This is a really difficult surgery and we know that ahead of time. When we examine this patient at the pre-operative consultation we note that she is highly hyperopic with poor dilation. She has pseudo-exfoliation syndrome and a shallow anterior chamber.
In the surgery, we note severe zonular laxity which makes it very difficult to perform the capsulorhexis. When we attempt to puncture the anterior lens capsule, it simply wrinkles and gives in as if we were trying to puncture an under-inflated balloon with a dull instrument. After we create a 5-mm capsulorhexis we note that it shifts side to side indicating very weak zonular support.
We end up placing a capsular tension ring and then implanting a three-piece IOL with the haptics in the sulcus and the optic captured behind the capsulorhexis. This can provide better long term stability than placing a single-piece IOL in the capsular bag.
click below to learn from this challenging case: