Eyeworld

90 | EYEWORLD | JULY 2021 ATARACT C Contact Fram: DrFram@avceye.com Kim: kim@professionaleye.com interface, and hybrid applanation/liquid inter- face allow for more stable and stronger capsulo- tomies, she said. Dr. Fram thinks the benefits of FLACS for zonulopathy cases are three-fold. First, it cre- ates a perfectly centered and sized capsulotomy, which is important in the setting of shallow chambers and pseudoexfoliation eyes, which are susceptible to capsule contraction. Second, the "pre-chop" fragmentation facilitates easier lens manipulation. Third, pneumodissection from the femtosecond laser bubbles reduce the need for hydrodissection and minimize the need for lens rotation. "All of these factors improve reproducibility of a complex surgery," she said, adding that her practice recently evaluated 32 eyes that had FLACS with Chang Modification capsule retrac- tors. In this review, there were two tears in the anterior capsule, both in aniridic eyes, which Dr. Fram said are known to be more friable. Dr. Fram said FLACS capsulotomy should be avoid- ed in aniridic eyes. Dr. Kim said he doesn't perform FLACS, but he thinks it has an advantage in creating a perfect capsulotomy and in lens segmentation. One drawback could be that some of the clues of zonulopathy are seen in certain stages of manual cataract surgery and would be lost in FLACS, he noted. Though he doesn't have experience with an automated capsulotomy device like Zepto (Centricity Vision) or miLOOP (Carl Zeiss Med- itec), Dr. Kim said these tools could be helpful in cases with zonulopathy. "There are many complex cataract surgery wet labs including at the ASCRS Annual Meet- ing and the AAO Annual Meeting. There are also model eyes such as the SimulEye [InsEYEt], which is easily accessible and can be practiced in the comfort of your own operating room," Dr. Kim said. Once any support devices are placed, Dr. Kim described "zonule-friendly lens disassem- bly." This includes using a technique that doesn't depend on a mobile lens or sculpting. "I developed double chop and cross chop, which enable the surgeon to divide the lens into smaller pieces without needing to rotate the lens within the capsular bag," 1 Dr. Kim ex- plained. "Learning new skills to disassemble the lens with minimal zonular stress can be a game changer for these situations." For IOL selection, Dr. Kim thinks a three- piece IOL is better for these cases. "If the IOL dislocates in the future, a single- piece acrylic IOL might have to be explanted and replaced, which results in a bigger surgery. In contrast, a three-piece acrylic IOL can be sal- vaged and secured by lassoing it with Gore-Tex sutured to the sclera," he said. Dr. Fram follows a similar technique for milder zonulopathy vs. more severe cases. She said she'll use capsule retractors, such as Chang Modification (MicroSurgical Technology), and a CTR for less than 3 clock hours of zonulopa- thy. Ahmed segments (Morcher) and Gore-Tex sutures can be used if the capsulorhexis doesn't center after CTR placement, she said. "Another indication for fixation with CTR segments, Cionni ring [Morcher], or modified Malyugin CTR [Morcher] includes diffuse zonu- lopathy. If the IOL is in the bag and the entire complex is mobile with clear pseudophacodo- nesis, it is important to fixate the capsule bag to the sclera as the CTR alone may not be a defin- itive solution. This is particularly important in the case of a planned toric or diffractive/EDOF IOL placement," Dr. Fram said. Zonulopathy and FLACS More modern settings on femtosecond lasers have improved capabilities that Dr. Fram said can have benefits in cataract cases that include zonulopathy. New settings including increased speed of the capsulotomy, flat docking, contact lens interface on the applanation system, liquid Atraumatic CTR insertion technique: The injector for the CTR is used with a Sinskey hook. As the CTR is delivered into the capsular bag, the Sinskey hook is used to hook the leading eyelet of the CTR to reduce torsional stress on the capsular bag and zonules. Source: D. Brian Kim, MD What's new? Dr. Fram included a few newer concepts and devices in her discussion on zonulopathy. She said there is a concept of a "dead bag," coined by Samuel Masket, MD. Such capsules have little to no fibrosis and over time will present with zonulopathy and a dislocated IOL-bag complex if the issue occurs near the zonule. Dr. Fram said Liliana Werner, MD, and Nick Mamalis, MD, have been examining specimens of this and have found that the capsules appear to resemble true exfoliation or delamination of the capsule. "Of note, these capsules do not hold anchoring segments well secondarily, and the best approach is an IOL exchange in these patients," Dr. Fram said. She also mentioned two OUS sutured segments that are showing promise: AssiAnchor designed by Ehud Assia, MD, and the Paperclip Capsule Stabilizer designed by Soosan Jacob, MD. Dr. Fram brought up the X1 Iris Speculum (Diama- trix), which, though indicated for iris expansion, has shown in an off-label capacity the ability to stabilize the capsule in cases of zonulopathy. continued from page 89

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