Eyeworld

EW CATARACT 48 October 2017 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer operating room when intraoperative tissue signs (i.e., puckering of the anterior capsule during rhexis cre- ation) reveal an underlying zonular fragility. "You want a good ocular surface, and you certainly want a pristine macula and retina, and to exclude any optic neuropathy such as in glaucoma patients. But three things that you must be comfortable with are ATIOL technology in and of itself, capsular tension devices, and suture fixation techniques," Dr. Yeu said. Dr. Yeu prefers performing therapeutic femtosecond laser-as- sisted cataract surgery in eyes with loose zonules because it provides a consistent, well-centered, size-appro- priate capsulotomy. She explained that manual capsulorhexis could be irregular and smaller than desired in the setting of loose zonules, where focal areas of fibrosis or lens opaci- fication within the lens are likely to represent areas of prior violation and affect tissue manipulation. Lens density might play an additional role in how comfortable physicians are managing cases associated with zonulopathy. Stabilizing the lens capsule for IOL implantation requires special consideration. "If you have some- one needing a toric lens with focal or mild zonulopathy, I'd always urge you to place a capsular tension ring," Dr. Yeu said. "In a presbyopia IOL setting, if the zonulopathy is focal and static and is not going to progress over time, then you can use a capsular tension ring alone. But in the case of someone with progressive zonulopathy, such as pseudoexfoliation syndrome, you must use caution as decentration is going to compromise the quality of vision. You should not place a pres- byopia-correcting lens unless you are going to employ a scleral fixation capsular tension device simultane- ously to ensure that there is longevi- ty to what you are doing." Extensive chair time with the patient is important with in-depth discussions to set expectations. The patient also needs to under- stand that a back-up plan has been mapped out should the planned lens not work out. Dr. Yeu recommended that surgeons consider placing man- ual limbal relaxing incisions if toric Cataract surgery in patients with loose zonules, requiring accommodating or toric IOLs, may need some special know-how I s it a good idea to implant accommodative or toric lenses in patients with loose zonules? The answer is: It depends on how comfortable you are with what you're doing. Added to the usual checklist for patients in line for cataract and refractive surgery, surgeons need to be able to identify and manage zonulopathy in the operative setting and understand what their best options are, both pre- and intraoperatively. Still, some cases may not be for the weak-heart- ed, according to Elizabeth Yeu, MD, Eastern Virginia Medical School, Norfolk, Virginia, who spoke at the 2017 ASCRS•ASOA Symposium & Congress during the symposium "Optimizing Outcomes: What am I Doing Differently?" If zonulopathy is known to the clinician, the first thing that needs to be done is to identify whether the zonulopathy is progressive or static, as this can influence the choices you make, according to Dr. Yeu. The patient's medical and ocular history should reveal the etiology of the zonulopathy as related to systemic causes like Marfan's syndrome or Ehlers-Danlos syndrome, or if it is a result of high myopia, pseudoexfoli- ation, or trauma. Next, a good eye exam with as much exposure as possible is crucial. "You want a good dilation and you want to perform synechiolysis to have the best exposure you can get. Someone who has had trauma, for instance, can have iridolenticular adhesions that need to be lysed, but I would advise caution about doing too much synechiolysis because adhesions themselves can provide some needed support. Also, you want to know how many clock hours are missing and whether you are dealing with a generalized weak- ness versus frank and gross disloca- tion," she said. Identifying eyes with loose zonules prior to cataract surgery may not always be possible. Often- times, patients will already be in the Loose lenses and cataract surgery Live anterior segment OCT image of patient with ectopia lentis. The crystalline lens is prolapsed partially into the anterior chamber due to its severe dislocated state. In order to safely disassemble the soft nucleus, an iris hook was used to stabilize a capsular tension segment in place prior to the nuclear disassembly. The 8-0 Gore-Tex suture used to fixate the capsular tension segment is not locked into place until after the IOL is centered within the capsular bag and the suture tension of the scleral fixation can be assessed. Source: Elizabeth Yeu, MD continued on page 50

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