Loose Zonules become evident during Capsulorhexis

This is a patient who had an unremarkable pre-operative consultation for cataract surgery, but when we came to the operating room it became evident that the zonules were loose. Looking at the picture here, we can see that upon attempted puncture of the anterior lens capsule there are raidal straie seen. This indicates that the anterior lens capsule is not taut and that the zonules are loose. 

We can still continue the case without complications as long as we are careful not to cause further stress to the zonular attachments. There are a few key points to consider:

  1. make a sufficiently large capsulorhexis which will aid in removing the cataract but also in limiting anterior capsular rim phimosis. 
  2. avoid techniques like divide-and-conquer which may exert too much outward force on the capsule during nucleus division
  3. if you feel there is focal zonular loss then a capsular tension ring may help, otherwise it is of limited benefit.

Click below to see this video of handling a case with mild zonular weakness:

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