Surgical strategies for the management of zonular compromise

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.

Zonular dialysis and cataract surgery: results from a UK tertiary eye care referral centre

OBJECTIVE

Zonular dialysis (ZD), referred to as the presence of a deficient zonular support for the lenticular capsule, might be the result of several causes and be detected only at the time of cataract surgery. The aim of this study was to evaluate pre-, intra-, and postoperative features of eyes with ZD regardless of the etiology detected during cataract surgery.

METHODS

A single-centre retrospective observational cohort study was performed at Moorfields Eye Hospital (NHS Foundation Trust, London, U.K.) to identify patients who underwent cataract surgery whose procedure was intraoperatively described as being complicated by ZD between January 1, 2014, and August 22, 2019. Patient characteristics, intraoperative clinical findings, visual and refractive outcomes, and postoperative complications were recorded.

RESULTS

ZD was identified intraoperatively in 447 eyes. In most cases (213 of 223; 96.8%), patients underwent a phacoemulsification procedure, not requiring any conversion to intracapsular or extracapsular extraction technique. Intraoperative complications increased to 46.2% (103 of 223), with no significant correlation with ZD width. Capsular tension rings (CTRs) were implanted in 43.4% of patients (97 of 223). The use of CTRs correlated with better postoperative visual and refractive outcomes.

CONCLUSIONS

ZD is a serious complication of cataract surgery requiring prompt intraoperative diagnosis and proper management. While it tends to worsen cataract surgery outcomes, the implantation of CTRs during the surgical procedure seems to be associated with better postoperative visual and refractive results.

Flanged iris hook for capsular bag stabilization

A new surgical technique was demonstrated for fixating the capsular bag to the sclera using a capsular tension segment (CTS) and a flanged iris hook. In a patient with a 180-degree zonular dialysis, a capsular tension ring was implanted into the capsular bag, and a CTS was placed into the zonular dialysis area after cataract removal. Then, an iris hook was directed to the anterior chamber through a side port opposite the zonular dialysis area. After the hook tip was placed into the eyelet of the CTS, a 30-gauge injector was used to guide the hook tip out. Tension was adjusted to ensure the capsular centralization, and a flange was created using cautery. Finally, the procedure was completed by embedding the flange into the sclera. This method is simple, minimally invasive, and time-saving by eliminating the scleral suturing, scleral flaps, or large conjunctival dissections.

Sutureless technique for repositioning and scleral fixation of the capsular bag-intraocular lens complex with permanent use of iris retractors

A new sutureless technique used for repositioning and scleral fixation of the capsular bag-intraocular lens (IOL) complex in the surgical treatment of subluxated lenses is described. Iris retractors were used not only to induce a tent effect on the capsule but also to permanently fix the capsular bag to the sclera in this method, without the need to prepare scleral or conjunctival flaps. Surgery with the use of a capsular tension ring (CTR) and iris retractors, the ends of which were brought out through the sclera and cauterized, was performed in 7 eyes of 7 patients with moderate or severe subluxation of the crystalline lens. In all cases, simultaneous use of a CTR and iris retractors ensured good centration of the capsular bag-IOL complex. The method was safe and effective in fixing the capsule to the sclera in the case of significant damage to the ligamentous apparatus of the lens.

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.

Results of using the AssiAnchor capsule device for subluxated crystalline lenses

Purpose:

To describe our results with the AssiAnchor capsule device in cases of subluxated crystalline lenses.

Methods:

This was a retrospective consecutive case series. Seven eyes of four patients with subluxated crystalline lenses underwent lensectomy/phacoemulsification with intraocular lens (IOL) implantation using the AssiAnchor capsule device in the Kaplan medical center, ophthalmology department. Three patients had Marfan syndrome and one patient had experienced blunt trauma. Demographic data were collected as well as parameters of pre- and postoperative distance visual acuity and refraction, intra-, and postoperative complications, and IOL stability and centration.

Results:

Six out of the seven surgical procedures were uneventful with in-the-bag implantation of the IOL. In the first surgery, a tear of the capsular bag lead to IOL exchanging and fixating to the AssiAnchor and to the iris. In the traumatic cataract case, two AssiAnchors were used. A capsular tension ring was implanted in six out of seven surgeries. The average follow-up time was 9.5 ± 6.8 months. All the IOLs were stable and well centered except for the first IOL that exhibited a slight temporal, but not clinically significant, decentration. The distance visual acuity and the refractive parameters improved significantly in all cases.

