Does the Newly Defined Nucleus Removal 'Rize Technique' in ECCE Offer an Advantage Over Phacoemulsification in High-Risk Eyes?

Does the Newly Defined Nucleus Removal 'Rize Technique' in ECCE Offer an Advantage Over Phacoemulsification in High-Risk Eyes? | 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 Does the Newly Defined Nucleus Removal 'Rize Technique' in ECCE Offer an Advantage Over Phacoemulsification in High-Risk Eyes? Şaban Şimşek, Gizem Doğan Gökçe, Yusuf Can Aydın, Hatice Selen Sönmez Kanar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7367849/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To define the new technique for nucleus removal and to compare the surgical outcomes of this technique with phacoemulsification (PE) surgery in high risky cataracts. Methods: The Rize technique in Extracapsular Cataract Extraction (ECCE) was described which involves the extraction of the nucleus through a 6,5-7 mm continuous curvilinear capsulorhexis (CCC) using two 27-gauge needles, and placement of the in intraocular lens (IOL) into the capsular bag . Pre and postoperative findings, early and late-stage complications were analyzed. Results: The mean age was 71.5±11.3 years (range: 42-92 years). In Group 1 (Rize technique), 32 patients (39.5%) had moderate risk, and 49 patients (60.5%) had high-risk cataract. In Group 2 (PE), 43 patients (53.1%) had moderate risk, 38 patients (46.9%) had high-risk cataracts (p=0.03). In Group 1;9 patients and in Group 2;13 patients experienced complications, including vitreous loss, zonular dialysis, and anterior capsular tears extending to the periphery (p=0.1). Group 1’s 73 (% 90) patients Group 2’s 70(% 86) patients had IOLs placed in the bag (p=0.4).Postoperatively, BCVA (≥6/12) was achieved in 50 patients (%61 ) in Group 1 and 65 patients (% 80) in Group 2 and the differences between two group was not statistically significant (p =0.1).The endothelial cell loss was statistically significant higher in group 2 (272± 167 cells/mm²) than group 1 (102± 52.4)(p=0.005). Postoperative astigmatism greater than 2D for 62 patients (76.5%) in Group 1 and 28 patients (34.5%) in Group 2(p<0.01). Discussion: The Rize technique for nucleus extraction is an effective and nontrauvmatic method. Figures Figure 1 Introduction Cataract is the leading cause of treatable blindness 1 .Treatment of cataract involves the surgical removal of the natural lens and replacement with an intraocular lens (IOL). 2 Currently, extracapsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS), and phacoemulsification (PE) are commonly used methods for this purpose. 3 , 4 , 5 Due to reduced complications and better visual outcomes, small incision cataract surgery (SICS) is preferred over ECCE for cataract treatment. However, in developing countries, issues such as surgical costs, lack of awareness, ongoing supply of consumables, and shortages of skilled human resources often hinder access to surgery. 6 For these reasons, ECCE remains the preferred method in many third-world countries. 7 , 8 Also one significant challenge of ECCE surgery is the inability to consistently and centrally perform a proper capsulorhexis, as well as the difficulty in extracting the nucleus intact and placing an IOL in the capsular bag. 9 , 10 Such challenges are about to be overcome this technique was developed for the safely and atraumatically nucleus removing from a 7 mm wide CCC capsulorhexis using a bimanual 27 G needle, and the IOL is placed in the bag aiming to reduce intraoperative and postoperative complications. In this study, we aim to describe the Rize technique applied to high-risk cataracts in ECCE surgeries and compare the outcomes with PE surgery . Method The study was conducted between January 2018 and May 2024 at Dr. Lütfi Kırdar Kartal City Hospital, in accordance with the principles of the Helsinki Declaration. This study was approved by the Ethics Committee of Dr. Lütfi Kırdar Kartal City Hospital (Decision/Protocol No: 2024/010.99/4/10), with the approval date of May 27, 2024. This study was designed retrospectively, and the requirement for informed consent was waived by the Ethics Committee .Data from patients who underwent the Rize technique for high-risk cataracts were reviewed. The surgical procedure of the Rize technique was described in Surgery Technique section. Eighty-one cataract patients with high-risk scores who underwent phacoemulsification (PE) were randomly selected. The patients who underwent the Rize technique in ECCE were classified as Group 1, and those who underwent PE were classified as Group 2. Surgical risk was categorized based on factors related to the eye. 11 Class 3 indicated moderate risk (3–5 points) and class 4 indicated (high risk, 6 points or more according to Agrawal et al . study (Table 1 ). In addition to the some factors, such as corneal endothelial cell count below 1200 cells/mm², or intraoperatively; sudden deepening of the anterior chamber, anterior capsular wrinkling, difficulty in performing capsulorhexis due to zonular insufficiency, were considered as risk factors and classified as category 3. Table 1 Cataract Surgical Risk Classification (Modified from Agrawal et al.) Category1 Catagory 2 Catagory 3 Non Previous vicrectomy Corneal scar Pupil size < 3mm Shallow AC Older than 75 years More than 6D miyopia,hyperopia Capsular plaque Mature cataract Pseudoexpholiation Phacodonesis Corneal endothelial cell count < 1200 cells/mm* Intraoperatively, sudden deepening of the anterior chamber* Anterior capsular wrinkling* Difficulty in performing capsulorhexis due to zonular * Each one is 1 point in catagory, 3 points in catagory4 *These are findings that suggest zonular weakness during surgery, and the modified version of the Agrawal et al. classification has been applied Exclusion criteria included prior intraocular surgeries, glaucoma, retinopathy, and failure to attend regular follow-up visits. Parameters to be evaluated The preoperative and postoperative best corrected visual acuity (BCVA) of all patients was assessed using the Snellen chart and converted to Logmar. And also BCVA was classified as > 6/12, 6/12 − 6/60, < 6/60, hand motion, or light perception. Intraocular pressure (IOP) was measured using the Goldman applanation tonometer. central corneal thickness (Optikon Pacline, Optikon Corp., Rome, Italy), endhotelial cell density (EDS) (Topcon Corporation, Tokyo, Japan) and autorefractometre values were recorded,. Anterior and posterior segment characteristics were evaluated with slit-lamp biomicroscopy. Intraoperative complications, including capsule rupture, vitreous loss, iris prolapse, hemorrhage, and postoperative complications such as intraocular pressure rise that could not be controlled with medical treatment, corneal edema, cystoid macular edema, retinal detachment, endothelial cell loss, surgically-induced astigmatism, and IOL dislocation, were assessed. Early postoperative complications were defined as those occurring between the 1st day and end of 6 weeks and late postoperative complications were those that developed after the 6-week period. Surgery Technique Extracapsular cataract extraction and phacoemulsification surgeries were performed under sub-Tenon anesthesia, using 3 cc lidocaine hydrochloride with epinephrine and 2 cc of 0.5% bupivacaine hydrochloride, following standard ocular surface and intraocular sterilization procedures. A partial-thickness anterior limbal incision was made between 10 and 2 o'clock positions using a 45-degree keratome. Side-port incisions were then created at both ends of the main incision. After filling the