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EW NEWS & OPINION 14 May 2015 by Steven G. Safran, MD T his is a 68-year-old woman referred in 5 months after femtosecond laser-assisted cataract surgery (FLACS) with a severe Crystalens (Bausch + Lomb, Bridgewater, N.J.) Z syndrome in her dominant right eye. Although she has had 3 separate extensive YAG laser treatments to the posterior capsule that attempted to re- solve this problem, the patient's astigmatism and visual complaints progressed over time with no evidence of improvement. She was referred to me with CF uncorrected vision and 5 D of myopic astigmatism that best corrects her to only 20/40. She has severe capsular fibrosis the posterior capsule is mostly absent but where present it is fibrotic and in some areas adherent to the anterior capsule in thickened bands, and there is vitreous herniating into the anterior cham- ber. The inferior haptic is severely bowed forward and the superior haptic bent back at an acute angle greater than 90 degrees. The inferior capsular bag appears slightly superi- orly displaced suggesting zonular instability in this region (Figures 1 and 2). Steven G. Safran, MD, ASGR editor Mike Snyder, MD, commented: "Thanks for sharing this horrifica - ly frustrating case. It demonstrates what I think all of us know in our hearts to be true: a perforated con- tinuous curvilinear capsulorhexis (CCC) is never as strong as a con- tinuous tear. The phimotic ring of lens epithelial cells (LECs) was just an innocent bystander injured by friendly fire. Also, phimosis may be more common because of the plas- ma-induced thermal cauterization of the peri-CCC LECs. "This case reminds me of when CCC first hit the stage and an A decision was made to perform a pars plana vitrectomy with removal of the Crystalens and re- placement with a 3-piece monofocal lens via optic capture in the anterior capsule opening. The surgery proceeded smoothly with- out incident until a very unusual intraoperative event occurred that I did not fully understand until I was able to go back and review the video of the surgery in super slow motion. The figures show a sequence of i - ages captured from the surgical vid- eo. In Figure 3 the case is being start- ed. A pars plana vitrectomy is then carried out. Iris retractors have been placed to stabilize and expand the anterior capsule and the lens optic has been cut and removed. Figure 4 shows the appearance of the anterior capsule rim, which is completely in- tact with iris retractors in place. Fig- ures 5 and 6, however, demonstrate something very unusual. Although the rhexis edge is clearly intact with a bridging band of phimosis, a radial tear has developed in the anterior capsule under the intact phimotic edge. Usually a radial tear starts at the rhexis edge but in this case the radial tear began under an intact fibrotic ring at the anterior capsule edge, which is something I've never seen. Ultimately the ring of fibrosis phimosis can be seen to finally give way, leading to a complete radial tear, which precludes the option of optic capture as planned (Figure 7). A decision was made instead to place the lens in the sulcus with scleral suture support of the superior haptic as seen in Figure 8. Although this patient did very well, recovering 20/20 vision with a low myopic correction within a week of surgery and was very happy with her outcome, I was disturbed by the development of a radial tear, which precluded the option of optic capture and complicated the proce- dure. I was very sure that I had not touched the anterior capsule in this region, and it wasn't until I carefully reviewed the video and analyzed it that I saw that the radial tear had actually begun under a ring of intact phimosis, which is not something I've ever seen occur during surgery. Every time I've ever seen a radial tear, it begins from the capsule edge, but in this case the capsule edge appears intact when the radial tear begins. This suggests to me a funda- mental weakness in the underlying anterior capsule in this case, which tears out underneath and despite the presence of an intact capsule edge. I felt this weakness (as well as some of the exuberant capsule contracture) may be a by-product of the use of a femtosecond laser to create the capsulorhexis in this case. I presented this case to a group of esteemed colleagues for discus- sion. We specifically focused on the role that the femtosecond laser may have played in the events that occurred. Rhexis misbehavin' Figures 1 and 2. Slit lamp appearance of the patient's right eye on presentation for treatment. Note the thickened anterior capsule, which is contracted, and the presence of a severe Z syndrome. The inferior haptic is bowed forward and the superior haptic bowed back with vitreous present in the anterior chamber. continued on page 16 Anterior segment grand rounds (ASGR) rePlay online content Watch a video of this surgery on EyeWorld Clinical rePlay now! clinical.ewreplay.org