Are you ready for a challenge? This patient is a relatively young construction worker who sustained a blunt traumatic ocular injury which was fortunately, non-penetrating. This resulted in the development of a focal lens opacity initially, which then progressed to a visually significant cataract requiring surgery. He was part of our charity surgery program given his inability to afford the cost of surgery.
The case starts our normally, with a successful capsulorhexis and minimal evidence of zonular instability. The first clue of an abnormality is the focal lens opacity noted at the pupil margin at the 10 to 11 o’clock position from the surgeon’s view. The next warning sign is the inability of the nucleus to rotate after hydro-dissection.
We are able to perform phaco-chop and bring each nuclear half out of the capsular bag and into the iris plane for aspiration. When we switch to the irrigation/aspiration probe for cortex removal, we really start to notice issues. During attempted cortex removal from the area of traumatic injury, extensive zonular loss becomes evident. The round capsulorhexis morphs into the D shape which indicates loss of zonules along the flat surface. The ideal next step would be to implant a capsular tension ring or a Cionni ring to bolster the weak area and to provide stability for IOL implantation.
A month ago we featured a video from guest surgeon Dr. Sam Masket which showed his effective technique of dealing with weak zonules in Marfan Syndrome. That procedure was beautifully performed and the patient did well with both a capsular tension ring as well as a sutured Ahmed segment.
In this situation, we do not have access to these devices so we must rely on the haptics of the IOL to provide support. We can implant the IOL so that one haptic is placed along the area of zonular weakness. This haptic will exert an outward force which will support the capsular bag equator and help keep the optic centered. This results in a well-centered optic and the capsulorhexis returns to a rounder appearance with resolution of the D shape mentioned above. I am happy to report that the patient has done very well and has a stable and well-centered IOL with excellent vision. Let’s hope that he is able to avoid future trauma.
Click below to see how we deal with traumatic zonular loss during cataract surgery:
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