Conclusion:

We found the AssiAnchor capsule device an effective tool with a short learning curve for treating subluxated lenses.

The effect of capsule tension ring on posterior capsule opacification: A meta-analysis

Background

Posterior capsule opacification is one of the most common complications after cataract surgery. Studies have suggested that the introduction of a capsule tension ring might play a critical role in the prevention of capsule opacification, yet quantitative evidence is still lacking. This work consists of a meta-analysis on available data in order to explore the influence of a capsule tension ring on posterior capsule opacification.

Methods

A comprehensive review of the literature on capsule tension ring and posterior capsule opacification was carried out using the Embase, Pubmed, Web of Science, and Cochrane electronic databases. The selected studies included randomized controlled trials, retrospective studies and prospective studies published before June 2020. The studies of interest were selected by two reviewers independently from the included studies. Odds ratios (ORs) and standardized mean differences (SMD) were used in order to assess the association. A fixed-effects model or a random-effects model was applied to combine data according to heterogeneities. Sensitivity analysis was used to assess the heterogeneity of the studies. Publication bias was estimated using the Egger test. Statistical analysis was performed using the stata15.1 software.

Results

The meta-analysis included in total 8 studies involving 379 cases and 333 controls. There was a statistically significant difference of Nd:YAG laser capsulotomy rate (OR=0.241, 95% CI: 0.145, 0.400 I²=42.1%) between the capsule tension ring group and the control group, indicating that the tension ring reduced the Nd:YAG laser capsulotomy rate. Further studies with continuous data also revealed that the use of capsule tension ring was associated with a lower posterior capsule opacification score (SMD = -1.402, 95% CI: -2.448, -0.355 I²=95.0%). The sensitivity analysis suggested that the result of the re-combined analysis did not change notably, indicating that the result was reliable and stable. Both pooled analysis showed no evidence of publication bias.

Conclusion

The findings of this meta-analysis confirmed that capsule tension ring might reduce capsule opacification. Further studies should be made to validate the result.

Effect of capsular tension ring implantation on capsular stability after phacoemulsification in patients with weak zonules: a randomized controlled trial. CTR implantation in cataract patients with weak zonules

BACKGROUND

The use of capsular tension ring (CTR) implantation to treat cataract patients with weak zonules is still controversial. The aim of this study was to examine the effects of CTR implantation on capsular stability after phacoemulsification in patients with weak zonules, especially patients who have undergone pars plana vitrectomy (PPV) or those who suffer from severe myopia.

METHODS

A total of 42 patients who underwent phacoemulsification and received an intraocular lens (IOL) were randomized to undergo CTR implantation or not. The control and CTR groups were compared in terms of uncorrected distant visual acuity (UDVA), best corrected distant visual acuity (BCDVA), refractive prediction error, the area of anterior capsulorhexis, and IOL inclination angle. Follow-up visits were conducted postoperatively at 1 day, 1 week, 1 month and 3 months. Subgroup analyses were performed based on PPV and severe myopia.

RESULTS

Surgery significantly improved UDVA and BCDVA to similar extents in CTR and control patients, and refraction prediction error was similar between the two groups at all follow-up times. At 3 months after surgery, the area of anterior capsulorhexis was significantly larger in CTR patients than in controls (p = 0.0199). These differences were also significant between the subgroups of patients with severe myopia. Vertical IOL inclination was less within CTR groups at 3 months after surgery, especially in patients with severe myopia (p = 0.0286). At 1 week postoperatively, the proportion of individuals whose posterior lens capsule that had completely adhered to the posterior IOL surface was significantly higher among CTR patients (p = 0.023). No serious surgical complications were observed.

CONCLUSION

CTR implantation can benefit cataract patients with weak zonules by maintaining the shape of the capsular bag, reducing capsule shrinkage and stabilizing IOL inclination.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-INR-17011217 , date of registration April 22, 2017, prospectively registered.

