Eyeworld

JULY 2021 | EYEWORLD | 89 C capsule with forceps for the capsulorhexis. "The spider sign occurs because the anterior capsule sags backward as the downward force is applied," he explained. As you're pulling the rhexis flap, the anteri- or capsule and bag will move, creating distinc- tive folds in front of the flap, if the zonules are weak, Dr. Kim continued. He added that capsule retractors can be placed behind the tear to pro- vide counterforce if the rhexis flap doesn't tear effectively. With hydrodissection, if the lens doesn't spin easily with the cannula, this could suggest zonulopathy. Dr. Kim said the surgeon should stop trying to spin the lens, as it could damage zonules further. When performing phaco, especially with current generation phaco units that can achieve high vacuum, Dr. Kim said any trampolining of the lens would be a sign of zonulopathy. Other intraoperative signs of zonulopathy, according to Dr. Kim, include the straight line sign, which occurs when there's striae parallel to the limbus around the peripheral capsular bag. Aggressive I/A in this case can cause the capsular bag to collapse into the I/A tip. In cases of zonulopathy, avoid pulling toward the center with I/A, opting for tangential movement with lower vacuum levels. Zonulopathy management Mild zonulopathy can be fairly uneventful in routine cataract surgery, provided key strategies are used to prevent further zonular damage, Dr. Kim said. More severe cases at risk for lens decentration, dislocation, or posterior capsule rupture and dropped lens require more ad- vanced surgical tools and techniques. "With proper planning one can achieve a successful cataract removal and a well-centered IOL," Dr. Kim said Trypan blue can be used to help visualize the capsulorhexis edge, which is important when capsule support devices are needed, Dr. Kim said. Dr. Kim advised capsule retractors, rather than iris hooks, due to their ability to support the bag, providing a wider base and longer reach for deeper capsular fornix support. He said he would use a capsular tension ring in cases of mild zonulopathy or those with 3 clock hours or less of zonular dehiscence. "My preferred technique is to use an injector for the CTR with a Sinskey hook. As the CTR is being delivered, the Sinskey hook is used to hook the leading eyelet, and the Sinskey hook holds the leading part of the CTR and reduces torsional stress on the capsular bag and zonules," Dr. Kim explained. If zonulopathy is more severe or zonular dehiscence is greater, he said he might use a CTR with extra support like a capsular tension segment with Gore-Tex sutured to the sclera. He said practicing skills in preparation for more advanced cases like this is imperative. Reference 1. Kim DB. Cross chop: Modified rotationless horizontal chop technique for weak zonules. J Cataract Refract Surg. 2009;35:1335–1337. Relevant disclosures Fram: None Kim: None If the rhexis flap doesn't tear effectively, capsule retractors can be placed behind the tear to provide a counterforce. The straight line sign: If you see a straight line parallel to the limbus around the peripheral capsular bag, this is a sign of focal zonular dehiscence. Source (all): D. Brian Kim, MD continued on page 90

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