EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/1160558
I CHALLENGING CATARACT CASES N FOCUS avoids placing stress on the capsular bag during nucleus division. He recommended caution during cortex removal to avoid further zonular compromise and careful IOL selection and placement to offer the best long-term results. Dr. Devgan recommended hydrodissection in which he tilts the nucleus on its side then begins to chop and use phacoemulsification. Sometimes signs of zonular weakness appear intraoperatively. "Using phaco chop, we can bring each nuclear half out of the capsular bag and into the iris plane for aspiration. If the shape of the capsulorhexis morphs from round to D-shaped, for example, during cortex removal using irrigation/aspiration, it indicates zonular loss along the flat surface. The ideal next step is to implant a capsular tension ring or a Cionni ring to bolster the weak area and to provide stability for IOL implantation," Dr. Devgan said. In the absence of the appropriate devices, the surgeon can use the IOL's haptics to pro- vide support. Dr. Devgan suggested implanting the IOL so that one haptic is placed along the area of zonular weakness. This haptic will exert an outward force supporting the capsular bag equator, resulting in a well-centered optic. Femto advantage Dr. Miller relies on a femtosecond laser when zonular weakness threatens to complicate cataract surgery. "Capsulorhexis is often very difficult in these eyes because the lens wants to follow you when you're doing a manual cap- sulorhexis. It is also stressful on the remaining zonules. If I can use a femto laser when a lens is not too far displaced, I prefer that. A lens capsule that is less than 2–3 mm off axis that I can visualize enough of to put down the treat- ment pattern is a great candidate for a femto- second laser capsulorhexis," Dr. Miller said. of the capsulorhexis, it should puncture easily. But if we see radial wrinkles from our attempt- ed puncture and the anterior capsule is not tightly stretched, this indicates zonular laxity. This is difficult to puncture and is an important warning sign that zonular weakness may pose challenges and induce complications during cataract surgery," he said. Dr. Devgan makes a generous capsulor- hexis between 5 and 5.5 mm in diameter and continued from page 61 62 | EYEWORLD | SEPTEMBER 2019 A situation surgeons hope to avoid by recognizing the extent of zonular laxity in cataract surgery Source (all): Kevin M. Miller, MD Diffuse zonulopathy associated with chronic ocular issues