Long-Term Outcome of Cataract Surgery in Eyes with Pseudoexfoliation Syndrome Associated with Weak Zonules: A Case Report

A cataract surgery in both eyes was scheduled for an 81-year-old female patient. However, ophthalmic examination revealed marked iridodonesis, phacodonesis and pseudoexfoliative material on the surface of the lens in both eyes indicating weak zonules caused by pseudoexfoliation syndrome, which was more pronounced in the left eye. Cataract surgery was performed initially in the left eye by phacoemulsification. Additionally, iris hooks and capsular tension ring (CTR) were used to stabilize the capsular bag, and the haptic of the intraocular lens (IOL) was sutured to the iris at the end of the surgery. The same procedure except haptic suturing was performed in the right eye after 6 months. The left eye remained stable, whereas the right eye developed considerable anterior capsular contraction 2 months postoperatively. Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy was performed to treat the condition. Moreover, 3 years after the initial surgery, late IOL-CTR-capsular-bag complex dislocation developed in the right eye, and reposition surgery was performed. Three days after IOL-CTR-capsular-bag complex reposition surgery, endophthalmitis developed; the eye responded well to 1 mg intravitreal vancomycin treatment. IOL in the right eye remained stable 3 years postoperatively.

Nuclear scaffold: Three-dimensional indigenous capsular bag support combined with IOL scaffold and capsular tension ring to prevent posterior capsule rupture in zonulopathy

We describe a technique for performing phacoemulsification in eyes with zonular fiber dehiscence of less than 90 degrees using hard nuclear fragments as a scaffold. In conjunction with a capsular tension ring (CTR), hard nuclear fragments and the intraocular lens (IOL) are used as scaffolds during different steps of nuclear emulsification to prevent posterior capsule rupture and aggravation of zonulopathy. Devices such as capsular hooks, CTRs, and IOLs are used to support the capsular bag associated with zonulopathy. The mass of hard nuclear fragments provides support toward the anteroposterior and the horizontal planes, thereby providing 3-dimensional capsular bag support.

Capsular bag stabilization during lens extraction and intraocular lens implantation in cases of Marfan syndrome with ectopia lentis using ultra-high-viscosity ophthalmic viscosurgical devices

Capsule-sparing lens surgery in the setting of compromised zonular support presents several surgical challenges. One challenge has been achieving early stabilization of the capsular bag prior to cataract removal. We developed a technique that uses a high-molecular-weight viscoadaptive substance to distend and stabilize the capsular bag from within, with or without early insertion of a capsular tension ring, during lens extraction and intraocular lens (IOL) implantation in cases of zonular insufficiency. The technique obviates the use of capsule hooks or similar devices that have been used traditionally for early stabilization of the capsular bag. It has also resulted in immediate and long-term stability of the IOL-zonule-capsular bag complex, with excellent visual outcomes in both pediatric and adult patients.

FINANCIAL DISCLOSURE

Dr. Rosenthal is a consultant to Abbott Medical Optics, Inc., Ophtec USA, and Bausch & Lomb/Valeant. Dr. Venkateswaran has no financial or proprietary interest in any material or method mentioned.

Intraoperative difficulties, complications and self-assessed visual function in cataract surgery

PURPOSE

To study associations between intraoperative difficulties and changes in patient-perceived and postoperative visual function and visual satisfaction after cataract surgery.

METHODS

Swedish multicenter, prospective, cross-sectional, nonrandomized, National Cataract Register study. A total of 10 979 patients (n = 10 979) who underwent cataract surgery from 2008 to 2011 completed the Catquest-9SF questionnaire before and 3 months postoperatively. Using Rasch analysis, we converted the nonparametric grading of the answers to parametric data and performed parametric statistical analyses. Multiple regression models were used to examine possible predictors associated with self-assessed visual function after cataract surgery.

RESULTS

Greater improvement in self-assessed visual function was seen in patients in whom trypan blue dye was used; those without a posterior capsular tear or an ocular comorbidity; and those who were younger, female and had low preoperative corrected distance visual acuity (CDVA) or high postoperative CDVA compared with their counterparts. Significantly higher self-assessed postoperative visual function was seen in patients in whom trypan blue dye was used and those with no posterior capsular tear or ocular comorbidity and no use of capsular hooks; and those who were younger and had low preoperative or high postoperative CDVA compared with their counterparts. The risk of general dissatisfaction after cataract surgery was significantly greater in patients with a posterior capsule tear, ocular comorbidity or low postoperative CDVA, and those in whom mechanical pupillary stretching was performed.

