Eyeworld

EW CATARACT 45 October 2018 device to place the fixation element at the very center of the zonular de- fect, in order to replace the missing zonules. The fixation element was repositioned on top of the anterior capsule. Then the suture was passed through the ciliary sulcus. The resid- ual cortical material was evacuated, and the IOL was implanted into the capsular bag." It can be useful to inject tri- amcinolone into the eye to iden- tify vitreous matter in the anterior chamber. If a vitreous prolapse is identified, vitrectomy is required. Dr. Malyugin proposed the use of a dry vitrectomy to not hydrate the vitreous, and apply viscoelastic to reposition it into the posterior chamber. "I use 9-0 polypropylene to fixate the eyelet of the CTR, which is partially retracted inside the injector tube, then I inject the device toward the zonular defect," he said. "The reason for this is be- cause when I have relatively healthy zonules in some areas, I take care to preserve the residual zonules and keep them from unzipping. It is also important to not press on the lens while injecting the CTR because in doing so you will induce the pro- lapse of the vitreous. Even with the modified CTR sutured to the scleral wall, the surgeon has to remember that vitreous can still seep through the zonular defect and excessive hydration of it should be avoided. "CTRs should be implanted as late as possible and as soon as necessary. The reason for that is because it compresses the cortical material to the equator and you can have a hard time evacuating cortical material during irrigation/ aspiration, which then takes much longer," Dr. Malyugin said. "Insert them at the very beginning of the case, following the anterior CCC, or after capsular bag content evac- uation. In eyes with generalized zonular laxity, use a combination of capsular tension segments (CTS) plus CTR, for instance the Malyugin CTR plus Ahmed CTS. In patients with zonular deficiency, be prepared for much longer surgical time and the right anesthesia, and do proper patient counseling. Finally, always have a backup plan because you cannot guarantee that the capsular bag will be intact or will be pre- served during the surgery. I always ask my assistant to prepare not only a single-piece but also a three-piece IOL because I may have to change the plan and suture the lens to the iris or fixate it to the sclera." EW Editors' note: Dr. Malyugin has finan- cial interests with Morcher (Stuttgart, Germany). Contact information Malyugin: boris.malyugin@gmail.com

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