position\u003c/p\u003e\n\u003cp\u003ePCO: Posterior capsular opacification\u003c/p\u003e\n\u003cp\u003eACCS: anterior capsule contraction syndrome\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.T. and F.Y. designed the study. Z.T. collected the data, performed the statistical analysis, and drafted the manuscript. F.Y. revised it for important intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo financial support or grants were received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Medical Ethics Committee of Zhongshan Hospital, Fudan University (approval No. B2023-313). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants for both participation in the study and publication of their clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patients for publication of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eChangsha Center for Disease Control and Prevention, Changsha 410004, China. \u003csup\u003e2\u003c/sup\u003eDepartment of Ophthalmology, Zhongshan Hospital, Fudan University, Shanghai 200032, China.\u003c/p\u003e\n\u003cp\u003e*Corresponding Author: Fei Yuan\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]; [email protected]\u003c/p\u003e\n\u003cp\u003eORCID number: 000900031474406X\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg. 1990;16(1):31-7.\u003c/li\u003e\n\u003cli\u003eHollick EJ, Spalton DJ, Meacock WR. The effect of capsulorhexis size on posterior capsular opacification: one-year results of a randomized prospective trial. Am J Ophthalmol. 1999;128(3):271-9.\u003c/li\u003e\n\u003cli\u003ePacker M, Teuma EV, Glasser A, Bott S. Defining the ideal femtosecond laser capsulotomy. Br J Ophthalmol. 2015;99(8):1137-42.\u003c/li\u003e\n\u003cli\u003eLi S, Hu Y, Guo R, Shao Y, Zhao J, Zhang J, et al. The effects of different shapes of capsulorrhexis on postoperative refractive outcomes and the effective position of the intraocular lens in cataract surgery. BMC Ophthalmol. 2019;19(1):59.\u003c/li\u003e\n\u003cli\u003eHolladay JT, Piers PA, Koranyi G, van der Mooren M, Norrby NE. A new intraocular lens design to reduce spherical aberration of pseudophakic eyes. 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J Refract Surg. 2017;33(12):808-12.\u003c/li\u003e\n\u003cli\u003eNagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12):1053-60.\u003c/li\u003e\n\u003cli\u003eKr\u0026aacute;nitz K, Takacs A, Mih\u0026aacute;ltz K, Kov\u0026aacute;cs I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011;27(8):558-63.\u003c/li\u003e\n\u003cli\u003eMastropasqua L, Toto L, Mattei PA, Vecchiarino L, Mastropasqua A, Navarra R, et al. Optical coherence tomography and 3-dimensional confocal structured imaging system-guided femtosecond laser capsulotomy versus manual continuous curvilinear capsulorhexis. J Cataract Refract Surg. 2014;40(12):2035-43.\u003c/li\u003e\n\u003cli\u003eQian DW, Guo HK, Jin SL, Zhang HY, Li YC. Femtosecond laser capsulotomy versus manual capsulotomy: a Meta-analysis. Int J Ophthalmol. 2016;9(3):453-8.\u003c/li\u003e\n\u003cli\u003eFriedman NJ, Palanker DV, Schuele G, Andersen D, Marcellino G, Seibel BS, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011;37(7):1189-98.\u003c/li\u003e\n\u003cli\u003eKr\u0026aacute;nitz K, Mih\u0026aacute;ltz K, S\u0026aacute;ndor GL, Takacs A, Knorz MC, Nagy ZZ. Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy. J Refract Surg. 2012;28(4):259-63.\u003c/li\u003e\n\u003cli\u003eZhu Y, Shi K, Yao K, Wang Y, Zheng S, Xu W, et al. Parameters of Capsulorrhexis and Intraocular Lens Decentration After Femtosecond and Manual Capsulotomies in High Myopic Patients With Cataracts. Front Med (Lausanne). 2021;8:640269.\u003c/li\u003e\n\u003cli\u003eDick HB, Schelenz D, Schultz T. Femtosecond laser-assisted pediatric cataract surgery: Bochum formula. J Cataract Refract Surg. 2015;41(4):821-6.\u003c/li\u003e\n\u003cli\u003eRavalico G, Tognetto D, Palomba M, Busatto P, Baccara F. Capsulorhexis size and posterior capsule opacification. J Cataract Refract Surg. 1996;22(1):98-103.\u003c/li\u003e\n\u003cli\u003eSzigeti A, Kr\u0026aacute;nitz K, Takacs AI, Mih\u0026aacute;ltz K, Knorz MC, Nagy ZZ. Comparison of long-term visual outcome and IOL position with a single-optic accommodating IOL After 5.5- or 6.0-mm Femtosecond laser capsulotomy. J Refract Surg. 2012;28(9):609-13.\u003c/li\u003e\n\u003cli\u003eSmith SR, Daynes T, Hinckley M, Wallin TR, Olson RJ. The effect of lens edge design versus anterior capsule overlap on posterior capsule opacification. Am J Ophthalmol. 