Be Cautious with the Wrinkly Old Bag

This is one wrinkly old bag! Of course, we are referring to the capsular bag in this cataract surgery. This is a very elderly patient, in the ninth decade of her life and her ocular tissues are quite delicate. When removing the cortex during irrigation / aspiration, the capsular bag has a tendency to flop around and it seems that the zonular support is not ideal and the anterior hyaloid face is like liquified.

Any routine maneuvers with the I/A probe tend to allow the posterior capsule to enter the aspiration port which we can see as radial wrinkles like in the photo shown here. The key to handling this situation is to keep the port away from the capsule, use a lower flow rate, and to do no harm. Leaving a slight amount of haze on the peripheral anterior capsular rim is better than risking a ruptured posterior capsule.

Click the video below to see how to deal with a wrinkly old bag:


  1. I had a similar case 5 years ago. Was very proud of myself that everything went well. The lens centered well etc. Just saw him, IOL in the bag still visible but dislocated inferiorly. No PXE hx.
    Should I have done something differently in hind sight? 3 piece in the sulcus with bag fixation?
    Capsular tension ring?

    1. These are tough cases with no perfect answers. For these 90+ year old patients, I would recommend doing just as you did — put the IOL in the bag. As we know, human bodies (and eye structures) will deteriorate with advanced age. We can go back and suture / secure the IOL in the future if required. Putting in a CTR may not help much because all the zonular support is weak (global weakness) — and we have seen plenty of patients where the entire IOL+bag+CTR complex was dislocated.

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