anterior chamber with a viscoelastic agent, a full-thickness main incision was performed at the 12 o’clock position using a 2.8 mm keratome. A continuous curvilinear capsulorhexis of approximately 6.5–7 mm in diameter was then completed, followed by hydrodissection and mobilization of the nucleus. Two 27-gauge needles were bent approximately 30 degrees, bevel facing upward. The main incision was extended to full thickness using the keratome. The first needle (held in the left hand) was introduced from the 12 o’clock position and inserted into the nucleus just anterior to the CCC margin, directed toward the 6 o’clock position. Once the equator of the nucleus became visible, the second needle was inserted from the right side of the equator and rotated in a circular motion to the left and anteriorly, toward the anterior capsule. While maintaining the position of the second needle, the first needle was reinserted into the right side of the equator using the same motion. Upon removal of the first needle and repeating the maneuver 2–3 times, the nucleus was delivered into the anterior chamber. Additional repetitions could be performed if necessary. (For left-handed surgeons, the maneuvers are performed in the opposite direction.) If required, the main incision was enlarged laterally depending on the size of the nucleus. Viscoelastic was injected behind, in front of, and inferior (at 6 o’clock) to the nucleus. At the final stage, gentle pressure was applied on the scleral side of the incision with a cannula or needle to facilitate delivery of the nucleus. One of the bent needles was reintroduced through the main incision at 10 o’clock to push the nucleus out of the anterior chamber from behind the equator. Subsequently, the corneoscleral wound was sutured, typically using five interrupted sutures.(Fig. 1) Using this closed system, residual cortical material and epinucleus were aspirated via conventional irrigation–aspiration, as in standard phacoemulsification. A foldable intraocular lens (IOL) was implanted into the capsular bag either through the sutured incision or, if spacing was inadequate, by temporarily removing one of the sutures. This technique is referred to as the **"Rize Technique"*. Results A total of 95 women and 67 men with mean age of 71.45 ± 11.3 years (range 42–92 years) were included in the study. The mean age of Group 1 was 75.3 ± 10.6 years, and the mean age of Group 2 was 67 ± 10.2 years. This difference was found statistically significantly in the mean ages between the groups (p < 0.01). Preoperative BCVA was2.05 ± 0.5Logmarin Group 1, and this classificated61 (79.5%) patients had hand motion and light perception, 16 (20.5%) patients had worse than 6/60. In Group 2 preoperative BCVA was 1.86 ± 0.6, according to VA levels 58 (71.6%) patients had hand motion and light perception, 15 (18.5%) patients had visual acuity of 6/60 or worse, and 8(9.9%) patients had visual acuity between 6/60 and 6/12. BCVA was found significantly difference between two groups (p = 0.04). Based on cataract risk scores, in Group 1, 32 patients (39.5%) had moderate risk and 49 patients (60.4%) had high risk, while in Group 2, 43 patients (53%) had moderate risk and 38 patients (46.9%) had high risk. There was a significant difference in the risk scores between the groups (p = 0.04). According to cataract density, 60 (%74) patients in Group 1 and 55 (%67) patients in group 2 had mature/negro cataracts. The other patients had grade 3 cataracts, which were surgically indicated. According to cataract density there was no difference observed between two groups (p = 0.3) The mean preoperative corneal endothelial cell count was1.462 ± 282mm 2 and 2.098 ± 263mm 2 in Group 1 an 2, respectively. In Group 1 mean of ECC was significantly lower than Group 2(p 0.05).Preoperative mean of central corneal thickness (CCT) was 545 ± 26.3 and 541 ± 20.2 micron in Group 1, Group 2 respectively.(p = 0.6) All demographic data and examination findings are presented in Table 2 and preoperative and postoperative parameters values were shown in Table 3 . Table 2 Demographic and Preoperative Examination Findings Variable n = 62 Mean Age (years) 71.45 ± 11.3 years Sex (Female) (n, %) (male) (n, %) 95 (% 58,6) 67 (%41,3) Cataract Stages (mature/negro) (n, %) (grade 3) (n, %) 115 (% ) 46(% ) VA (Logmar) 1.96 ± 0.5 Risc score 3.48 ± 0.5 Table 3 Preoperative and Postoperative Parameters of Group 1 (Rize Technique) and Group 2 (PE) Group 1 (Rize Technique ) n = 81 Group 2 (PE) n = 81 P Age 75.3 ± 10.6 67.0 ± 10.7 p < 0.01 Sex (n) female male 48 34 51 33 P = 0.2 Visual Acuity (Logmar) preoperative postoperative 2.05 ± 0.5 0.27 ± 07 1.86 ± 0.6 0.22 ± 0.13 p = 0.04 p = 0.2 Cataract stages Mature/negred(n,%) Grade 3(n,%) Risc score 60 (%74) 21 (%26) 3.58 ± 0.5. 55 (%67) 26 (%33) 3.4 ± 0.5 p = 0.3 p = 0.03 Intraocular Pressure (mm/Hg) preoperative postoperative 15.6 ± 2.3 14.7 ± 1.6 16.2 ± 3.2 14.8 ± 2.5 p > 0.05 p > 0.05 Endhotelial cell count cell/ mm 2 preoperative postoperative 1.462 ± 282 1371 ± 275 2.098 ± 263 1868 ± 229 p < 0.01 p 2D(n) 1.02 ± 0.7 3.11 ± 1.05 19 62 1.3 ± 0.3 1.86 ± 0.5 53 28 p = 0.7 p < 0.01 p < 0.01 Intra-operative Complications In Group 1, 5 patients experienced zonular-related vitreous loss. Three of these patients had IOLs implantation to sulcus with capsular tension rings, while the other 2 of them underwent IOL implantation with suturless scleral fixation due to severe zonular weekness. Additionally, 4 patients had anterior capsular tears extending to the equator, 1 of which were successfully completed with reverse capsulorhexis. At final in 3 patients, the IOLs could not be placed during the initial surgery and sulcus IOL implanted after 2 months. In Group 2, 6 patients had posterior capsule perforation and 2 of these patients required pars plana vitrectomy due to nucleus fragment drop into the vitreous. Sulcus IOL was implanted in 3 patients and suturless scleral fixation performed in the other 3 patients. Vitreous loss in 3 patients with zonular insufficiency occurred and IOLs implantation to sulcus with capsular tension rings. Four patients had anterior capsular tears extending to the equator and 2 of which were successfully completed with reverse capsulorhexis and sulcus IOL implantation performed in 2 of them. Totally IOL-in bag implanted in 73 of Group1 and 70 of Group 2. The difference between the two groups in terms of IOL placement in the bag was not found to be statistically significant. (p = 0.4) Intraoperative complications were more commonly observed in Group 2, but this difference was not statistically significant.(p = 0.1) In Table 4 the complications were showed. Table 4 Intraoperative Complications İntraoperative Complication Group 1 (Rize Technique ) n = 81 Group 2 (PE) n = 81 Posterior Capsule Perforation - 6 Zonular-Related Vitreous Loss 5 3 Anterior Capsular Tear (Extending to the Equator) 4 4 9 13 PostoperativeComplications In Group 1, Four patients had elevated IOP > 21 mmHg, which was controlled with medical treatment. Four patients which experienced Seidel's sign with the mean IOP was 8.3 ± 2.2.In these 4 patients and the additional other 3 patients who had iris prolapse to the corneal incision area, suture revision was performed in 7 patients.In Group 2, six patients had elevated IOP > 21 mmHg which was controlled with medical treatment. Postoperatively first week;Group 1’s mean CCT was 576 ± 29.5 mand Group 2’ s was: 587 ± 35.3 m. There was a significantly difference found in mean CCT of first week values between Group 1 and Group2 (p = 0.03) . Evaluation of late post-operative complications, Irvine-Gass syndrome (IRG) was detected inone patient in Group 1. In Group 2, 3 patients developed IRG, and 3patients required Descemet Membrane Endothelial Keratoplasty (DMEK) surgery related to endothelial defficiency. The differences of late post-operative complication numbers oftwo group was not found significantly.