EyeWorld Asia-Pacific December 2011 Issue

36 December 2011 EW DEVICES Early CTR placement. Placing the ring early can cause future complications Source: Iqbal (Ike) K. Ahmed, MD Zonular weakness varies in these patients and may present at slit lamp or on operating table P seudoexfoliation syndrome patients with zonular weakness present a variety of challenges for surgeons during cataract surgery. Physicians, however, have a plethora of choices in their armamentarium to help them manage pseudoexfoliation (PXF) zonulopathy, including the intraoperative use of capsular tension devices. Surgeons may opt for capsular tension devices to help ease the safe removal of a patient’s crystalline lens, as well as place an IOL that will remain central and stable for the long term. The first sign that a surgeon may need to use a capsular tension device due to loss of zonular integrity may present itself during a pre-op slit lamp examination. There, a surgeon might see a mobile or displaced lens or a deepening on one side of the chamber and not the other, according to Garry P. Condon, MD, chairman, ophthalmology department, Allegheny General Hospital, Pittsburgh, Pa., USA. “You can get some hints pre- operatively, but even if things look good in the exam room, they can be completely different in the operating room,” Dr. Condon said. “Cataract surgery in pseudoexfoliation patients is the proverbial box of chocolates. You don’t know what you’re going to be dealing with until you actually get in there and start.” Dr. Condon said he knows a case is going to be challenging when he attempts the capsulorhexis and the capsular bag either wrinkles or moves entirely. “It tells you there’s not a lot of zonular support going on there,” he said. “At that point, I’m already thinking about additional support devices to do the surgery safely.” John C. Hart Jr., MD, co-director of anterior segment surgery, William Beaumont Medical Center, West Bloomfield, Mich., USA, said he routinely uses capsular tension rings in patients with PXF, except in those patients with mild or unilateral disease. Two types of CTRs have been approved for use in the US: the Reform Ring (Morcher GmbH, Stuttgart, Germany) and the StabilEyes Ring (Abbott Medical Optics, AMO, Santa Ana, Calif., USA). “My plan could change depending on what I find during surgery,” Dr. Hart said about using CTRs in surgery. “If I see any phacodonesis or any sign that that might be going on, I’m very quick to pull the trigger to put one in.” Dr. Condon said that a CTR doesn’t provide enough zonular support to justify its use prior to or during removal of the crystalline lens. “The stress of inserting it can result in further loss (of zonules) and potentially make the situation worse,” he said. Timing, apparently, is crucial. “We found that if you place the ring early, it does cause more stress on the zonules and has more potential for complications,” said Iqbal (Ike) K. Ahmed, MD , assistant professor, University of Toronto, and clinical assistant professor, University of Utah, Salt All about support: Capsular tension devices urged for PXF patients with weak zonule by Jena Passut EyeWorld Staff Writer Lake City, Utah, USA. “If you put it in after the bag has been evacuated, it’s much easier to put in and you don’t risk having cortex trapped behind it.” Alternatives/additions to CTRs Dr. Condon said iris retractors enlarge small pupils and hook around the edges of the capsulorhexis to provide support to the capsular bag while a surgeon works on the nucleus of the cataract. However, “capsule retractors do the best job of supporting the capsule during the surgery,” he said. “The nice thing about these is that they go all the way out to the capsule equator and not only support the capsular bag but also tension the posterior capsule because the other challenging part of doing surgery on PXF patients is that they often have a very redundant and floppy capsular bag.” In order to avoid creating loss of zonular integrity or support during the cataract procedure, capsular tension segments may also be used— either temporarily An eye with two CTRs