EyeWorld India September 2021 Issue

CATARACT ÓÈ EWAP SEPTEMBER 2021 by Liz Hillman EyeWorld Editorial Co-Director Contact information Fram: DrFram@avceye.com Kim: kim@professionaleye.com This article originally appeared in the July 2021 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. H ere are many potential complications cataract surgeons need to prepare for in the OR. One of them is zonulopathy. “Recognizing zonulopathy and adopting strategies to mitigate zonular damage is critically important not only for short-term success but perhaps more importantly long-term success to reduce the risk of late IOL dislocation,” said D. Brian Kim, MD. Preoperative recognition Past ocular history such as trauma, retinitis pigmentosa, angle closure glaucoma attack, a family history of ectopia lentis, or history of pseudoexfoliation “should raise your index of suspicion for zonulopathy,” Dr. Kim said. He also said a small pupil coupled with a dense cataract should be treated like a case with loose zonules “until proven otherwise.” Nicole Fram, MD, said that obvious signs include areas of missing zonules, such as colobomatous changes, Marfan syndrome, pseudoexfoliation with phacodonesis, and Recognizing zonulopathy and what to do traumatic cataract. More subtle signs include pseudoexfoliation in the setting of a shallow chamber, asymmetric shallowing of the AC where the depth changes as the anterior chamber is examined. “Surgeons should always proceed with caution in patients with pseudoexfoliation, high myopia, history of PPV or trabeculectomy, uveitis or retinopathy of prematurity, aniridia. All of these conditions cause a disturbance of the blood aqueous barrier and can lead to weak zonules,” Dr. Fram said. Intraoperative signs and management One has to constantly be on the lookout for zonulopathy at various stages in the case, Dr. Kim said. “Unfortunately, patients often may not show signs of zonulopathy until you are in the operating room,” he said. There might be signs of zonulopathy before even starting your incision. Dr. Fram said if you see more of the edge of the crystalline lens than normal or if there is a jiggle indicative of phacodonesis, these are warning signs of loose zonules. Dr. Kim said cases with zonulopathy or zonular laxity will see the lens move backward more than usual when filling the anterior chamber with OVD. Another opportunity to identify zonulopathy is when starting the capsulorhexis. “There is often striae resembling elephant’s skin, indicating weak zonules,” Dr. Fram said. “In the moment, you can stain with trypan to make sure the rhexis edge can always be identified.» Dr. Kim described this as the spider sign, which occurs when just puncturing the anterior capsule with forceps for the capsulorhexis. “The spider sign occurs because the anterior capsule sags backward as the downward force is applied,” he explained. As you’re pulling the rhexis flap, the anterior capsule and bag will move, creating distinctive folds in front of the flap, if the zonules are weak, Dr. Kim continued. He added that capsule retractors can be placed behind the tear to The spider sign is seen when puncturing the anterior capsule for capsulorhexis. The central anterior capsule stretches and forms striae toward the puncture point, creating a spider-liMe appearance because the anterior capsule sags bacMward as the downward force is applied. If the zonules are weaM, the force used to pull the flap can cause the capsular bag to move and create distinctive folds in front of the flap as it is being pulled. Source (all): D. Brian Kim, MD