SEPTEMBER 2023 | EYEWORLD | 29
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this, a scleral-fixated CTR, like a Cionni ring,
is indicated. "There are times where you place
a standard CTR but you realize that there is
insufficient zonular support," he said. "In these
cases, you can combine a suture-fixated Ahmed
capsular tension segment with a standard
CTR. I use a sclerally fixated Cionni CTR in
all Marfan syndrome patients."
Dr. Hart said he thinks surgeons should
practice using CTRs in pseudoexfoliation
syndrome patients when the placement is
relatively easy. "That way when they encounter
more complex zonular abnormalities, they are
more comfortable using CTRs," he said. "It is
important to dedicate extra OR time when you
are operating on someone with zonular abnor-
malities. These cases typically take longer than
routine cases. There is no shame in referring
these patients out to surgeons who routinely
handle these cases."
for CTR placement to prevent loss of the device
into the vitreous cavity." He also mentioned that
the 'S' sign when placing a CTR is an important
warning that should alert the surgeon to stop
and attempt a different manner of CTR place-
ment, noting an article from the Journal of Cata-
ract & Refractive Surgery that discussed this.
1
Additional considerations
Dr. McKee cautioned that when using a CTR,
you should avoid sulcus placement or attempted
placement in a torn/broken capsule.
Other problems can accompany zonular
damage, Dr. McKee said, such as vitreous pro-
lapse, iris damage, peripheral retinal tears, and
cystoid macular edema. "A CTR is often used in
a complex case, and a high index of suspicion
for other problems should be present."
Dr. Hart said that as a general rule for three
or less clock hours of zonular dialysis, you can
use a standard CTR. If the dialysis is larger than
