EyeWorld Asia-Pacific December 2019 Issue

EWAP DECEMBER 2019 17 FEATURE Z onulopathy is encountered in a wide spectrum of clinical situations. Synonymous with zonular dehiscence or zonular dialysis, it describes a weakened state of zonular support that affects the integrity of the lens capsule unit and plays an important role in the approach a surgeon takes to cataract surgery. EyeWorld interviewed Uday Devgan, MD, and Kevin M. Miller, MD, to gain insight into this frequently encountered clinical entity and learn how to best deal with it. Identify zonulopathy Identifying zonulopathy will allow the surgeon to plan cataract surgery for the patient, select the appropriate devices, and prepare for the management of potential zonulopathy-related complications. Zonulopathy can be segmental, which is most commonly traumatic or iatrogenic, or diffuse, as seen in eyes with pseudoexfoliation syndrome, retinitis pigmentosa, retinopathy of prematurity, extreme age, extreme myopia, multiple previous pars plana vitrectomies, or with silicone oil tamponade. Additionally, systemic conditions associated with diffuse zonulopathy include Marfan syndrome, homocystinuria, Weill-Marchesani syndrome, Ehlers-Danlos syndrome, Rieger syndrome, ÃՏwÌi œÝˆ`>Ãi `iwVˆi˜VÞ] >˜` Crouzon syndrome. The preoperative evaluation is important to differentiate acquired zonulopathy from chronic issues, according to Dr. Devgan. “Patients with a history of recent trauma can have zonular compromise, usually for just a few clock hours, and this is not expected to worsen in the future as long as additional trauma can be avoided. However, patients with chronic ocular issues such as pseudoexfoliation and retinitis pigmentosa will likely see progression of the zonulopathy in the future. Even systemic conditions such as Marfan syndrome, homocystinuria, and other diseases can cause a progressive deterioration of zonular strength with age,” Dr. Devgan said. The manner in which zonulopathy presents itself is highly varied and necessitates a sharp eye on the part of the surgeon. “At the slit lamp, we can often see areas of zonular loss with good dilation,” Dr. Devgan said. “Other times, the extent of the zonular loss ˆÃ Ü È}˜ˆwV>˜Ì ̅>Ì Ì…iÀi ˆÃ phacodonesis with movement of the entire crystalline lens with eye movement. In extreme cases, the entire lens can become dislocated and can sunset out of the visual axis and even into the mid-vitreous. Placing the patient in a supine position in the examination room can help to highlight this issue,” he said. Preserve the zonules Preserving the integrity of ̅i ✘Տ>À wLiÀà ˆÃ ۈÌ>° /…i zonular attachments to the lens capsule not only provide stability during cataract surgery, they also directly affect the long-term visual outcome of the procedure. When the zonules are compromised, surgery is adapted to preserve the remaining zonules as best as possible and to ensure stability of the intraocular lens implant. According to Dr. Miller, the extent of zonular laxity or dehiscence can at times be obvious. More often, however, the pathology is subtle, and therefore knowing the indicators of zonular weakness is paramount. “Look for iridodonesis and phacodonesis. Often, the lens will be deep to the iris and you may see vitreous in the anterior chamber. In these cases, the vitreous needs to be removed completely from the anterior chamber, the capsular bag stabilized, and the cataract gently removed. In all cases, I will use a capsular tension ring to reduce further damage to the ✘Տ>À wLiÀÃ]»…i Ã>ˆ`° Missing zonules of one or two clock hours do not present a dire situation, however, Dr. Miller always places a capsular Be prepared for loose zonules AT A GLANCE • The cataract surgeon needs to adapt his or her approach to cataract surgery based on the degree of zonulopathy present in the eye. • Zonulopathy caused by trauma is generally segmental while diffuse zonulopathy is associated with a variety of disease states. • The surgeon’s main goal is to preserve the integrity of the Ài“>ˆ˜ˆ˜} ✘Տ>À wLiÀÃ] ܅ˆV… stabilize the lens capsule and affect the long-term visual outcomes. Contact information Devgan: devgan@gmail.com Miller: miller@jsei.ucla.edu by Stefanie Petrou Binder, MD EyeWorld Contributing Writer This article originally appeared in the September 2019 issue of EyeWorld . +V JCU DGGP UNKIJVN[ OQFKƂGF CPF appears here with permission from the ASCRS Ophthalmic Services Corp. &KHHWUG \QPWNCT NCZKV[ CU UGGP KP VJKU TGV - roillumination slit lamp photograph, can make cataract surgery challenging.