( p = 0.054) In Group 1, the mean suture removal time was 3.2 ± 1.2 months. After suture removal, The mean astigmatism values were 3.11 ± 1.05 and 1.86 ± 0.5 respectly in Group 1 and Group 2. In Group 1 this was significantly higher (p < 0.01). There were 62 (%76) patients with an astigmatism value greater than 2.0D, and 28(%34) patients in Group 1. At the 6-month visit, the corneal endothelial cell count in Group 1 was 1371 ± 275 cell/ mm 2 , Group 2 was 1868 ± 229 cell/ mm 2 (p < 0.01). And the difference between the mean of peroperative and postoperative cell counts were 102 ± 52.4cell/ mm 2 and 272 ± 167 cell/ mm 2 respectely.This difference in endothelial cell loss between the two groups was statistically significant.(p = 0.005) The mean final BCVAwas 0.27 ± 07 Logmar in Group 1 and 0.22 ± 0.13 Logmar in Group 2.There was no significantly difference between two groups.(p = 0.2) On the other hand In Group 1, 50 patients had a visual acuity higher than 6/60, while in Group 2, 65 patients had a visual acuity higher than 6/60. This difference in visual acuity of 6/60 was found to be statistically significant (p = 0.02) All results showed in Table 3 . Discussion In this study, we described a non-traumatic and safe method of extracting the nucleus, approximately 8.0-8.5 mm in size, from a 6,5mm CCC using two 27G needles in the Rize technique. When compared to PE in high-risk cataract surgeries, the Rize technique demonstrated lower complication rates and allowed early recovery withless corneal endothelial loss. Many studies pointed out that outcomes and costs of ECCE and PE were widely different. Some studies found that PE performed by an experienced surgeon yielded better clinical results than planned ECCE but at higher costs. 12 , 13 Other studies confirmed that PE leads to better visual acuity and fewer complications compared to ECCE, although it involves higher costs. 14 These studies examining all stages of cataract found similar results. 15 However, when focusing on high-risk cataract cases, studies have shared ECCE outcomes, suggesting that ECCE might be a safer option in mature cataracts. 16 PE surgeries in high-risk eyes, especially those with advanced cataracts or pseudoexfoliation (PEX), have a higher risk of complications such as posterior capsule rupture and vitreous loss. In our study, we observed that in the PE group, advanced cataracts with PEX were associated with a higher incidence of posterior capsule rupture. 17 Mohanty et al. emphasize that PE, MSICS and ECCE each have their importance and should be tailored to the cataract’s risk factors. In their study, 6 patients in 207 patients developed posterior capsule rupture intraoperatively, with sulcus IOL placement in some and anterior chamber IOL implantation in one patient. 18 In contrast, in our study, even though Group 1 had more high-risk patients, the complication rates were lower, and 72 of the 81 patients successfully received an IOL placed within the bag. In can-opener capsulorhexis, anterior capsule tears can occur, potentially compromising the centration of the IOL. 19 The ideal anatomical placement of the IOL is within the bag, where it has the highest stability and better optical resolution. 20 In the Rize technique, performing a CCC ensures a safe space for PCIOL implantation, with the smooth edges of CCC providing additional strength. 21 For PE surgery, the appropriate capsulorhexis size ranges from 5 to 6 mm. In eyes with weak zonules, capsulorhexis may be enlarged by 0.5-1.0 mm to prevent capsule contraction, with an average optimal size of 5.5 mm 22 . In our study, we found that a 7mm capsulorhexis was ideal for non-traumatic, single-piece nucleus extraction. By using two 27G needles, the nucleus can be easily removed from this range, and PCIOL can be safely placed, providing a low-cost, accessible approach. Another important contribution of the Rize technique is its ability to reduce endothelial cell loss. In study where 186 cataractous eyes with nuclear sclerosis ≤ grade 3 were randomized for ECCE, SICS, or PE with PMMA lens implantation, no significant difference in endothelial cell loss was observed among the groups 23 . In our study, we hypothesize that ECCE in high-risk cataracts should result in less endothelial cell loss compared to PE and SICS. The approach to the anterior chamber is achieved through maneuvering using a bi-manual needle, followed by application to the sclera. The nucleus then carefully everted with light pressure; it is essential to ensure that no pressure is applied to the eye or cornea during this phase in order to maintain endothelial protection and the duration of nucleus removal is significantly shortened. Our results showed that endothelial cell count remained nearly intact in the Rize technique, with rapid visual recovery and a clear cornea even in the early postoperative period. Not only for mature cataract surgeries, The technique can be applied in selected cases such as PEX. A study investigated that PEX have found that endothelial cell pleomorphism was present in 65% of cases, which may be a contributing factor to endothelial dysfunction. 24 In PEX eyes or in patients with low endothelial cell count or high pleomorphism, we believe that the Rize technique may help prevent endothelial dysfunction and corneal failure. The increasing popularity of modern PE has reduced the use of ECCE, but ECCE remains relevant in cases where PE is not feasible or carries high risk. Numerous detailed surgical videos emphasize the technical aspects of PE, but there is a lack of instructional content for ECCE. One study highlighted that surgical training videos could facilitate learning ECCE. 25 We also would like share a video of the Rize technique could significantly contribute to training new surgeons. Our study has some limitations. This study has retrospective design. We compared our outcomes just with PE results but we did not make comparison with standard ECCE surgery. In conclusion, ECCE remains an essential technique for cataract surgery in cases where PE is not viable or carries significant risk. We believe the Rize technique, which overcomes the disadvantages of conventional ECCE, should be more widely adopted by surgeons to improve accessibility and surgical outcomes. Future prospective studies comparing these techniques are warranted to validate and generalize the findings. * Named in honor of the surgeon’s birthplace, Rize, a province located on the eastern coast of the Black Sea region of Turkey. Declarations Author Contribution S.S conceived and developed the surgical technique and performed all surgical procedures. G.D.G. carried out a comprehensive literature review, performed statistical data extraction, and drafted the initial version of the manuscript. Y.C.A. conducted a retrospective review of patient data and contributed to the literature review. H.S.S. participated in the literature review and contributed to manuscript writing. All authors critically revised the manuscript, approved the final version, reviewed the manuscript in its entirety, and agree to be accountable for all aspects of the work. 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Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. Ophthalmic Epidemiol. 2005;12(5):293–7. https://doi.org/10.1080/09286580591005778 Javagal A, Sandeep K, Chikkanayakanahalli K, Acharya P, Sreelekshmi SR, Narendra N. Assessment on the evaluation of corneal endothelial cell morphology and cell count in cataract with pseudoexfoliation. Indian J Clin Exp Ophthalmol. 2023;9(1):92–6. Jun Rong VP, Au B, Arundhati A, Long QB. Impact of extracapsular cataract extraction surgical instructional video on self-directed learning of surgical skills in a tertiary eye care centre. BMJ Simul Technol Enhanc Learn. 2017;5(2):114–5. doi: 10.1136/bmjstel-2017-000256 . PMID:35519831; PMCID:PMC8936876. Additional Declarations No competing interests reported. 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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-7367849","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506327367,"identity":"2d4b3805-86d9-4a1d-b126-37e8fb0ec62b","order_by":0,"name":"Şaban Şimşek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYDCCA0CcAMQS7A0MzCRq4TlAihYQkJBIIFIL3+3jjz88zKmTk5z5xvBzQYUNA397dwJeLZLncswkErcdNpaWzjGWnnEmjUHizNkNeLUYnOFhY0jcdiBxnnSOgTRv22EGA4lcQlrYH39I3FZXP0/yjPFvIrUA1SRuY06QluAxI84WyTM8YL8YzuxJK7PmOZPGQ9AvfECHffy5rU5e4vjhzbd5Kmzk+Nt78WtBAhwGIJKHWOUgwP6AFNWjYBSMglEwggAA6cxFx9TXjGgAAAAASUVORK5CYII=","orcid":"","institution":"Kartal Dr. Lutfi Kirdar City Hospital","correspondingAuthor":true,"prefix":"","firstName":"Şaban","middleName":"","lastName":"Şimşek","suffix":""},{"id":506327368,"identity":"f3733f75-edec-4443-9c24-90627265f1c4","order_by":1,"name":"Gizem Doğan Gökçe","email":"","orcid":"","institution":"Kartal Dr. Lutfi Kirdar City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gizem","middleName":"Doğan","lastName":"Gökçe","suffix":""},{"id":506327369,"identity":"781ddf80-a638-4679-af45-a96e35b6ff07","order_by":2,"name":"Yusuf Can Aydın","email":"","orcid":"","institution":"Kartal Dr. Lutfi Kirdar City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yusuf","middleName":"Can","lastName":"Aydın","suffix":""},{"id":506327372,"identity":"2dfa1446-c9f8-4e19-b016-75b99dacfe35","order_by":3,"name":"Hatice Selen Sönmez Kanar","email":"","orcid":"","institution":"Kartal Dr. Lutfi Kirdar City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hatice","middleName":"Selen Sönmez","lastName":"Kanar","suffix":""}],"badges":[],"createdAt":"2025-08-13 19:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7367849/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7367849/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90443760,"identity":"7f0dcea7-317a-48e6-87f1-9b687f1a1758","added_by":"auto","created_at":"2025-09-02 19:11:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1011971,"visible":true,"origin":"","legend":"\u003cp\u003eA:Anterior continuous and curvilinear capsulotomy approximately 6,5 mm\u003c/p\u003e\n\u003cp\u003eB:Needles are used to apply a certain amount of pressure to santral nucleus in order to reach the periphery.\u003c/p\u003e\n\u003cp\u003eC : An needle is inserted from the needle nucleus equator and rotated in the indicated direction of the arrow (for right-handed users, as far as possible from the right side of the equator).And the nucleus is rotated in the indicated arrow direction.\u003c/p\u003e\n\u003cp\u003eD,E : While one needle is being inserted into the nucleus, the other needle is inserted again into the right side of the nucleus. Steps C, D, and E are repeated 2 or 3 times, and the nucleus is moved to the anterior chamber. At this stage, if necessary, viscoelastic is injected behind the nucleus from the bag.\u003c/p\u003e\n\u003cp\u003eF: The size of the nucleus is measured, and the corneal incision is enlarged\u003c/p\u003e\n\u003cp\u003eG,H: With the help of one needle, minimal pressure is applied to slightly open the wound, making a minimal incision. At this stage, to assist with the nucleus extraction,\u003c/p\u003e\n\u003cp\u003ethe anterior chamber is filled with viscoelastic material at the 6 o'clock position. The other needle is used to displace the nucleus from the equator, allowing the nucleus to be removed.\u003c/p\u003e\n\u003cp\u003eI: The incision is sutured, thus advancing irrigation, aspiration, and lens implantation in the bag as a closed system, The subsequent steps proceed in the same manner as cataract surgery.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7367849/v1/475cdf9980bc9b005ff660e5.jpeg"},{"id":93337333,"identity":"5bd1b0b5-0848-4c28-88d0-0090e4a9f189","added_by":"auto","created_at":"2025-10-12 14:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1570117,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7367849/v1/4d765883-dfc0-43f6-a184-1115db65c5ec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does the Newly Defined Nucleus Removal 'Rize Technique' in ECCE Offer an Advantage Over Phacoemulsification in High-Risk Eyes?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCataract is the leading cause of treatable blindness\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.Treatment of cataract involves the surgical removal of the natural lens and replacement with an intraocular lens (IOL).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Currently, extracapsular cataract extraction (ECCE), manual small incision cataract surgery (MSICS), and phacoemulsification (PE) are commonly used methods for this purpose.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Due to reduced complications and better visual outcomes, small incision cataract surgery (SICS) is preferred over ECCE for cataract treatment.\u003c/p\u003e\u003cp\u003eHowever, in developing countries, issues such as surgical costs, lack of awareness, ongoing supply of consumables, and shortages of skilled human resources often hinder access to surgery.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003eFor these reasons, ECCE remains the preferred method in many third-world countries.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Also one significant challenge of ECCE surgery is the inability to consistently and centrally perform a proper capsulorhexis, as well as the difficulty in extracting the nucleus intact and placing an IOL in the capsular bag.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSuch challenges are about to be overcome this technique was developed for the safely and atraumatically nucleus removing from a 7 mm wide CCC capsulorhexis using a bimanual 27 G needle, and the IOL is placed in the bag aiming to reduce intraoperative and postoperative complications. In this study, we aim to describe the Rize technique applied to high-risk cataracts in ECCE surgeries and compare the outcomes with PE surgery .\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e The study was conducted between January 2018 and May 2024 at Dr. L\u0026uuml;tfi Kırdar Kartal City Hospital, in accordance with the principles of the Helsinki Declaration. This study was approved by the Ethics Committee of Dr. L\u0026uuml;tfi Kırdar Kartal City Hospital (Decision/Protocol No: 2024/010.99/4/10), with the approval date of May 27, 2024. This study was designed retrospectively, and the requirement for informed consent was waived by the Ethics Committee .Data from patients who underwent the Rize technique for high-risk cataracts were reviewed. The surgical procedure of the Rize technique was described in \u003cem\u003eSurgery Technique section.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEighty-one cataract patients with high-risk scores who underwent phacoemulsification (PE) were randomly selected. The patients who underwent the Rize technique in ECCE were classified as Group 1, and those who underwent PE were classified as Group 2. Surgical risk was categorized based on factors related to the eye.