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EW NEWS & OPINION 18 May 2015 Perhaps laser capsulotomy should be delayed, when possible, until the 'managing' surgeon is confident that such capsulotomy is likely to help and that IOL exchange will not likely be necessary. 2) Because the Z syndrome is a well recognized, albeit uncommon, untoward effect of Crystalens IOL implantation, a discussion should take place regarding maneuvers that may decrease the likelihood of this complication: a) Meticulous cleaning of the cortex and lenticular epithelial cells (LECs). Does an FS-prepared cap- sulotomy lend itself to the same? b) Sizing of the Crystalens as a func- tion of axial length, IOL power, etc. c) Role of a capsular tension ring in certain Crystalens implantation cases, and, if so, in which cases d) Identifying subcategories of Z syndromes (not all Z syndromes are created equal) that may benefit from YAG laser capsulotomy, rath- er than the frequently employed strategy of YAG first and see what happens 3) Issues specific to FLACS and the subsequent management of compli- cations: a) The term continuous curvilinear capsulorhexis may be a triple mis- nomer when it comes to the cre- ation of a FS-assisted capsulotomy; it is certainly not continuous, as electron microscopy studies have shown, and the terms curvilinear and rhexis may not apply b) Although the increased incidence of intraoperative capsular tears during FLACS has all but been established, this case demonstrates the weakened capsular edge, which makes further manipula- tion difficult and fraught with potential complications c) The relationship between capsu- lar contraction, fibrosis, and the development of phimotic rings (potentially separate from the edge of the capsule itself) requires further delineation. Is there an increased incidence of the above with FLACS? Is it a function of the method of creation of the capsu- lotomy, the difficulty in achie - ing adequate hydrodissection, or the reticence of the surgeon to aggressively clean the cortical rem- nants and LECs for fear of creating a radial tear, a concern he/she may not have had after a manual Rhexis continued from page 16 CCC? This situation may have no bearing on the implantation of a monofocal 1-piece or 3-piece IOL. An accommodative IOL may respond differently." I felt it was important to share this case because recently I've experienced a significant increase in Crystalens Z syndromes referred to my practice, and virtually all of these cases have occurred in FLACs cases. I do feel that the use of a femtosecond laser confers a greater risk of capsule contraction due to reasons pointed out in the contribu- tors' comments, and this may confer a higher risk of asymmetric vaults (Z syndrome) with the Crystalens. We do have studies suggesting that anterior capsule tears may be more likely during cataract surgery when the rhexis has been performed by a femtosecond laser because of the "micro can opener" capsulotomy that the laser makes rather than a smooth continuous tear. It does appear that the greater risk of radial tear may also be present during sec- ondary procedures to deal with the complications of capsular contrac- tion, even when a thickened fibrotic ring of phimosis exists at the capsule edge as it did in this case. Surgeons who perform these cases may wish to consider this in the planning of their procedures. EW Reference 1. Abell RG, Davies PE, Phelan D, et al. Anterior capsulotomy integrity after femtosecond laser- assisted cataract surgery. Ophthalmology. 2014;121(1):17–24. Editors' note: The physicians have no financial interests related to their comments. Contact information Arbisser: drlisa@arbisser.com Berke: sjberke@optonline.net Davies: pejd@bigpond.net.au Hannush: SBHannush@comcast.net Safran: safran12@comcast.net Snyder: msnyder@cincinnatieye.com Figure 6. The radial tear progresses and the anterior capsule rim becomes thinner and more tenuous. Figure 7. The radial tear is now completely precluding the option of optic capture. Figure 8. The implant has been placed in the sulcus with suture support. Source: Steven G. Safran, MD Watch a video of this surgery on EyeWorld Clinical rePlay now! clinical.ewreplay.org rePlay online content