Eyeworld

EW CATARACT 30 July 2018 by Liz Hillman EyeWorld Senior Staff Writer will behave strangely or start shoot- ing out. When I see a large area of zonular instability during the rhexis, I generally will put in capsular sup- port hooks right from the get-go. "During phaco, I also will look for how the nucleus is behaving. If the bag/nuclear complex is very mo- bile with chopping or if the entire nucleus is decentered, this is anoth- er sign you have zonular instability," Dr. Schallhorn continued. "Howev- er, the most common time that I see zonular issues is after the nucleus has been removed and you can see the bag folding in during irrigation and aspiration. … After cortical removal, a decentered capsulorhexis is a good clue there is zonular laxity. The capsule will pull away from the area of laxity and toward the area of intact zonules. Significant ovaliza- tion of the capsule after IOL place- ment is also a sign of diffuse zonular weakness." Dr. Arbisser said when the lens won't rotate after a good the management of loose zonules, including capsule hooks, CTRs, and CTSs, and the relevant tools the sur- geon would need to employ those devices. In addition, she advised planning one's surgical schedule with these cases in mind, schedul- ing more complicated cases for later in the day. Dr. Arbisser noted that these cases seem to have more in- flammation postoperatively, so she would advise a preoperative NSAID and a longer course of NSAIDs. Intraoperative signs of loose zonules There might be cases where you don't determine there are weak zonules preoperatively, but there are several intraoperative clues to look for. "For very weakened or absent zonules, the first indication is usually with the capsulorhexis," Dr. Schallhorn said. "When you don't have the radial tension from intact zonules to pull against, the rhexis Experts discuss the why, when, and how of capsular tension hooks, rings, and segments A s a referral-based cata- ract and cornea surgeon, Brandon Ayres, MD, cornea service, Wills Eye Hospital, and instructor, Jefferson Medical College, Thomas Jefferson University, Philadelphia, said zonular laxity is the number one reason cataract patients are sent to him. While he might be well- versed in handling these cases now, there was a time when he, like resi- dents and those early in professional practice, didn't have any experience in the effective management of loose zonules, using capsular hooks, capsular tension rings (CTRs), and capsular tension segments (CTSs). "If this is something that you have a passion for, you've got to say YES connect Managing cases of loose zonules with hooks, rings, and segments L oose zonule cases can be intimidating for surgeons of all ages. Thankfully our toolbox of techniques and instruments related to this surgical challenge continues to expand. In my experience, a zonular case that goes well is tremendously reward- ing and can significantly boost surgeon confidence. Undoubtedly, preparation is paramount for success. This includes practicing surgical techniques in the wet lab and working in an operating room where the staff and surgical supply inventory are prepared to handle a complex case. In this month's "YES connect" column, Brandon Ayres, MD, Lisa Arbisser, MD, and Julie Schallhorn, MD, share invalu- able insights into managing weak zonules. I would add that recently I have found the miLOOP (Iantech, Reno, Nevada) to be an excellent instrument that can be used to disassemble very dense, loose lenses without inducing zonular stress because of its unique mechanism of action. Anything that can help avoid exacerbation of already weak zonules can be a tremendous asset in handling these difficult cases. Zachary Zavodni, MD, YES connect co-editor High-magnification photo of a capsular retracting hook. The rounded tip allows for safe placement in the capsular bag. 'yes' at some point, and see what happens," Dr. Ayres said. "With proper planning and backup if you need it from a more senior surgeon, these case are doable, and I don't think people should shy away from them as long as they have a game plan." Dr. Ayres, Lisa Arbisser, MD, adjunct professor, Department of Ophthalmology and Visual Scienc- es, University of Utah School of Medicine, Salt Lake City, and Julie Schallhorn, MD, assistant professor, Department of Ophthalmology, Uni- versity of California, San Francisco, shared their thoughts on what that game plan might look like, from what to look for in the preoperative exam through the intraoperative nuances of using the variety of de- vices that might be needed to safely complete these cases. Preoperative planning With a thorough history and pre- operative exam, being surprised by loose zonules in the operating room should be a rare, uncommon occur- rence, Dr. Arbisser said. Drs. Arbisser, Ayres, and Schall- horn all had similar advice on what to look for. On the history, compli- cations with the first eye, if it has already been done, could be a red flag, as well as a history of trauma, prior ocular surgeries (including vitrectomy and glaucoma), and con- genital cataract. A history of Marfan syndrome or an eye that is very myopic refractively without a lot of nuclear sclerosis and without the axial length and measurements that would be expected with high myo- pia could be an indicator of zonular problems as well, Dr. Arbisser said. On examination, physicians should look for signs of phacodone- sis. Dr. Schallhorn and Dr. Ayres said they'll tap or rock the eye and have the patient look left to right and straight again to see if there is any motion of the lens. Signs of pseudoexfoliation, pseudoexfoliative material on the pupil border, or a pupil that doesn't dilate well should "raise your an- tenna for potential problems during surgery," Dr. Ayres said. Traumatic iridodialysis or iris defect could be a sign of weak zonules in that area as well, he added. Dr. Arbisser said every OR should have materials available for

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