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eClass 3 indicated moderate risk (3\u0026ndash;5 points) and class 4 indicated (high risk, 6 points or more according to Agrawal \u003cem\u003eet al\u003c/em\u003e. study (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition to the some factors, such as corneal endothelial cell count below 1200 cells/mm\u0026sup2;, or intraoperatively; sudden deepening of the anterior chamber, anterior capsular wrinkling, difficulty in performing capsulorhexis due to zonular insufficiency, were considered as risk factors and classified as category 3.\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\u003eCataract Surgical Risk Classification\u003c/p\u003e \u003cdiv class=\"Credit\"\u003e\u003cp\u003e(Modified from Agrawal et al.)\u003c/p\u003e\u003c/div\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\u003eCategory1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCatagory 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCatagory 3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrevious vicrectomy\u003c/p\u003e\u003cp\u003eCorneal scar\u003c/p\u003e\u003cp\u003ePupil size\u0026thinsp;\u0026lt;\u0026thinsp;3mm\u003c/p\u003e\u003cp\u003eShallow AC\u003c/p\u003e\u003cp\u003eOlder than 75 years\u003c/p\u003e\u003cp\u003eMore than 6D miyopia,hyperopia\u003c/p\u003e\u003cp\u003eCapsular plaque\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMature cataract\u003c/p\u003e\u003cp\u003ePseudoexpholiation\u003c/p\u003e\u003cp\u003ePhacodonesis\u003c/p\u003e\u003cp\u003eCorneal endothelial cell count\u0026thinsp;\u0026lt;\u0026thinsp;1200 cells/mm*\u003c/p\u003e\u003cp\u003eIntraoperatively, sudden deepening of the anterior chamber*\u003c/p\u003e\u003cp\u003eAnterior capsular wrinkling*\u003c/p\u003e\u003cp\u003eDifficulty in performing capsulorhexis due to zonular\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eEach one is 1 point in catagory, 3 points in catagory4\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e*These are findings that suggest zonular weakness during surgery, and the modified version of the Agrawal et al. classification has been applied\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Exclusion criteria included prior intraocular surgeries, glaucoma, retinopathy, and failure to attend regular follow-up visits.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParameters to be evaluated\u003c/h2\u003e\u003cp\u003eThe preoperative and postoperative best corrected visual acuity (BCVA) of all patients was assessed using the Snellen chart and converted to Logmar. And also BCVA was classified as \u0026gt;\u0026thinsp;6/12, 6/12\u0026thinsp;\u0026minus;\u0026thinsp;6/60, \u0026lt;\u0026thinsp;6/60, hand motion, or light perception. Intraocular pressure (IOP) was measured using the Goldman applanation tonometer. central corneal thickness (Optikon Pacline, Optikon Corp., Rome, Italy), endhotelial cell density (EDS) (Topcon Corporation, Tokyo, Japan) and autorefractometre values were recorded,. Anterior and posterior segment characteristics were evaluated with slit-lamp biomicroscopy. Intraoperative complications, including capsule rupture, vitreous loss, iris prolapse, hemorrhage, and postoperative complications such as intraocular pressure rise that could not be controlled with medical treatment, corneal edema, cystoid macular edema, retinal detachment, endothelial cell loss, surgically-induced astigmatism, and IOL dislocation, were assessed.\u003c/p\u003e\u003cp\u003eEarly postoperative complications were defined as those occurring between the 1st day and end of 6 weeks and late postoperative complications were those that developed after the 6-week period.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgery Technique\u003c/h3\u003e\n\u003cp\u003eExtracapsular cataract extraction and phacoemulsification surgeries were performed under sub-Tenon anesthesia, using 3 cc lidocaine hydrochloride with epinephrine and 2 cc of 0.5% bupivacaine hydrochloride, following standard ocular surface and intraocular sterilization procedures.\u003c/p\u003e\u003cp\u003eA partial-thickness anterior limbal incision was made between 10 and 2 o'clock positions using a 45-degree keratome. Side-port incisions were then created at both ends of the main incision. After filling the anterior chamber with a viscoelastic agent, a full-thickness main incision was performed at the 12 o\u0026rsquo;clock position using a 2.8 mm keratome. A continuous curvilinear capsulorhexis of approximately 6.5\u0026ndash;7 mm in diameter was then completed, followed by hydrodissection and mobilization of the nucleus.\u003c/p\u003e\u003cp\u003eTwo 27-gauge needles were bent approximately 30 degrees, bevel facing upward. The main incision was extended to full thickness using the keratome. The first needle (held in the left hand) was introduced from the 12 o\u0026rsquo;clock position and inserted into the nucleus just anterior to the CCC margin, directed toward the 6 o\u0026rsquo;clock position. Once the equator of the nucleus became visible, the second needle was inserted from the right side of the equator and rotated in a circular motion to the left and anteriorly, toward the anterior capsule. While maintaining the position of the second needle, the first needle was reinserted into the right side of the equator using the same motion. Upon removal of the first needle and repeating the maneuver 2\u0026ndash;3 times, the nucleus was delivered into the anterior chamber. Additional repetitions could be performed if necessary. (For left-handed surgeons, the maneuvers are performed in the opposite direction.)\u003c/p\u003e\u003cp\u003eIf required, the main incision was enlarged laterally depending on the size of the nucleus. Viscoelastic was injected behind, in front of, and inferior (at 6 o\u0026rsquo;clock) to the nucleus. At the final stage, gentle pressure was applied on the scleral side of the incision with a cannula or needle to facilitate delivery of the nucleus. One of the bent needles was reintroduced through the main incision at 10 o\u0026rsquo;clock to push the nucleus out of the anterior chamber from behind the equator. Subsequently, the corneoscleral wound was sutured, typically using five interrupted sutures.(Fig.\u0026nbsp;1)\u003c/p\u003e\u003cp\u003eUsing this closed system, residual cortical material and epinucleus were aspirated via conventional irrigation\u0026ndash;aspiration, as in standard phacoemulsification. A foldable intraocular lens (IOL) was implanted into the capsular bag either through the sutured incision or, if spacing was inadequate, by temporarily removing one of the sutures.\u003c/p\u003e\u003cp\u003eThis technique is referred to as the **\"Rize Technique\"*.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 95 women and 67 men with mean age of 71.45\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years (range 42\u0026ndash;92 years) were included in the study. The mean age of Group 1 was 75.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 years, and the mean age of Group 2 was 67\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 years. This difference was found statistically significantly in the mean ages between the groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003cp\u003ePreoperative BCVA was2.