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EW CATARACT 31 July 2016 Watch a video of this case at EyeWorld Clinical rePlay clinical.ewreplay.org Figure 2. Same eye after dilation showing decentered IOL capsular bag complex, retained cortex and zonular dialysis Figure 3. Day 1 postoperative photo shows good centration of the IOL and rhexis. Source: Steven Safran, MD with a bimanual technique. At this point the IOL appeared centered and stable, but the rhexis was small and off center relative to the IOL and the pupil, so a decision was made to retear that using a microforceps, which was successfully carried out. I felt that there was no need for suture fixation as the IOL/capsular bag complex appeared stable at this point. The patient did very well and had uncorrected 20/40 vision the next day with the appearance at the slit lamp as shown in Figure 3. The lens remained in good position, and the patient subsequently underwent phacoemulsification of the other eye under topical anesthesia with avoid- ance of all sedation to encourage cooperation. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Hester: hesterchristianc@gmail.com Masket: sammasket@aol.com Oren: rlodad@bellsouth.net Pyfer: mpyfer@verizon.net Safran: safran12@comcast.net ters the lens in limited zonular loss. If the IOL/capsular bag complex remains decentered, the Cionni CTR eyelet can be used to fixate the ring to sclera using Gore-Tex CV-8 suture material (off label and not approved for ophthalmic use). Then, remove the residual cortex and viscoelastic." What was done As suggested by Dr. Hester, general anesthesia was used for this repair, which was done as urgently as possible. Two pars plana trocars were placed 3 mm posterior to the lim- bus, and the vitreous stained with triamcinolone. A combination of pars plana and anterior vitrectomy through a paracentesis was per- formed to amputate and remove all the vitreous coming up through the zonular dialysis. Infusion was initial- ly through the pars plana trocar, but later moved to the anterior cham- ber to prevent chamber collapse as anterior segment maneuvers were carried out. Once the vitreous was addressed, the capsular bag was di- lated with dispersive viscoelastic and a Morcher 14 CTR placed in the bag using a 2 hand "spiral" maneuver holding the tip with a Sinskey hook as the ring was injected into the bag. The residual cortex was removed would tie the Gore-Tex suture using a slipknot and gently tighten the knot until the suture is still slightly loose and the IOL/bag complex has centered before rotating the knot into one of the sclerotomies. Once I have confirmed there is no vitreous in the anterior chamber by restain- ing with dilute triamcinolone, I would proceed with closure." Finally, Brad Oren, MD, Boynton Beach, Florida, added his thoughts: "In cases like this, I employ a stepwise approach. First, I would do a paracentesis and refor- mation of the anterior chamber with dispersive viscoelastic. Next would be a posterior vitrectomy with caution as a short eye has a short pars plana. I would be sure to clear vitreous from the area of zonular dehiscence. Maintaining bimanual vitrectomy with irrigation in the an- terior chamber, I would remove the anterior vitreous strand, relieving its iris and corneal traction. The next step is inspection. It is unlikely the IOL has recentered following release of vitreous traction. If it has, one could consider ending the case. If not, the next step is viscodissection of the 1-piece IOL from the anterior capsular bag. I would place a Cionni CTR in the bag, which often cen- insert a Type 14 Morcher [Stuttgart, Germany] capsular tension ring (the smallest size available to me). Next, I would suture a CTS to the sclera with Gore-Tex suture by making my scleral stab incisions with my side port blade 3.5 mm apart and rough- ly 2 mm posterior from the limbus (the incisions may need to be placed more anteriorly in this very small eye). I would enter perpendicular to the sclera, then angle my blade parallel to the iris. It is better to be a little posterior in order to avoid iris chaffing. I then would create a 300-micron deep incision between the sclerotomies to act as a trench for the Gore-Tex suture. "Next, I would feed the Gore- Tex suture through the CTS eyelet while it's outside of the eye, use a Sinskey hook to place the CTS in the eye through the previously created main incision, and use the Sinskey hook to center the CTS around the capsule at the point of maximum zonular loss. I'd make sure the bend in the CTS arm is oriented toward the cornea before insertion. With the CTS in proper position, I would insert a J-hook through the scleroto- mies into the eye and then pull the Gore-Tex suture out of the eye through the sclerotomies. Finally, I

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