Risks of Capsular Tension Ring Implantation May Outweigh Vision Benefits

A recent study analyzing the influence of capsular tension ring (CTR) implantation on intraocular lens (IOL) position and IOL tilt in patients without crystalline lens dislocation or zonular rupture supports the association between CTRs and enhanced stability of IOL rotation. However, it is associated with reduced IOL tilt in high myopia and may increase anterior chamber depth (ACD) in eyes implanted with plate haptic IOLs.1

Despite the frequent use of CTRs in cataract surgery, their actual effect on plate stability and ACD is still debated. Prior studies have proven contradictory, with some indicating a deeper ACD because of CTR usage.1

“It remains uncertain whether CTR can stabilize the IOL position with different haptic designs or in certain patient populations,” wrote Haowen Lin, MD, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, and colleagues. “A systematic review of the impact of CTR on IOL position is warranted to elucidate the indications for CTR implantation.”1

The team’s previous study, a randomized clinical trial (RCT), suggested CTR implantation could reduce the C-loop IOL decentration and tilt in eyes with ≥30mm axial length (AL), but was unable to affect ACD in patients with high myopia. However, other studies indicated the opposite, with CTR not decreasing IOL decentration or tilt in normal eyes. Investigators noted the limited effect of CTR in normal eyes was largely due to normal IOL decentration and tilt in the study population.2

This systematic review and meta-analysis collected studies from PubMed, Embase, and Cochrane Library. Inclusion criteria included RCTs or cohort studies involved patients undergoing cataract surgery, some with CTRs implanted, and studies reporting data on IOL rotation, decentration, tilt, or ACD after cataract surgery. Studies involving patients with crystalline lens dislocation or zonular rupture were excluded, along with those without a control group.1

An initial total of 1545 publications were included; after removing duplicates and screening titles and abstracts, 52 articles were selected for full review. A final total of 18 were included in the final study. In total, 809 eyes with CTR and 822 without were examined, with 772 included for ACD assessment, 822 for IOL decentration assessment, 862 for IOL tilt assessment, and 821 for IOL rotation assessment. 7 studies included patients with high myopia, while the remaining 11 enrolled patients with non-specific ocular conditions.1

Lin and colleagues found IOL tilt (mean difference [MD], -1.04°; 95% CI, -2.05° to -.03°; P = .04) and rotation (MD, -.82°; 95% CI, -1.27° to -.37°; P <.001) were lower in the CTR group than control. No difference was noticed in ACD (MD, .01°; 95% CI, -.03° to .04°; P = .72) or IOL decentration (MD, -.05 mm; 95% CI, -.12 to .02 mm; P =.15) between the 2 groups.1

Subgroup analysis of ACD (I2 = 70.7%, P = .03), decentration (I2 = 66.5%, P = .08), and tilt (I2 = 76.7%, P = .01) revealed heterogeneity among the subgroups stratified by IOL haptic design. Subgroup analysis also demonstrated a deeper ACD in eyes implanted with plate haptic IOLs in the CTR group (MD, .11 mm; 95% CI, .02 to .20 mm; P = .01) and a smaller IOL tilt in highly myopic eyes (MD, -1.43°; 95% CI, -2.59° to -.26°; P = .02) compared with control. No difference was identified in the remaining subgroup analyses.1

Despite the clarity of these results, Lin and colleagues acknowledged several limitations inherent in the study structure. A limited number of included publications, particularly in regard to IOL rotation analysis, and substantial heterogeneity in IOL decentration, tilt, and rotation meta-analysis inhibited the study’s ability to determine CTR in a larger population.1

“CTR implantation also may increase ACD in eyes implanted with plate haptic IOLs, associated with a hyperopic refractive shift that may require target refraction adjustment,” Lin and colleagues wrote. “The clinical relevance of these findings merits further study.”1

References

1. Lin H, Zhang Y, Xie X, et al. Capsular tension ring implantation for intraocular lens position. JAMA Ophthalmology. Published online June 12, 2025. doi:10.1001/jamaophthalmol.2025.1623

2. Lin H, Zhang J, Zhang Y, et al. Capsular tension ring implantation for intraocular lens decentration and tilt in highly myopic eyes. JAMA Ophthalmology. 2024;142(8):708. doi:10.1001/jamaophthalmol.2024.2215