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5Logmarin Group 1, and this classificated61 (79.5%) patients had hand motion and light perception, 16 (20.5%) patients had worse than 6/60. In Group 2 preoperative BCVA was 1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6, according to VA levels 58 (71.6%) patients had hand motion and light perception, 15 (18.5%) patients had visual acuity of 6/60 or worse, and 8(9.9%) patients had visual acuity between 6/60 and 6/12. BCVA was found significantly difference between two groups (p\u0026thinsp;=\u0026thinsp;0.04). Based on cataract risk scores, in Group 1, 32 patients (39.5%) had moderate risk and 49 patients (60.4%) had high risk, while in Group 2, 43 patients (53%) had moderate risk and 38 patients (46.9%) had high risk. There was a significant difference in the risk scores between the groups (p\u0026thinsp;=\u0026thinsp;0.04). According to cataract density, 60 (%74) patients in Group 1 and 55 (%67) patients in group 2 had mature/negro cataracts. The other patients had grade 3 cataracts, which were surgically indicated. According to cataract density there was no difference observed between two groups (p\u0026thinsp;=\u0026thinsp;0.3)\u003c/p\u003e\n\u003cp\u003eThe mean preoperative corneal endothelial cell count was1.462\u0026thinsp;\u0026plusmn;\u0026thinsp;282mm\u003csup\u003e2\u003c/sup\u003eand 2.098\u0026thinsp;\u0026plusmn;\u0026thinsp;263mm\u003csup\u003e2\u003c/sup\u003e in Group 1 an 2, respectively. In Group 1 mean of ECC was significantly lower than Group 2(p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The mean preoperative intraocular pressure (IOP) in Group 1 was 15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3mmHgand 16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 mmHg in Group 2, were similar in two group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).Preoperative mean of central corneal thickness (CCT) was 545\u0026thinsp;\u0026plusmn;\u0026thinsp;26.3 and 541\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2 micron in Group 1, Group 2 respectively.(p\u0026thinsp;=\u0026thinsp;0.6)\u003c/p\u003e\n\u003cp\u003eAll demographic data and examination findings are presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and preoperative and postoperative parameters values were shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e .\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic and Preoperative Examination Findings\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable \u003cem\u003en\u0026thinsp;=\u0026thinsp;62\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.45\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e(Female)\u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(male) \u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e95 (% 58,6)\u003c/p\u003e\n \u003cp\u003e67 (%41,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCataract Stages\u003c/p\u003e\n \u003cp\u003e(mature/negro)\u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e(grade 3)\u003cem\u003e(n, %)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e115 (% )\u003c/p\u003e\n \u003cp\u003e46(% )\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVA (Logmar)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRisc score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePreoperative and Postoperative Parameters of Group 1 (Rize Technique) and Group 2 (PE)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 38.6029%;\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003eGroup 1 (Rize Technique )\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;81\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup 2 (PE)\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;81\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e75.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eSex (n)\u003c/p\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eVisual Acuity (Logmar)\u003c/p\u003e\n \u003cp\u003epreoperative\u003c/p\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003cp\u003e0.27\u0026thinsp;\u0026plusmn;\u0026thinsp;07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n \u003cp\u003e0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;=\u0026thinsp;0.04\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eCataract stages\u003c/p\u003e\n \u003cp\u003eMature/negred(n,%)\u003c/p\u003e\n \u003cp\u003eGrade 3(n,%)\u003c/p\u003e\n \u003cp\u003eRisc score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e60 (%74)\u003c/p\u003e\n \u003cp\u003e21 (%26)\u003c/p\u003e\n \u003cp\u003e3.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e55 (%67)\u003c/p\u003e\n \u003cp\u003e26 (%33)\u003c/p\u003e\n \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.3\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;=\u0026thinsp;0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eIntraocular Pressure (mm/Hg)\u003c/p\u003e\n \u003cp\u003epreoperative postoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n \u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ep\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eEndhotelial cell count cell/ mm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003epreoperative\u003c/p\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.462\u0026thinsp;\u0026plusmn;\u0026thinsp;282\u003c/p\u003e\n \u003cp\u003e1371\u0026thinsp;\u0026plusmn;\u0026thinsp;275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.098\u0026thinsp;\u0026plusmn;\u0026thinsp;263\u003c/p\u003e\n \u003cp\u003e1868\u0026thinsp;\u0026plusmn;\u0026thinsp;229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eCentral Corneal Thickness\u003c/p\u003e\n \u003cp\u003epreoperative\u003c/p\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e545\u0026thinsp;\u0026plusmn;\u0026thinsp;26.3\u003c/p\u003e\n \u003cp\u003e577\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e541\u0026thinsp;\u0026plusmn;\u0026thinsp;20.2\u003c/p\u003e\n \u003cp\u003e587\u0026thinsp;\u0026plusmn;\u0026thinsp;32.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.6\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 38.6029%;\"\u003e\n \u003cp\u003eMean astigmatisma\u003c/p\u003e\n \u003cp\u003epreoperative\u003c/p\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003cp\u003e\u0026le;2D(n)\u003c/p\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;2D(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 33.6397%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\n \u003cp\u003e3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\n \u003cp\u003e1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.7\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eIntra-operative Complications\u003c/h3\u003e\n\u003cp\u003eIn Group 1, 5 patients experienced zonular-related vitreous loss. Three of these patients had IOLs implantation to sulcus with capsular tension rings, while the other 2 of them underwent IOL implantation with suturless scleral fixation due to severe zonular weekness. Additionally, 4 patients had anterior capsular tears extending to the equator, 1 of which were successfully completed with reverse capsulorhexis. At final in 3 patients, the IOLs could not be placed during the initial surgery and sulcus IOL implanted after 2 months.\u003c/p\u003e\n\u003cp\u003eIn Group 2, 6 patients had posterior capsule perforation and 2 of these patients required pars plana vitrectomy due to nucleus fragment drop into the vitreous. Sulcus IOL was implanted in 3 patients and suturless scleral fixation performed in the other 3 patients. Vitreous loss in 3 patients with zonular insufficiency occurred and IOLs implantation to sulcus with capsular tension rings. Four patients had anterior capsular tears extending to the equator and 2 of which were successfully completed with reverse capsulorhexis and sulcus IOL implantation performed in 2 of them. Totally IOL-in bag implanted in 73 of Group1 and 70 of Group 2. The difference between the two groups in terms of IOL placement in the bag was not found to be statistically significant. (p\u0026thinsp;=\u0026thinsp;0.4) Intraoperative complications were more commonly observed in Group 2, but this difference was not statistically significant.