Operating on a highly myopic eye with a pre-existing iris-claw (Artisan/Verisyse) phakic IOL and zonular instability requires a sophisticated, staged approach. The deep anterior chamber typical of high myopia often hides “floppy” or weak zonules, making the capsular bag prone to shifting. The procedure begins by injecting a viscodispersive OVD to protect the endothelium, followed by a viscocohesive OVD to stabilize the space between the phakic IOL and the cataract. The surgeon must disenclavate the iris-claw lens by gently releasing the iris tissue from the haptics before performing phacoemulsification. Because of the zonular weakness, a Capsular Tension Ring (CTR) is injected into the bag, ideally after cortical removal, to redistribute forces and provide 360-degree support. The rigid phakic IOL, typically 6 mm wide, is then explanted through an enlarged incision which is then sutured close. While I like to use the same sutured incision for the cataract surgery, our guest surgeon prefers a new, second incision for that. Finally, a new posterior chamber IOL is placed within the stabilized bag. This restores clarity while the CTR ensures the new implant remains centered despite the compromised zonular integrity.
