Eyeworld

88 | EYEWORLD | JULY 2021 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Nicole Fram, MD Advanced Vision Care Los Angeles, California D. Brian Kim, MD Private Practice Professional Eye Associates Dalton, Georgia The spider sign is seen when puncturing the anterior capsule for capsulorhexis. The central anterior capsule stretches and forms striae toward the puncture point, creating a spider-like appearance because the anterior capsule sags backward as the downward force is applied. If the zonules are weak, the force used to pull the flap can cause the capsular bag to move and creates distinctive folds in front of the flap as it is being pulled. Source (all): D. Brian Kim, MD T here are many potential complications cataract surgeons need to prepare for in the OR. One of them is zonulopathy. "Recognizing zonulopathy and adopting strategies to mitigate zonular damage is critically important not only for short-term success but perhaps more important- ly long-term success to reduce the risk of late IOL dislocation," said D. Brian Kim, MD. Preoperative recognition Past ocular history such as trauma, retinitis pigmentosa, angle closure glaucoma attack, a family history of ectopia lentis, or history of pseudoexfoliation "should raise your index of suspicion for zonulopathy," Dr. Kim said. He also said a small pupil coupled with a dense cataract should be treated like a case with loose zonules "until proven otherwise." Nicole Fram, MD, said that obvious signs include areas of missing zonules, such as colo- bomatous changes, Marfan syndrome, pseudo- exfoliation with phacodonesis, and traumatic cataract. More subtle signs include pseudoex- foliation in the setting of a shallow chamber, asymmetric shallowing of the AC where the depth changes as the anterior chamber is examined. "Surgeons should always proceed with caution in patients with pseudoexfoliation, high myopia, history of PPV or trabeculectomy, uveitis or retinopathy of prematurity, aniridia. All of these conditions cause a disturbance of the blood aqueous barrier and can lead to weak zonules," Dr. Fram said. Intraoperative signs and management One has to constantly be on the lookout for zonulopathy at various stages in the case, Dr. Kim said. "Unfortunately, patients often may not show signs of zonulopathy until you are in the operating room," he said. There might be signs of zonulopathy before even starting your incision. Dr. Fram said if you see more of the edge of the crystalline lens than normal or if there is a jiggle indicative of phacodonesis, these are warning signs of loose zonules. Dr. Kim said cases with zonulopathy or zonular laxity will see the lens move backward more than usual when filling the anterior cham- ber with OVD. Another opportunity to identify zonulopa- thy is when starting the capsulorhexis. "There is often striae resembling elephant's skin, indicating weak zonules," Dr. Fram said. "In the moment, you can stain with trypan to make sure the rhexis edge can always be identified." Dr. Kim described this as the spider sign, which occurs when just puncturing the anterior Recognizing zonulopathy and what to do

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