2004;138(4):521-6.\u003c/li\u003e\n\u003cli\u003eGu X, Chen X, Jin G, Wang L, Zhang E, Wang W, et al. Early-Onset Posterior Capsule Opacification: Incidence, Severity, and Risk Factors. Ophthalmology and therapy. 2022;11(1):113-23.\u003c/li\u003e\n\u003cli\u003eAykan U, Bilge AH, Karadayi K, Akin T. The effect of capsulorhexis size on development of posterior capsule opacification: small (4.5 to 5.0 mm) versus large (6.0 to 7.0 mm). Eur J Ophthalmol. 2003;13(6):541-5.\u003c/li\u003e\n\u003cli\u003eLin X, Ma D, Yang J. Exploring anterion capsular contraction syndrome in cataract surgery: insights into pathogenesis, clinical course, influencing factors, and intervention approaches. Front Med (Lausanne). 2024;11:1366576.\u003c/li\u003e\n\u003cli\u003eJoo CK, Shin JA, Kim JH. Capsular opening contraction after continuous curvilinear capsulorhexis and intraocular lens implantation. J Cataract Refract Surg. 1996;22(5):585-90.\u003c/li\u003e\n\u003cli\u003eLin H, Tan X, Lin Z, Chen J, Luo L, Wu X, et al. Capsular Outcomes Differ with Capsulorhexis Sizes after Pediatric Cataract Surgery: A Randomized Controlled Trial. Sci Rep. 2015;5:16227.\u003c/li\u003e\n\u003cli\u003eOhmi S, Uenoyama K. Decentration associated with asymmetric capsular shrinkage and intraocular lens design in a rabbit model. J Cataract Refract Surg. 1995;21(3):293-6.\u003c/li\u003e\n\u003cli\u003eRossi T, Ceccacci A, Testa G, Ruggiero A, Bonora N, D\u0026apos;Agostino I, et al. Influence of anterior capsulorhexis shape, centration, size, and location on intraocular lens position: finite element model. J Cataract Refract Surg. 2022;48(2):222-9.\u003c/li\u003e\n\u003cli\u003eWallace BRI. Capsulotomy diameter mark. Journal of Cataract \u0026amp; Refractive Surgery. 2003;29(10):1866-8.\u003c/li\u003e\n\u003cli\u003eFoster GJL, Allen QB, Ayres BD, Devgan U, Hoffman RS, Khandelwal SS, et al. Phacoemulsification of the rock-hard dense nuclear cataract: Options and recommendations. J Cataract Refract Surg. 2018;44(7):905-16.\u003c/li\u003e\n\u003cli\u003eVargas LG, Auffarth GU, Becker KA, Rabsilber TM, Holzer MP. Performance of the 1CU accommodating intraocular lens in relation to capsulorhexis size. J Cataract Refract Surg. 2005;31(2):363-8.\u003c/li\u003e\n\u003cli\u003eXu J, Zheng T, Lu Y. Effect of Decentration on the Optical Quality of Monofocal, Extended Depth of Focus, and Bifocal Intraocular Lenses. J Refract Surg. 2019;35(8):484-92.\u003c/li\u003e\n\u003cli\u003eTackman RN, Kuri JV, Nichamin LD, Edwards K. Anterior capsulotomy with an ultrashort-pulse laser. J Cataract Refract Surg. 2011;37(5):819-24.\u003c/li\u003e\n\u003cli\u003eSchultz T, Joachim SC, Tischoff I, Dick HB. Histologic evaluation of in vivo femtosecond laser-generated capsulotomies reveals a potential cause for radial capsular tears. Eur J Ophthalmol. 2015;25(2):112-8.\u003c/li\u003e\n\u003cli\u003eLuo WJ, Hu SQ, Wang Y, Zheng HS, Zhou SW, Ortega-Usobiaga J. Comparison of the actual diameter of capsulotomy and predicted diameter of capsulotomy after femtosecond laser-assisted capsulotomy. J Cataract Refract Surg. 2022;48(11):1264-9.\u003c/li\u003e\n\u003cli\u003eAkaishi M, Teshigawara T, Hata S, Meguro A, Mizuki N. Multiple linear regression model for improving accuracy of capsulorhexis size calculation in femtosecond laser-assisted cataract surgery for adults: a retrospective single-center study. BMC Ophthalmol. 2023;23(1):19.\u003c/li\u003e\n\u003cli\u003eBarraquer RI, Michael R, Abreu R, Lamarca J, Tresserra F. Human lens capsule thickness as a function of age and location along the sagittal lens perimeter. Invest Ophthalmol Vis Sci. 2006;47(5):2053-60.\u003c/li\u003e\n\u003cli\u003eLiao M, Guo D, Liao S, Zhang W, Lin D, Tang Q. Study on the enlargement index of femtosecond laser-assisted capsulorhexis in 2-6-year-old patients with congenital cataract. BMC Ophthalmol. 2021;21(1):441.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"femtosecond laser, capsulotomy, deviation diameter, predictive model","lastPublishedDoi":"10.21203/rs.3.rs-7407175/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7407175/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDifferences between actual and programmed capsulotomy diameter were found in femtosecond laser\u0026ndash;assisted cataract surgery (FLACS). This study aimed to evaluate the deviation between the programmed capsulotomy diameter (PDC) and the actual capsulotomy diameter (ADC) in FLACS, identify the influencing factors, and establish a predictive model to improve the accuracy of capsulotomy size.