2983: lot of phacodonesis in pseudo-exfoliation
This 94 year old patient presents with cataracts and pseudoexfoliation (PXF) syndrome, with the right eye having more stability and the left having less (Figure 1). Given that the patient is a nonagenarian, the ocular structural tissues are already fragile. When you combine that with the progressive zonular weakness of pseudoexfoliation, the risk of intraoperative capsular bag loss, pseudo-phacodonesis, or post-operative IOL dislocation escalates dramatically.
The patient first had successful cataract surgery of the right eye, which had less pseudo-exfoliation fibrillar material and better dilation. There was no phacodonesis noted intraoperatively and the patient received a single-piece acylic IOL in the capsular bag without the need for a capsular tension ring. During the pre-operative examination of this patient’s left eye (OS), some degree phacodonesis was noted while the patient was seated at the slit lamp and then while supine in the operating room it was markedly more pronounced. This visual indication of zonular instability means we need a proactive, meticulous surgical plan before we make the first incision.
In cases like this, waiting until a zonular dialysis occurs during phaco to react can lead to disaster. The goal is early stabilization of the capsular bag before any major mechanical stress is applied. By employing sequential capsule hook support, a capsular tension ring (CTR), and a three-piece IOL optic capture technique, we can achieve complete long-term lens stability.
This approach avoids the trauma, complexity, and extended surgical time of an invasive suture-fixation of the capsular bag or IOL complex to the sclera. Given the patient’s advanced age of 94, this targeted surgical approach is robust and will likely provide stability for the rest of our patient’s natural life.
The Pre-Operative Assessment and Early Intervention
The first critical step is the pre-placement of capsule hooks via paracentesis incisions into the anterior chamber. These small incisions are placed in the quadrants where we anticipate needing immediate capsular support. By creating these tracks early and filling the anterior chamber with an ophthalmic viscosurgical device (OVD) to maintain space and minimize lens movement, the capsule hooks are ready to be deployed the moment the capsulorhexis is initiated.
Performing a continuous curvilinear capsulorhexis in the presence of severe phacodonesis is notoriously difficult because the lens lacks the counter-traction normally provided by healthy zonules. To overcome this, the capsulorhexis is performed step-by-step in an intentional, incremental fashion. We perform the tearing in quadrants, completing approximately 90 degrees at a time. After each completed quarter, a pre-placed capsule hook is carefully placed under the newly formed anterior lens capsule edge. The hook is then gently retracted to support the capsular bag out to the lens equator and provide support during cataract removal.
This sequential placement provides immediate mechanical counter-traction for the next 90 degrees of the tear. By the time the 360-degree capsulorhexis is complete, the capsular bag is fully suspended and anchored by four capsule hooks, effectively neutralizing the baseline zonular weakness and centering the bag for phacoemulsification.
Phacoemulsification and Cortical Clean-up Strategy
With the capsular bag completely stabilized by the capsule hooks, phacoemulsification can proceed safely. We use a gentle, low-fluidic setting and a slow phaco chop technique to minimize stress on the remaining zonules. Because the hooks pull the equator of the bag outward, they prevent the capsular bag from collapsing inward or moving toward your phaco tip. Following safe nucleus removal, cortical clean-up is performed carefully, stripping cortex parallel to the hook support to avoid tangential stress. Only after the nucleus has been fully evacuated and the cortex has been thoroughly cleaned do we introduce the capsular tension ring.
While it is tempting to place a CTR immediately after completing the capsulorhexis, doing so traps the cortical fibers against the equator of the bag, making cortical clean-up more difficult and perilous. Rely on capsule hooks for equatorial support during phacoemulsification and cortical removal, and save the CTR for later.
The CTR is carefully guided into the clean capsular bag which has been expanded with a cohesive OVD. Utilizing a Sinskey hook allows for a highly controlled, manual delivery (figure 2), helping the leading eyelet of the CTR to follow the natural curvature of the bag equator without snagging or puncturing the capsule. The role of the CTR here is to redistribute mechanical forces evenly across all 360 degrees of the zonular apparatus, bridging the areas of severe weakness and preventing future localized capsular phimosis or bag contraction.
Definitive Stabilization via Optic Capture
Once the CTR is securely in place, we proceed to the definitive fixative maneuver: optic capture of a three-piece IOL. While a single-piece acrylic lens is great for an intact bag with good zonular support, it is not the preferred choice for this unstable capsular bag. Instead, a three-piece IOL is injected, and its haptics are placed into the ciliary sulcus where they provide a broad, stable support (Figure 3). Next, using a dialing instrument, the optic of the three-piece IOL is gently pushed posteriorly and captured behind the intact continuous curvilinear capsulorhexis edge.
Optic capture provides an good mechanical lock. Because the haptics are in front of the capsular rim (in the sulcus) and the optic is behind it (inside the bag), the lens complex becomes centered and immobile. This configuration eliminates pseudo-phacodonesis, the unwanted postoperative shimmering or shaking of the IOL during eye movement. This intraoperative stability is highly satisfying, as it bypasses the need for complex, time-consuming scleral or iris-sutured IOL techniques that carry higher risks of chronic inflammation and prolonged recovery.
Post-Operative Outcome
On post-operative day 1, the clinical result is excellent and the eye is quiet, clear, and with a stable IOL (figure 4). There is an absence of pseudo-phacodonesis when the patient moves the eye, confirming stability. By optimizing the mechanics of capsule hooks, a CTR, and optic capture, we successfully provided an efficient, definitive solution that will ensure excellent visual function and lens stability for the rest of this patient’s natural life.
