Performing cataract surgery in the presence of a lens coloboma with 180° of zonular absence requires a careful approach to prevent intra-operative bag collapse. Due to the profound lack of structural integrity, surgeons must utilize specialized hardware like Capsular Tension Segments (CTS) or a Cionni CTR. These devices provide a permanent eyelet for scleral fixation, essentially replacing the missing zonules. The fixation process involves anchoring the device to the sclera using non-absorbable sutures, such as 8-0 Gore-Tex (my preference) or 9-0 (or 10-0) Prolene like in this video. To prevent long-term complications like suture erosion, knots are often buried within a scleral groove or under a scleral flap. During the surgery, an Osher-style “slow-motion” phacoemulsification technique is employed with lowered fluidic parameters to minimize turbulence. Temporary capsule retractors can provide a crucial scaffold during nuclear emulsification, while the titrated tension of the scleral suture ensures the bag is perfectly centered. This comprehensive stabilization strategy allows for successful IOL implantation and long-term visual rehabilitation despite the extensive congenital defect.
