Eyeworld

52 | EYEWORLD | SPRING 2026 ATARACT C achieving a successful wave is a sign that the lens-to-bag adhesions are stronger than the zonules. "You should avoid trying to spin the lens with brute force, which will only rip more zonules, and instead employ a no-rotation lens disassembly technique," Dr. Kim said. 6. Less effective sculpting: If you notice that the lens doesn't cut well while sculpting, this can be from lack of zonular support, which causes the lens to push backward with each sculpt maneuver. "Try increasing the phaco setting for more effective sculpt- ing," he said. "Alternatively, you can place a chopper around the contralateral lens equator to hook and support the lens as you push down to sculpt." 7. Difficulty pulling lens pieces out of the bag: Pulling pieces out of the bag requires you to first embed then impale the phaco tip into the lens material, which is more difficult when there is zonulopathy, Dr. Kim said. Since the bag is floppier, it may be more ad- herent to the lens pieces and may collapse into the phaco tip when applying vacuum, which increases the risk for posterior cap- sule rupture. "Use a second instrument such as the chopper to get around the lens piece from the capsule fornix, and pull it out of the bag from behind," he said. "Alternative- ly, you can try and re-hydrodissect or vis- codissect the lens off the adherent capsular bag. This is a more gentle, effective, and safer strategy." 8. Difficult cortical removal: "You have to be very careful with high aspiration and vacu- um because you can inadvertently grab the capsular bag and rip more zonules," Dr. Kim said. "If you grab the bag, stop and initiate reflux to release the capsule material." He added that careful foot pedal control with lower levels of aspiration and vacuum are essential to prevent ripping more zonules. A low flow polish setting is helpful to gently remove the fine lens material. "Alternative- ly, you can use an irrigating cannula used for polishing. If the material is too difficult to remove, it's best to leave it and place the IOL," he said. "You can always perform a YAG capsulotomy later if needed." It's important to have a diverse toolbox when it comes to these cases, Dr. Verkade said, because not every zonulopathy case is going to behave the same. Depending on the case and the severity of zonulopathy, she said she may use different techniques. "I usually like to start out with combining the use of a dispersive viscoelastic and filling the remainder of the anterior chamber with a high molecular weight cohesive viscoelastic. Using the dispersive viscoelastic becomes even more important, especially if you have a hy- permature cataract or a white cataract coupled with zonulopathy and you need to use trypan to stain your capsule," she said. In these cases, Dr. Verkade prefers to use the dispersive viscoelas- tic to tamponade the areas of zonulopathy and stain the anterior capsule with a trypan using the "paint technique," where you paint it under- neath the viscoelastic. This allows you to avoid filling the whole anterior chamber with trypan blue and risk trypan entering through the area of the zonular loss. This will cause the red reflex to turn blue, making the case more challenging. "During the rhexis if you're seeing signs of wrinkling of the capsular bag, I like to grab a second instrument in my non-dominant hand," she said, which allows her to have counter- traction on the capsular bag opening. Often in severe zonulopathy, there's no tension to pull against when you're trying to bring the flap around. "I use gentle counter-tension with a second instrument, like a Kuglen manipulator, which can often be helpful to facilitate the capsulorhexis and keep it round and centered," she said. "I usually like to place capsular hooks as early as I can to allow for even support of the capsular bag." Other things she's conscious of during the case include not overly rotating the lens when hydrodissecting. When you're removing cortical material, remove cortex more circumferentially toward the area of zonular loss rather than pull- ing in centrally and radially, which can poten- tially make the zonulopathy worse, Dr. Verkade said. These are cases where she likes to use viscodissection as well, which can help loosen cortex and nuclear pieces and bring them up and out when needed. For stability, when you're inserting the lens, if there's a mild, diffuse zonulopathy or a focal area, Dr. Verkade likes 3 to 4 clock hours or less. "Then I'll use a CTR combined with the three- piece IOL." If there's more severe zonulopathy or an area that's more than 4 clock hours, Dr. Verkade continued from page 51 continued on page 54

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