A different surgical approach to cases with zonular weakness or dialysis: sutureless transscleral fixated intraocular lens implantation and stabilization of lens capsule

Proportion and risk factors of zonulopathy in patients with age-related cataract

Purpose

To investigate the proportion of zonulopathy in patients with age-related cataract, and further explore demographics and ocular characteristics, as well as potential risk factors.

Methods

Hospital-based, observational, cross-sectional study. We enrolled consecutive patients who were 45 years or older and diagnosed with age-related cataract and underwent surgery between October 2022 and April 2023 at the Division of Cataract, Beijing Tongren Hospital. Zonulopathy was diagnosed based on intraoperative signs. We calculated the total proportion, age, and gender specific proportions of zonulopathy. We compared the demographic and ocular characteristics between the cases with and without zonulopathy. Univariate and multivariate logistic regression analyses were employed to determine the risk factors associated with the presence of zonulopathy in patients with age-related cataract.

Results

A total of 640 age-related cataract patients with a median age of 70.0 (64.0-77.0) were enrolled. Zonulopathy was diagnosed intraoperatively in 70 patients (10.9%). Compared with the patients having no zonulopathy, those with zonulopathy were likely to be older (P < 0.001), have a shallower central ACD (P < 0.001), a thicker lens (P < 0.001) and a shorter AL (P = 0.010). Logistic regression analyses showed that the risk predictors associated with the presence of zonulopathy in patients with age-related cataract were older age (OR, 1.042; P = 0.035) and shallower central ACD (OR, 0.834; P < 0.001).

Conclusion

Zonulopathy in age-related cataract patients is not an uncommon finding. Clinicians should be mindful of zonulopathy in patient population with advanced age and shallower ACD.

Intrascleral fixation of capsular bag and intraocular lens in cases with large zonular dialysis

PURPOSE

To evaluate the clinical outcomes of sutureless capsular bag and intraocular lens (IOL) fixation with flattened, flanged intrascleral fixation technique in patients with large zonular dialysis.

METHODS

Fifty-five eyes of 51 patients who underwent flattened flanged intrascleral capsular bag and IOL fixation and optic capture for traumatic cataract, subluxated cataract, and pseudoexfoliation syndrome (PEX) with zonular dialysis greater than 180° were included in the study. The main difference of this technique from the Yamane technique is that it has a flattened flange with sharp borders at the haptic tip. Uncorrected visual acuity, corrected distance visual acuity (CDVA), astigmatism, endothelial cell loss, IOL tilt, and intraoperative and postoperative complications were evaluated.

RESULTS

The mean age of the patients was 57.4 ± 15.1 years (range 18-83). Of the patients, 28 (55%) were male and 23 (45%) were female. The mean duration of follow-up after surgery was 19.3 ± 6.5 months (range 12-36). The mean preoperative and postoperative CDVA were 0.71 ± 0.16 logMAR and 0.13 ± 0.20 logMAR, respectively (p < 0.001). The mean preoperative and postoperative astigmatism were 2.0 ± 1.4 D and 1.0 ± 0.7 D, respectively (p < 0.001). The mean IOL tilt was 5.7° ± 5.2°. The mean endothelial cell loss was 9% (range 0.9-19.5). Anterior capsular phimosis was developed in 2 eyes (4%).

CONCLUSION

The flattened flanged intrascleral technique of the capsular bag combined with optic capture provides good visual outcomes, robust capsular bag-IOL fixation, and minimal adverse events. However, further studies with more patients are needed for long-term results.

Loose zonules in cataract surgery

PURPOSE OF REVIEW

This review will focus on identifying causes of zonulopathy during cataract surgery and discuss various modalities for treatment.

RECENT FINDINGS

There are multiple different options for capsular bag support in the setting of zonulopathy, including capsular or iris hooks, capsular tension rings as well as capsular tension segments (CTS). Surgical techniques on how to insert these devices are many and can be customized based upon the surgeon's preference and the patient's eye anatomy.

SUMMARY

Recognizing zonular weakness is critical to achieve stable postoperative vision and avoid future complications. Depending on the degree of zonulopathy, various treatment options can be pursued, ranging from capsular tension hooks or iris hooks, capsular tension rings or sutured or scleral fixated CTS.

The novel haptic-twist method for a sutureless double-needle intrascleral haptic fixation technique

PURPOSE

Description of a novel modified technique known as haptic-twist method for placing a trailing haptic into a 27 G needle during double-needle intrascleral haptic fixation (Yamane technique) in the absence and/or inadequacy of capsular support.

METHODS

The trailing haptic was threaded into the needle lumen using a haptic-twist method in 12 eyes of 11 patients with aphakia. The haptic was grasped by a forceps 2-3 mm from the tip, while the forceps was rotated by 180° counter-clockwise around its own axis. This maneuver enabled the trailing haptic to be slightly twisted without any deformation and to coordinate with the needle in the proper angle. The surgical technique has also been mentioned in a surgical video.

RESULTS

Mean age of the patients was 62 years ± 18 (range 46-78 years). Although the mean pre-operative best-corrected visual acuity was 0.70 ± 0.35 logarithm of the minimum angle of resolution (logMAR) (range 1.30-0.20 logMAR), an improvement of up to 0.40 ± 0.32 logMAR (range 1.0-0.1 logMAR) was observed 3 months after surgery. No trailing haptic bending or breakage was observed during the process. Furthermore, no optical tilting or decentralization was observed post-operatively.

CONCLUSIONS

Although threading the leading haptic into the needle is reasonably straightforward, the trailing haptic positioning can be difficult due to an inappropriate gesture of both the haptic and the needle. We fervently believe that this novel haptic-twist method can provide a much simpler and easier approach, and thus contribute to better surgical outcomes.