This challenging cataract case has loose zonular architecture globally, not focally. There is no prior trauma and there is not a focal area of confined zonular loss or weakness. All of the zonular attachments seem lax and the anterior capsule wrinkles when we attempt to puncture it. There is no other ocular disease such as pseudo-exfoliation syndrome. The patient is 90 years old and is in reasonable health, but of course there are challenges in surgery for nonagenarians.
We are still able to create a round and well-centered capsulorhexis and we can remove the nucleus without issues. Even cortex removal is straightforward and no evidence of zonular loss or breakage appears during that critical step. When we implant the single-piece toric IOL into the capsular bag, we note that the formerly round capsulorhexis is now oval shaped, corresponding to the position of the haptics. The IOL appears stable and there is no pseudo-phakodonesis. We want to use a toric IOL given the high degree of corneal astigmatism. Note that there is no sulcus-based toric IOL in the US, so that is not an option.
Would you implant a CTR or leave it as is? Please leave a comment below
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