Eyeworld

SPRING 2026 | EYEWORLD | 51 C Lenses for mild zonulopathy When choosing a lens, Dr. Kim said a three- piece acrylic IOL is preferable to a single-piece acrylic IOL. "In my opinion, a three-piece IOL provides more equatorial capsule support due to the relative stiffness of the haptics," he said. "Furthermore, if the IOL/bag complex sublux- ates in the future, one can scleral fixate the existing three-piece IOL, which for me is the Sensar AR40 lens [Johnson & Johnson Vision], to perform the Yamane technique." Although studies have shown that a CTR does not prevent lens/bag dislocation, a CTR is helpful if the lens/bag complex dislocates in the future by scleral suture fixating the lens/bag/ CTR complex, Dr. Kim said. Sulcus fixation with optic capture with a three-piece IOL is another strategy that can be used to minimize capsule contraction, which can stress the zonules. "In my opinion, this is a good option for mild zonu- lopathy but not for severe cases." Dr. Kim said he encounters mild zonulop- athy regularly, and it occurs with hypermature cataracts, post-vitrectomized eyes, post-trauma, and pseudoexfoliation. Dr. Verkade said her preference is a three- piece IOL. If you have a case of mild or diffuse zonulopathy, a three-piece IOL, particularly coupled with a CTR, can make the bag complex much more stable. Additionally, Dr. Verkade said that placing a three-piece IOL or a CTR allows her to have something to fixate later in case there is further dislocation down the road. Zonulopathy during surgery Dr. Kim said there are also signs of zonulopa- thy while doing a case. "A keen awareness and active observation are required so that you are not taken off guard to avoid iatrogenic zonular dehiscence or posterior capsule rupture." Starting from the beginning of the case, he mentioned several signs to look out for: 1. Filling the anterior chamber with OVD: The lens/bag complex may push backward much more than it should, he said. 2. Puncturing the anterior capsule: Dr. Kim said the spider sign is when you attempt to puncture the central anterior capsule, but it fails to puncture and simply pushes backward from lack of zonular support, resulting in striae that looks like a spider. "A sharp instrument or two-handed technique may be required to grasp and fixate the capsule with forceps while puncturing with the other hand with a cystotome or sharp forceps." 3. Striae folds within the capsulorhexis flap: The lack of zonular support causes striae and difficulty pulling the rhexis flap with hypermobility of the lens/bag complex. Dr. Kim said adding capsule retractors is help- ful for counter fixation. 4. Hyper-deepening of the AC from infusion pressure: When placing the phaco probe in the eye, the infusion pressure can cause an unusually deep AC from the lens/bag complex being pushed backward. "If there is reverse pupillary block, you can lift the pupillary edge to break it," Dr. Kim said. Consider switching to a lower flow setting, i.e., lower the bottle height, lower vacuum, and be judicious with ultrasound. However, lower infusion pressure means the chamber might be less stable, and careful foot pedal modulation is necessary to avoid chamber shallowing. 5. Difficulty spinning the lens after hydrodis- section: Trouble spinning the lens despite continued on page 52 A capsule retractor is placed just behind the rhexis edge to provide counter-force and stability to facilitate capsulorhexis. Source: D. Brian Kim, MD

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