EyeWorld India September 2021 Issue

CATARACT EWAP SEPTEMBER 2021 27 provide counterforce if the rhexis flap doesn’t tear effectively. With hydrodissection, if the lens doesn’t spin easily with the cannula, this could suggest zonulopathy. Dr. Kim said the surgeon should stop trying to spin the lens, as it could damage zonules further. When performing phaco, especially with current generation phaco units that can achieve high vacuum, Dr. Kim said any trampolining of the lens would be a sign of zonulopathy. Other intraoperative signs of zonulopathy, according to Dr. Kim, include the straight line sign, which occurs when there’s striae parallel to the limbus around the peripheral capsular bag. Aggressive I/A in this case can cause the capsular bag to collapse into the I/A tip. In cases of zonulopathy, avoid pulling toward the center with I/A, opting for tangential movement with lower vacuum levels. Zonulopathy management Mild zonulopathy can be fairly uneventful in routine cataract surgery, provided key strategies are used to prevent further zonular damage, Dr. Kim said. More severe cases at risk for lens decentration, dislocation, or posterior capsule rupture and dropped lens require more advanced surgical tools and techniques. “With proper planning one can achieve a successful cataract removal and a well-centered IOL,” Dr. Kim said Trypan blue can be used to help visualize the capsulorhexis edge, which is important when capsule support devices are needed, Dr. Kim said. Dr. Kim advised capsule retractors, rather than iris hooks, due to their ability to support the bag, providing a wider base and longer reach for deeper capsular fornix support. He said he would use a capsular tension ring in cases of mild zonulopathy or those with 3 clock hours or less of zonular dehiscence. “My preferred technique is to use an injector for the CTR with a Sinskey hook. As the CTR is being delivered, the Sinskey hook is used to hook the leading eyelet, and the Sinskey hook holds the leading part of the CTR and reduces torsional stress on the capsular bag and zonules,” Dr. Kim explained. If zonulopathy is more severe or zonular dehiscence is greater, he said he might use a CTR with extra support like a capsular tension segment with Gore-Tex sutured to the sclera. He said practicing skills in preparation for more advanced cases like this is imperative. “There are many complex cataract surgery wet labs including at the ASCRS Annual Meeting and the AAO Annual Meeting. There are also model eyes such as the SimulEye [InsEYEt], which is easily accessible and can be practiced in the comfort of your own operating room,” Dr. Kim said. Once any support devices are placed, Dr. Kim described “zonule-friendly lens disassembly.” This includes using a technique that doesn’t depend on a mobile lens or sculpting. “I developed double chop and cross chop, which enable the surgeon to divide the lens into smaller pieces without needing to rotate the lens within the capsular bag,” 1 Dr. Kim explained. “Learning new skills to disassemble the lens with minimal zonular stress can be a game changer for these situations.” For IOL selection, Dr. Kim thinks a three-piece IOL is better for these cases. “If the IOL dislocates in the future, a single-piece acrylic IOL might have to be explanted and replaced, which results in a bigger surgery. In contrast, a three-piece acrylic IOL can be salvaged and secured by lassoing it with Gore-Tex sutured to the sclera,” he said. Dr. Fram follows a similar technique for milder zonulopathy vs. more severe cases. She said she’ll use capsule retractors, such as Chang Modification (MicroSurgical Technology), and a CTR for less than 3 clock hours of zonulopathy. Ahmed segments (Morcher) and Gore-Tex sutures can be used if the capsulorhexis doesn’t center after CTR placement, she said. “Another indication for fixation with CTR segments, Cionni ring [Morcher], or modified Malyugin CTR [Morcher] includes diffuse zonulopathy. If the IOL is in the bag and the entire complex is mobile with clear pseudophacodonesis, it is important to fixate the capsule bag to the sclera as the CTR alone may not be a definitive solution. This is particularly important in the case of a planned toric or diffractive/ EDOF IOL placement,” Dr. Fram said. Zonulopathy and FLACS More modern settings on femtosecond lasers have improved capabilities that Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Dr. Fram included a few newer concepts and devices in her discussion on zonulopathy. She said there is a concept of a “dead bag,” coined by Samuel Masket, MD. Such capsules have little to no fibrosis and over time will present with zonulopathy and a dislocated IOL-bag complex if the issue occurs near the zonule. Dr. Fram said Liliana Werner, MD, and Nick Mamalis, MD, have been examining specimens of this and have found that the capsules appear to resemble true exfoliation or delamination of the capsule. “Of note, these capsules do not hold anchoring segments well secondarily, and the best approach is an IOL exchange in these patients,” Dr. Fram said. She also mentioned two OUS sutured segments that are showing promise: AssiAnchor designed by Ehud Assia, MD, and the Paperclip Capsule Stabilizer designed by Soosan Jacob, MD. Dr. Fram brought up the X1 Iris Speculum (Diamatrix), which, though indicated for iris expansion, has shown in an off-label capacity the ability to stabilize the capsule in cases of zonulopathy. What’s new?