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EW CATARACT 50 October 2017 hook. She was then able to slowly and carefully disassemble the crys- talline lens using viscodissection, with generous use of viscoelastic to loosen up and remove the cortical fibers. Gentle manipulation of the capsule and lens material was crucial in preserving the patency of the bag and the fragile zonule fibers. Unhappy with the juxtaposition of the lens capsule equator to the scleral wall, Dr. Yeu created a tenta- tive fixation of the capsular tension segment (CTS) using a single throw of the 9-0 Gore-Tex to the scleral wall, and supplemented the seg- ment with a capsular tension ring, deciding to wait until the artificial lens was implanted and centered before creating a permanent fixation of the CTS to the sclera. A Cionni capsular tension ring could be used as an alternative to the capsular ten- sion segment, but although a viable option, she thought it was both ergonomically and technically more challenging to implant. Dr. Yeu implanted a mid-add multifocal IOL that was aligned according to the first Purkinje image. Once carefully aligned and centered, she fixated the IOL and capsular tension segment into place and glued the wound. Alignment was more complicated as the patient had a retrobulbar block and was unable to assist, making the use of a Placido disk preoperatively indispensable. "Therapeutic femtosecond laser-assisted cataract surgery can be quite beneficial in managing loose lenses. Before you consider employ- ing advanced technology options when you have a loose lens, you have to gain confidence with loose lens management in general," Dr. Yeu said. "The Cionni capsular ten- sion rings are going to be the most difficult to get comfortable with, as they are more difficult to place technically. But we don't necessarily need to use them since we have the combination techniques. You also want alternative options for these patients, like scleral or iris fixation, ACIOL, or even aphakia. The option to leave the patient aphakic and take the time to plan for a future, secondary IOL may be the best and safest choice in the moment for the patient," Dr. Yeu said. EW Editors' note: Dr. Yeu has no financial interests related to her comments. Contact information Yeu: eyeulin@gmail.com lens implantation is difficult. Back- up lenses using iris or scleral fixation techniques or an anterior chamber IOL should also be considered. Case report Dr. Yeu said that patients typically present with progressively worsen- ing visual acuity because of a dislo- cated or subluxated lens and signs of iridodonesis or lentodonesis upon closer examination. One 52-year-old female patient who presented with these symptoms, with deteriorating visual acuity over 5 years, had high expectations for a good visual range of focus and spectacle freedom. In her treatment of this patient, Dr. Yeu created a larger than usual capsulotomy to ensure maneuver- ability of the grossly dislocated and decentered crystalline lens that had prolapsed into the anterior chamber, and made certain to tamponade the vitreous before any further manip- ulations were carried out to prevent vitreous prolapse. Weak zonules have a greater tendency to break and allow the vitreous to prolapse ante- riorly. Dr. Yeu opted for a capsular tension segment that has an eyelet at one end, which she stabilized through a paracentesis using an iris HOW DOES YOUR EMR COMPARE? According to the 2015 ASOA EHR Satisfaction Survey Results* • EYEMD EMR HEALTHCARE SYSTEMS SCORED HIGHER ON OVERALL SYSTEM FUNCTIONALITY THAN ANY OTHER VENDOR! • USERS EXPERIENCE LESS HIDDEN COSTS WITH EYEMD EMR THAN ANY OTHER VENDOR! • USERS ARE MORE LIKELY TO RECOMMEND EYEMD EMR OVER ANY OTHER VENDOR! EyeMD EMR is the complete solution designed specifically for ophthalmologists. 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