(p\u0026thinsp;=\u0026thinsp;0.1)\u003c/p\u003e\n\u003cp\u003eIn Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e the complications were showed.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIntraoperative Complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eİntraoperative Complication\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup 1 (Rize Technique )\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;81\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup 2 (PE)\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;81\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior Capsule Perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZonular-Related Vitreous Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnterior Capsular Tear (Extending to the Equator)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch3\u003ePostoperativeComplications\u003c/h3\u003e\n\u003cp\u003eIn Group 1, Four patients had elevated IOP\u0026thinsp;\u0026gt;\u0026thinsp;21 mmHg, which was controlled with medical treatment. Four patients which experienced Seidel\u0026apos;s sign with the mean IOP was 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2.In these 4 patients and the additional other 3 patients who had iris prolapse to the corneal incision area, suture revision was performed in 7 patients.In Group 2, six patients had elevated IOP\u0026thinsp;\u0026gt;\u0026thinsp;21 mmHg which was controlled with medical treatment.\u003c/p\u003e\n\u003cp\u003ePostoperatively first week;Group 1\u0026rsquo;s mean CCT was 576\u0026thinsp;\u0026plusmn;\u0026thinsp;29.5 mand Group 2\u0026rsquo; s was: 587\u0026thinsp;\u0026plusmn;\u0026thinsp;35.3 m. There was a significantly difference found in mean CCT of first week values between Group 1 and Group2 (p\u0026thinsp;=\u0026thinsp;0.03) .\u003c/p\u003e\n\u003cp\u003eEvaluation of late post-operative complications, Irvine-Gass syndrome (IRG) was detected inone patient in Group 1. In Group 2, 3 patients developed IRG, and 3patients required Descemet Membrane Endothelial Keratoplasty (DMEK) surgery related to endothelial defficiency. The differences of late post-operative complication numbers oftwo group was not found significantly.( p\u0026thinsp;=\u0026thinsp;0.054) In Group 1, the mean suture removal time was 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 months. After suture removal, The mean astigmatism values were 3.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05 and 1.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 respectly in Group 1 and Group 2. In Group 1 this was significantly higher (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). There were 62 (%76) patients with an astigmatism value greater than 2.0D, and 28(%34) patients in Group 1.\u003c/p\u003e\n\u003cp\u003eAt the 6-month visit, the corneal endothelial cell count in Group 1 was 1371\u0026thinsp;\u0026plusmn;\u0026thinsp;275 cell/ mm\u003csup\u003e2\u003c/sup\u003e, Group 2 was 1868\u0026thinsp;\u0026plusmn;\u0026thinsp;229 cell/ mm\u003csup\u003e2\u003c/sup\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). And the difference between the mean of peroperative and postoperative cell counts were 102\u0026thinsp;\u0026plusmn;\u0026thinsp;52.4cell/ mm\u003csup\u003e2\u003c/sup\u003e and 272\u0026thinsp;\u0026plusmn;\u0026thinsp;167 cell/ mm\u003csup\u003e2\u003c/sup\u003erespectely.This difference in endothelial cell loss between the two groups was statistically significant.(p\u0026thinsp;=\u0026thinsp;0.005)\u003c/p\u003e\n\u003cp\u003eThe mean final BCVAwas 0.27\u0026thinsp;\u0026plusmn;\u0026thinsp;07 Logmar in Group 1 and 0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13 Logmar in Group 2.There was no significantly difference between two groups.(p\u0026thinsp;=\u0026thinsp;0.2) On the other hand In Group 1, 50 patients had a visual acuity higher than 6/60, while in Group 2, 65 patients had a visual acuity higher than 6/60. This difference in visual acuity of 6/60 was found to be statistically significant (p\u0026thinsp;=\u0026thinsp;0.02)\u003c/p\u003e\n\u003cp\u003eAll results showed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we described a non-traumatic and safe method of extracting the nucleus, approximately 8.0-8.5 mm in size, from a 6,5mm CCC using two 27G needles in the Rize technique. When compared to PE in high-risk cataract surgeries, the Rize technique demonstrated lower complication rates and allowed early recovery withless corneal endothelial loss.\u003c/p\u003e\u003cp\u003eMany studies pointed out that outcomes and costs of ECCE and PE were widely different. Some studies found that PE performed by an experienced surgeon yielded better clinical results than planned ECCE but at higher costs.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Other studies confirmed that PE leads to better visual acuity and fewer complications compared to ECCE, although it involves higher costs.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e These studies examining all stages of cataract found similar results.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e However, when focusing on high-risk cataract cases, studies have shared ECCE outcomes, suggesting that ECCE might be a safer option in mature cataracts.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePE surgeries in high-risk eyes, especially those with advanced cataracts or pseudoexfoliation (PEX), have a higher risk of complications such as posterior capsule rupture and vitreous loss. In our study, we observed that in the PE group, advanced cataracts with PEX were associated with a higher incidence of posterior capsule rupture.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Mohanty et al. emphasize that PE, MSICS and ECCE each have their importance and should be tailored to the cataract\u0026rsquo;s risk factors. In their study, 6 patients in 207 patients developed posterior capsule rupture intraoperatively, with sulcus IOL placement in some and anterior chamber IOL implantation in one patient.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In contrast, in our study, even though Group 1 had more high-risk patients, the complication rates were lower, and 72 of the 81 patients successfully received an IOL placed within the bag. In can-opener capsulorhexis, anterior capsule tears can occur, potentially compromising the centration of the IOL.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e The ideal anatomical placement of the IOL is within the bag, where it has the highest stability and better optical resolution.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e In the Rize technique, performing a CCC ensures a safe space for PCIOL implantation, with the smooth edges of CCC providing additional strength.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e For PE surgery, the appropriate capsulorhexis size ranges from 5 to 6 mm. In eyes with weak zonules, capsulorhexis may be enlarged by 0.5-1.0 mm to prevent capsule contraction, with an average optimal size of 5.5 mm\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. In our study, we found that a 7mm capsulorhexis was ideal for non-traumatic, single-piece nucleus extraction. By using two 27G needles, the nucleus can be easily removed from this range, and PCIOL can be safely placed, providing a low-cost, accessible approach.