EyeWorld Asia-Pacific December 2015 Issue

December 2015 16 EWAP FEATURE Zonular issues can complicate cataract surgery by Michelle Dalton EyeWorld Contributing Writer AT A GLANCE • Creating a safe and stable rhexis is crucial in cases of zonular deficiencies. • Examine the patient in an undilated state; dilation can dampen the zonular state. • Always be prepared to suture, and have CTRs or CTSs present. Use retractors liberally. An example of familial ectopia lentis where the lens is not centered on the pupil and iris retractors are used to assist in the rhexis Source: Steven Safran, MD The key here, experts say, is being vigilant about recognizing issues preoperatively and always having the right tools on hand in the OR Z onular issues—caused by any number of conditions from pseudoexfoliation syndrome to trauma, congenital disorders (Marfan syndrome or ectopia lentis), increased age, or vitrectomy, among others—can turn a straightforward cataract surgery into a much more complicated procedure. Sometimes, however, “there is no obvious etiology and zonular deficiencies aren’t noticed until the patient undergoes surgery,” said Bonnie An Henderson, MD , clinical professor of ophthalmology, Tufts University School of Medicine, Boston. Agreed Robert J. Cionni, MD , medical director of The Eye Institute of Utah, Salt Lake City: In post-vitrectomized eyes where there may have been “some underlying pathology that was already present; because the vitreous is no longer supporting the capsular zonular IOL anatomy, it may allow for an increase in the dialysis or lens dislocation, be it the phakic or pseudophakic lens.” The key to easing the potentially difficult surgery is “to get the lens into position to do a safe rhexis, to stabilize the lens during rhexis and phaco, and to place the intraocular lens in the capsular bag safely while maintaining or providing support to the extent that is needed to provide centration and stability for the life expectancy of the patient,” said Steve Safran, MD , in private practice, Lawrenceville, NJ. Iqbal “Ike” K. Ahmed, MD , assistant professor of ophthalmology, University of Toronto, said “it’s not a great idea” to use the femtosecond laser in these patients; the capsulotomy “is not as strong with the femto as with manual, and the capsule is stronger without the femto,” he said. He said that capsulotomy strength is particularly important in these cases as capsule hooks and capsular tension devices are used on the capsule edge and if there is weakness there is increased risk of tearing, which could not only result in serious complications but prevent the use of a capsular device to support the zonulopathy. Dr. Cionni disagreed, saying “in every case of zonular compromise, my strong preference is to use the femtosecond laser. One of the toughest parts of these surgeries is achieving an appropriately sized capsulotomy centered on the lens, not the pupil” and the femto helps reduce the anxiety. “The added benefit of the femto is that you can de-center that capsulotomy and very precisely size it to your advantage,” Dr. Cionni said. continued on page 18