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective study included 47 eyes from 47 adult patients who underwent FLACS. The ADC was measured using Image Pro Plus version 6.0 based on intraoperative video images, and the diameter deviation of the capsulotomy (DDC) was calculated by subtracting the PDC from the ADC. Simple bivariate correlation and partial correlation analyses were performed to evaluate relationships between ADC or DDC and demographic as well as ocular biometric parameters. A stepwise multiple linear regression model was developed to predict ADC.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean ADC (5.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34 mm) was significantly greater than the PDC (5.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15 mm, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the overall cohort. The average DDC was 0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31 mm, with 63.8% of eyes exhibiting a DDC greater than 0.20 mm. No significant difference in DDC was observed between the 5.5 mm and the 5.8 mm subgroups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.732). Age showed a significant negative correlation with both ADC and DDC; after adjustment for ocular biometric variables, it remained the sole independent predictor of both parameters. A predictive model was constructed using age and PDC as independent variables: ADC\u0026thinsp;=\u0026thinsp;2.531\u0026thinsp;\u0026minus;\u0026thinsp;0.011\u0026middot;Age\u0026thinsp;+\u0026thinsp;0.741\u0026middot;PDC (F\u0026thinsp;=\u0026thinsp;14.265, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; adjusted R2\u0026thinsp;=\u0026thinsp;0.366, Durbin-Watson statistic\u0026thinsp;=\u0026thinsp;2.294).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSignificant differences were observed between PDC and ADC in adult patients. Age was found to be the most influential factor contributing to diameter deviations, possibly due to age-related changes in anterior capsule elasticity. The proposed regression model for ADC may assist surgeons in setting a more accurate and individualized capsulotomy diameter.\u003c/p\u003e","manuscriptTitle":"Deviation between programmed and actual capsulotomy diameter in femtosecond laser–assisted cataract surgery: a clinical study of influencing factors and predictive modeling","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:47:38","doi":"10.21203/rs.3.rs-7407175/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-27T08:06:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T13:12:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2025-10-22T07:56:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T14:14:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T05:51:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76377585984646772252514524165854041387","date":"2025-09-24T05:42:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31334866743264264641283288463235592729","date":"2025-09-22T05:45:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231496752600163643202224296104593061141","date":"2025-09-20T08:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318891525589554615666490447691725968101","date":"2025-09-18T13:14:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229135063368095933705608542277378665192","date":"2025-09-16T07:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-15T06:51:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-21T11:42:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T04:53:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-21T04:52:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-08-19T09:51:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc35111c-884d-4ac0-8ae1-62ff88133601","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:10:55+00:00","versionOfRecord":{"articleIdentity":"rs-7407175","link":"https://doi.org/10.1186/s12886-025-04586-8","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-12-23 15:58:34","publishedOnDateReadable":"December 23rd, 2025"},"versionCreatedAt":"2025-09-23 07:47:38","video":"","vorDoi":"10.1186/s12886-025-04586-8","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04586-8","workflowStages":[]},"version":"v1","identity":"rs-7407175","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7407175","identity":"rs-7407175","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}