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18 EW NEWS & OPINION Taking continued from page 17 September 2012 Figure 4. This shows the acute bend of the temporal haptic, which like the previous case is inserted anterior to the equator. There is vitreous prolapse through the YAG opening, and this is adherent to the nasal hinge Figure 5. This demonstrates the forward bend of the nasal haptic. This haptic appears to be inserted posterior to the equator of the bag on gonioscopy Figure 7. Case 1 day 1 s/p PPV/capsulectomy/CTR placement and IOL repositioning behind the posterior capsule. This eliminated the Z syndrome. Vision is 20/20-2 uncorrected. Refraction is +0.25 I believe this case perfectly demonstrates the etiology of most severe Z syndromes. Asymmetric haptic placement combined with severe fibrosis (due to retained cor- tex/LECs) pushes one plate back and the other forward. It is the metaplas- tic transformation of LECs into my- ofibroblasts that leads to fibrosis and contraction of the capsular bag. This fibrosis is what "pushes" the lens around leading to problems. I be- lieve that with careful placement of the haptics in the equator of the bag and meticulous cortical cleanup and lens epithelial cell removal, Z syn- dromes can be virtually eliminated. Case 3 discussion While the majority of surgeons on the panel recommended YAG laser (followed by LVC or piggyback lens if needed) for this patient, some of the panel members felt an exchange for another Crystalens was a "clear cut" option. This was my choice in this case. The patient had an excel- lent experience with the Crystalens in her other eye and was strongly motivated to have the same out- come in this eye. She needed a lens of slightly higher power so if I was going to do surgery, I felt an IOL ex- change would be better than a repo- sitioning. I also wished to eliminate some corneal astigmatism she had from her previous surgery. In this case I did a Crystalens exchange, CTR placement to stiffen the capsu- lar bag, and reconstruction of her previous cataract wound while oper- ating on her steep axis to reduce her 1.5 diopters of corneal astigmatism. She ended up with a –0.5–0.5X180 outcome, which suited her needs very well in this, her nondominant Figure 8. IOL optic can be seen behind the posterior capsule, and the fibrosis has been stripped away. Compare to pre-op (Figure 2). The Z syndrome is resolved eye. Here is a link to the surgical video: www.youtube.com/ watch?v=-bV1D255sfU. It is my personal preference to avoid YAG laser in a region of cap- sule not tamponaded by the implant because the risk of vitreous prolapse is too high. In cases like this where there is no contact between the optic and the capsule, I prefer to avoid YAG laser and approach the problem surgically with either repo- sitioning or exchange. In most of these cases I will place a CTR at the time of surgery. I would like to add that a major- ity of the cases referred to me for Z syndrome have been either eyes that are quite short (under 22 mm) or very long (over 28 mm). As a result of this observation I now primarily place a CTR when I perform cataract surgery with Crystalens on eyes under 22 mm and over 28 mm. I also primarily place a CTR in post- vitrectomy Crystalens cases. I believe that with meticulous cortical cleanup and LEC removal, careful haptic placement, and selective use of CTRs, Z syndromes can be virtually eliminated. In the rare Crystalens patient who does present with a post-op Z syndrome, I believe it is wise to consider the individual variables in the case carefully and weigh all surgical options prior to performing a YAG procedure that may severely complicate or limit those future surgical options. In addition to myopic astigmatism the presence of a tilted lens induces coma, which is not readily corrected by laser vision correction. This is one reason I am strongly biased toward doing whatever is necessary to eliminate lens tilt rather than to