Eyeworld

54 | EYEWORLD | SPRING 2026 ATARACT C Relevant disclosures Kim: None Verkade: None Contact Kim: kim@professionaleye.com Verkade: ajverkad@med.umich.edu will use a CTR with capsular tension segments in the areas of most severe zonulopathy and combine that with the three-piece IOL. "I like to use a manual insertion technique for my CTRs, where I'll place it through an incision that will allow for the placement of the ring toward the areas of zonulopathy, then I'll usually have a Sinskey hook or another instru- ment in my second hand to allow for counter- traction against the CTR to avoid pressure on the capsule and potential worsening of zonulop- athy," she said. "It allows me to get a better feel in case I run into resistance, then I can easily maneuver out and go in a different direction or through a different incision, compared to poten- tially using an injector for CTRs." Dr. Verkade likes to suture the CTR using a CV-8 Gore-Tex suture rather than prolene and use either a Hoffman pocket or bury the knots within the sclera coupled with a scleral groove. There are also capsular tension devices, like the Cionni ring, which Dr. Verkade said has a nice additional eyelet for fixation where you can put that along the area of most severe zonulopathy. If there is very severe zonulopathy or great- er than 9 clock hours, Dr. Verkade opts for a secondary fixation of a three-piece IOL like the Sensar AR40. "I prefer the Yamane technique in these cases, as it requires a smaller incision compared to other techniques, and in my hands, it's a little more efficient," she said, though she noted that there are other techniques like a glued or sutured IOL or even anterior chamber IOL that can be used. When dealing with more severe zonulop- athy, this can make the case trickier, and Dr. Kim said, "many factors will affect your plan of attack." He also suggested first painting the an- terior capsule surface with trypan blue because this will aid with capsulorhexis, lens disassem- bly, and improve visualization for capsule retrac- tor, CTR, and CTS placement. "If you are unable to perform capsulorhexis, capsule retractors are very helpful," he said. "You want to place the retractor just behind your rhexis flap to provide counterforce." Dr. Kim also mentioned that using a CTR provides circumferential support. "There is de- bate as to when the CTR should be placed," he said. It's Dr. Kim's opinion that there is no value in placing the CTR early, as this can make cor- tical removal more difficult. "I always place the CTR after all the lens material is removed, and I employ cross chopping techniques to bypass the need to rotate the lens," he said. "I use a CTR injection technique to minimize torsional stress on the zonules. As the CTR is advanced, a Lester hook is placed through the leading eyelet to ap- ply a compression force to shrink the diameter of the CTR as it is being delivered." Dr. Kim said that if there are more than 4 clock hours of zonular dehiscence, a CTR may not provide enough equatorial support, and therefore, scleral suture fixation with a CTS or modified CTR with eyelet can be used. "The AssiAnchor [Hanita Lenses] is another device, but it's not available in the U.S.," he said. "A modified CTR can be used but needs to be rotated such that the eyelet is positioned over the area of weakness which can further stress the zonules. I prefer a scleral sutured Gore-Tex CTS because I can strategically place it over the areas of zonular weakness." Take-home messages Zonulopathy is not that common, Dr. Verkade said, but it is more common if you're seeing pa- tients post-trauma or with certain ocular diseas- es. We hope to catch zonulopathy preoperative- ly, she said, but many times, patients can have zonulopathy for unknown reasons and without obvious preoperative signs. It's important to have a variety of tools and techniques at your fingertips. "Preparation is key, and the more we can plan and anticipate the needs preoperative- ly, the better the case will go intraoperatively. It's very important to take time to practice these techniques either in a wet lab or in your OR. It's also important to learn from experts at meetings when you can," Dr. Verkade said. She added that if you don't have a chance to practice the techniques or aren't comfortable executing them, it's OK to leave a patient apha- kic and come back, to fixate later or send to someone more comfortable with fixation if you do not routinely perform these surgeries. Dr. Kim said the most important take-home message is to recognize this early and to avoid doing anything to worsen the zonulopathy. "You can turn a routine case into a complicated one if you don't pay careful attention with every step of the case," he said. "Finally, despite your best efforts, the lens-bag complex may not be sal- vageable, and you should have the skills to place an IOL in the absence of capsule support." continued from page 52

• Cover