Eyeworld

I CHALLENGING CATARACT CASES N FOCUS 60 | EYEWORLD | SEPTEMBER 2019 by Stefanie Petrou Binder, MD EyeWorld Contributing Writer role in the approach a surgeon takes to cataract surgery. EyeWorld interviewed Uday Devgan, MD, and Kevin M. Miller, MD, to gain insight into this frequently encountered clinical entity and learn how to best deal with it. Identify zonulopathy Identifying zonulopathy will allow the surgeon to plan cataract surgery for the patient, select the appropriate devices, and prepare for the management of potential zonulopathy-related complications. Zonulopathy can be segmental, which is most commonly traumatic or iatrogen- ic, or diffuse, as seen in eyes with pseudoexfo- liation syndrome, retinitis pigmentosa, reti- nopathy of prematurity, extreme age, extreme myopia, multiple previous pars plana vitrec- tomies, or with silicone oil tamponade. Addi- tionally, systemic conditions associated with diffuse zonulopathy include Marfan syndrome, homocystinuria, Weill-Marchesani syndrome, Ehlers-Danlos syndrome, Rieger syndrome, sul- fite oxidase deficiency, and Crouzon syndrome. The preoperative evaluation is important to differentiate acquired zonulopathy from chronic issues, according to Dr. Devgan. "Patients with a history of recent trauma can have zonular compromise, usually for just a few clock hours, and this is not expected to worsen in the future as long as additional trauma can be avoided. However, patients with chronic ocular issues such as pseudoexfoliation and retinitis pigmen- tosa will likely see progression of the zonulopa- thy in the future. Even systemic conditions such as Marfan syndrome, homocystinuria, and other diseases can cause a progressive deterioration of zonular strength with age," Dr. Devgan said. The manner in which zonulopathy pres- ents itself is highly varied and necessitates a sharp eye on the part of the surgeon. "At the slit lamp, we can often see areas of zonular loss with good dilation," Dr. Devgan said. "Other times, the extent of the zonular loss is so significant that there is phacodonesis with movement of the entire crystalline lens with eye movement. In extreme cases, the entire lens Z onulopathy is encountered in a wide spectrum of clinical situations. Syn- onymous with zonular dehiscence or zonular dialysis, it describes a weakened state of zonular support that affects the integrity of the lens capsule unit and plays an important Be prepared for loose zonules Sectoral zonulopathy of a few clock hours Source (all): Kevin M. Miller, MD Diffuse zonular laxity, as seen in this retroillumination slit lamp photograph, can make cataract surgery challenging.

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