Cataract Surgery with Traumatic Zonular Loss

traumatic zonular loss title

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.

traumatic cataract preop

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.

zonular place haptic

Click below to see how we deal with traumatic zonular loss during cataract surgery:

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  1. Thank you for your excellent videos, I just recently came across your website and I just cant seem to watch enough videos per day to catch up and learn all of it !

    I was recently operating on a case (no video on my microscope so not 100% sure of what happened or videos to send to you 🙁 ) during which I think I did not have a good enough hydrodissection which resulted in a stuck epinucleus which i had trouble to remove. Unfortunately I ended up with around 3 clock hours of zonular dehicence as above sub incisionally, and there was some vitreous prolapse. There was also a radial tear in the anterior capsule but luckily it seemed to have stopped at the equator.

    Would you be so kind as to guide me on how you would have dealt with the complications ?
    Can you insert a CTR if there is a radial tear in the ant capsule?

    Thank you for your excellent work and dedication ! I look forward to your reply

    1. Avoid the CTR if the capsulorhexis is not intact. In this case a sulcus IOL could be placed after removing the prolapsed vitreous from the anterior segment.

  2. Hey! Could you show us how you do the Cionni scleral fixation technique? Thanks for everything you teach us!

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