\u003c/p\u003e\u003cp\u003eAnother important contribution of the Rize technique is its ability to reduce endothelial cell loss. In study where 186 cataractous eyes with nuclear sclerosis\u0026thinsp;\u0026le;\u0026thinsp;grade 3 were randomized for ECCE, SICS, or PE with PMMA lens implantation, no significant difference in endothelial cell loss was observed among the groups\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In our study, we hypothesize that ECCE in high-risk cataracts should result in less endothelial cell loss compared to PE and SICS. The approach to the anterior chamber is achieved through maneuvering using a bi-manual needle, followed by application to the sclera. The nucleus then carefully everted with light pressure; it is essential to ensure that no pressure is applied to the eye or cornea during this phase in order to maintain endothelial protection and the duration of nucleus removal is significantly shortened. Our results showed that endothelial cell count remained nearly intact in the Rize technique, with rapid visual recovery and a clear cornea even in the early postoperative period. Not only for mature cataract surgeries, The technique can be applied in selected cases such as PEX. A study investigated that PEX have found that endothelial cell pleomorphism was present in 65% of cases, which may be a contributing factor to endothelial dysfunction.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e In PEX eyes or in patients with low endothelial cell count or high pleomorphism, we believe that the Rize technique may help prevent endothelial dysfunction and corneal failure.\u003c/p\u003e\u003cp\u003eThe increasing popularity of modern PE has reduced the use of ECCE, but ECCE remains relevant in cases where PE is not feasible or carries high risk. Numerous detailed surgical videos emphasize the technical aspects of PE, but there is a lack of instructional content for ECCE. One study highlighted that surgical training videos could facilitate learning ECCE. \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e We also would like share a video of the Rize technique could significantly contribute to training new surgeons.\u003c/p\u003e\u003cp\u003eOur study has some limitations. This study has retrospective design. We compared our outcomes just with PE results but we did not make comparison with standard ECCE surgery.\u003c/p\u003e\u003cp\u003eIn conclusion, ECCE remains an essential technique for cataract surgery in cases where PE is not viable or carries significant risk. We believe the Rize technique, which overcomes the disadvantages of conventional ECCE, should be more widely adopted by surgeons to improve accessibility and surgical outcomes. Future prospective studies comparing these techniques are warranted to validate and generalize the findings.\u003c/p\u003e\u003cp\u003e* \u003cem\u003eNamed in honor of the surgeon\u0026rsquo;s birthplace, Rize, a province located on the eastern coast of the Black Sea region of Turkey.\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.S conceived and developed the surgical technique and performed all surgical procedures. G.D.G. carried out a comprehensive literature review, performed statistical data extraction, and drafted the initial version of the manuscript. Y.C.A. conducted a retrospective review of patient data and contributed to the literature review. H.S.S. participated in the literature review and contributed to manuscript writing. All authors critically revised the manuscript, approved the final version, reviewed the manuscript in its entirety, and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request and are provided in an Excel file format.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeite Arieta CE, de Oliveira DF, de Carvalho Lupinacci AP, Novaes P, Paccola M, Jose NK, Limburg H. Cataract remains an important cause of blindness in Campinas, Brazil. Ophthalmic Epidemiol. 2009;16(1):58\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtallah MR, Amescua G. Cataract Extraction: Extracapsular (ECCE). In: Rosenberg ED, Nattis AS, Nattis RJ, editors. Operative Dictations in Ophthalmology. 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PMID:30900573; PMCID:PMC6446625.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRandleman JB, Ahmed IIK, editors. Intraocular Lens Surgery. New York: Thieme Medical Publishers; 2016:10\u0026ndash;8, 138\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKranitz K, Takacs A, Mihaltz K. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011;27:558\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArshinoff S. Mechanics of capsulorhexis. J Cataract Refract Surg. 1992;18:623\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeorge R, Rupauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. 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PMID:35519831; PMCID:PMC8936876.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7367849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7367849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo define the new technique for nucleus removal and to compare the surgical outcomes of this technique with phacoemulsification (PE) surgery in high risky cataracts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe Rize technique in Extracapsular Cataract Extraction (ECCE) was described which involves the extraction of the nucleus through a 6,5-7 mm continuous curvilinear capsulorhexis (CCC) using two 27-gauge needles, and placement of the in intraocular lens (IOL) into the capsular bag\u003cstrong\u003e. \u003c/strong\u003ePre and postoperative findings, early and late-stage complications were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe mean age was 71.5±11.3 years (range: 42-92 years). In Group 1 (Rize technique), 32 patients (39.5%) had moderate risk, and 49 patients (60.5%) had high-risk cataract. In Group 2 (PE), 43 patients (53.1%) had moderate risk, 38 patients (46.9%) had high-risk cataracts (p=0.03). In Group 1;9 patients and in Group 2;13 patients experienced complications, including vitreous loss, zonular dialysis, and anterior capsular tears extending to the periphery (p=0.1). Group 1’s 73 (% 90) patients Group 2’s 70(% 86) patients had IOLs placed in the bag (p=0.4).Postoperatively, BCVA (≥6/12) was achieved in 50 patients (%61 ) in Group 1 and 65 patients (% 80) in Group 2 and the differences between two group was not statistically significant (p =0.1).The endothelial cell loss was statistically significant higher in group 2 (272± 167 cells/mm²) than group 1 (102± 52.4)(p=0.005). Postoperative astigmatism greater than 2D for 62 patients (76.5%) in Group 1 and 28 patients (34.5%) in Group 2(p\u0026lt;0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThe Rize technique for nucleus extraction is an effective and nontrauvmatic method.\u003c/p\u003e","manuscriptTitle":"Does the Newly Defined Nucleus Removal 'Rize Technique' in ECCE Offer an Advantage Over Phacoemulsification in High-Risk Eyes?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-02 19:11:08","doi":"10.21203/rs.3.rs-7367849/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd32295b-2337-4d3e-8638-a69b79ab2ca0","owner":[],"postedDate":"September 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-12T14:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-02 19:11:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7367849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7367849","identity":"rs-7367849","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}