Eyeworld

50 | EYEWORLD | SPRING 2026 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians D. Brian Kim, MD Professional Eye Associates Dalton, Georgia Angela Verkade, MD Clinical Assistant Professor of Ophthalmology and Visual Sciences Kellogg Eye Center University of Michigan Ann Arbor, Michigan lens abnormalities, such as Marfan syndrome and homocystinuria, can be warning signs. Dr. Verkade stressed the importance of the preoperative exam in preparing for cases with zonulopathy. She said that asking the patient about history, especially history of trauma or ocular trauma, is crucial, as well as taking a history of tissue disorders. Slit lamp signs, like asymmetric dilation on one side, might be sug- gestive of zonulopathy on that side. Pseudoexfo- liation on exam, colobomas, aniridia, or asym- metric cataracts (like a hypermature cataract on one side) can be associated with zonulopathy, she said. Phacodonesis, Dr. Verkade continued, is suggestive of severe zonulopathy, and it's im- portant to check these patients before dilation as it is often easier to see phacodonesis pre-dila- tion. Any decentration of the lens after dilation is suggestive of zonulopathy as well. It's also important to look for other entities that are associated in their history, such as a previous vitrectomy, high myopia, history of uveitis, or other retinal disorders. With imaging, you might see an asymmet- ric anterior chamber depth on your biometry in cases of zonulopathy. You can obtain a UBM preoperatively that might be helpful to identify the location and extent of zonulopathy, she said. H aving varying degrees of zonulopathy can make a case more challenging. D. Brian Kim, MD, and Angela Verkade, MD, discussed what they look for to determine if a patient has some form of zonulopathy, the best lenses and tools to use in these cases, and other important approaches to proceeding with surgery. Signs of zonulopathy Dr. Kim said there are several signs he looks for to determine if a patient has some form of zonulopathy. He first noted pseudoexfoliation on the anterior lens capsule. He also indicat- ed phacodonesis and said that he will ask the patient to move the eye side to side and up and down, looking for a wobbly lens/bag complex. "A dense cataract in one eye with a comparative- ly minimal cataract in the other eye may suggest trauma, which is associated with zonulopathy," Dr. Kim said. A shallower anterior chamber depth in one eye compared to the other eye on optical biometry suggests zonulopathy. "Hypermature cataracts, advanced age, prior ocular trauma, prior retinal surgery, prior angle closure glau- coma attack, retinitis pigmentosa, and uveitis are risk factors for zonulopathy," Dr. Kim said. Finally, he said that family history of hereditary Zonulopathy: signs and surgical management Observe the striae (aka spider sign) within the capsule as the capsulorhexis forceps is used to puncture the anterior capsule. Source: D. Brian Kim, MD Trypan blue facilitates visibility. Observe the striae within the rhexis flap and the localized area of zonular dehiscence contraincisionally. Source: D. Brian Kim, MD

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