For loose zonules, bring the nucleus up and out

In this seemingly routine case, we find that the anterior lens capsule wrinkles when we attempt the capsulorhexis. This means that the zonular support is loose and there is higher risk associated with this case. Normally, the anterior lens capsule is taut like the head of a drum and that makes it easy to puncture to start the capsulorhexis. But in this case, it is tough to puncture because it is so loose. When we touch the anterior lens capsule it induces radial wrinkles.

We want to make a 5 to 5.5 mm capsulorhexis and then bring the nucleus up, out of the capsular bag using hydro-dissection. We do this and tilt the nucleus on its side and it can then be chopped and phaco-emulsified.

After the IOL goes into the capsular bag, we again see evidence of the loose zonules because there is a wrinkling of the posterior capsule as well. With time, the capsule will shrink wrap and this central posterior capsule wrinkle should flatten out. If not, we can always do a future YAG laser capsulotomy.

Finally, in this case, ink from the limbal alignment marks makes its way into the corneal stroma of the incision. Despite multiple attempts, it proves difficult to remove. We make the decision to leave it be, as it will likely dissipate within a few months.

Click below to learn from this interesting cataract surgery:

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