CONCLUSION

Several intraoperative difficulties, posterior capsular tear, ocular comorbidity, age, gender, and preoperative and postoperative CDVAs affect patient improvement and self-assessed visual function after cataract surgery.

Objective classification of zonular weakness based on lens movement at the start of capsulorhexis

Purpose

To quantify zonular weakness based on lens movement at the start of continuous curvilinear capsulorhexis (CCC) and establish a classification system for it.

Setting

Kozawa Eye Hospital and Diabetes Center, Mito, Japan.

Design

Retrospective interventional case series.

Methods

We examined 402 consecutive eyes of 316 patients who underwent CCC, phacoemulsification and aspiration (PEA), and intraocular lens (IOL) implantation. The movement of the lens capsule was measured using images from video recordings of the CCC procedure. Zonular weakness was classified based on the shifted distance: Grade I, less than 0.20 mm; Grade II, 0.20–0.39 mm; and Grade III, greater than 0.40 mm. For each of these grades, we examined the use of the capsule stabilization device during PEA, the surgical procedure for lens removal, and IOL fixation.

Results

We classified 276 eyes (68.6%) as Grade I, 102 eyes (25.4%) as Grade II, and 24 eyes (6.0%) as Grade III. As the grade increased, the use of the capsule stabilization device in PEA and scleral suture fixation of IOL increased.

Conclusions

Zonular weakness was quantified by measuring the movement of the lens capsule. An objective classification of zonular weakness based on lens movement may be useful for selecting the appropriate device and procedure during cataract surgery.

Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation

We describe a technique to manage late spontaneous intraocular lens (IOL) and capsular tension ring (CTR) dislocation within the intact capsular bag. The subluxated IOL and CTR complex can be positioned in a closed chamber and fixed to the pars plana at both 3 and 9 o’clock quadrants with the presented ab externo direct scleral suturation technique which provides an easy, safe and effective surgical option for such cases.

New Management Strategies for Ectopia Lentis

Ectopia lentis refers to displacement of the crystalline lens in the setting of various systemic and metabolic disorders. A literature review was conducted to investigate the management of non-traumatic ectopia lentis in the pediatric population, particularly focusing on surgical intervention. Both limbal and pars plana approaches for lensectomy are well established in the literature. Surgical options for intraocular lens implantation in pediatric eyes with ectopia lentis include anterior chamber intraocular lenses and iris-fixated or scleral-fixated posterior chamber intraocular lenses. Recently, the use of capsular tension rings has also been described with promising results. Visual rehabilitation and treatment of amblyopia are essential for patients within the amblyogenic age group following surgical intervention.

Femtosecond Laser-assisted Cataract Surgery in Patients With Marfan Syndrome and Subluxated Lens

PURPOSE

To report femtosecond laser-assisted cataract surgeries in patients with Marfan syndrome with mild, moderate, and severe lens subluxation.

METHODS

Case reports.

RESULTS

Two patients with Marfan syndrome underwent femtosecond laser-assisted cataract surgery (Alcon LenSx Lasers Inc., Aliso Viejo, CA). One patient had a mild lens subluxation in one eye and a moderate lens subluxation in the fellow eye. The other patient had a severe lens subluxation in one eye. In all eyes, the laser was able to perform a circular and free-floating anterior capsulotomy and lens fragmentation. In two of the eyes it was also helpful in decreasing corneal astigmatism by making corneal intrastromal relaxing incisions. There were no postoperative complications.

CONCLUSIONS

Femtosecond laser-assisted cataract surgery is an effective approach for cataract surgery in patients with Marfan syndrome with mild, moderate, and even severe lens subluxation, with the benefits of causing minimal further zonular damage and being able to treat corneal astigmatism with relaxing incisions.

Modified capsule expander implantation to reposition and fixate the capsular bag in eyes with subluxated cataractous lenses and phacodonesis: intermediate-term results

PURPOSE

To report the intermediate-term results of capsule stabilization for scleral fixation with implantation of the Yaguchi hook, a modified capsule expander stabilization hook.

SETTING

Department of Ophthalmology, School of Medicine, University of Showa, Fujigaoka Rehabilitation Hospital, Yokohama, Japan.

DESIGN

Retrospective case series.

METHODS

Patients with zonular dialysis and phacodonesis were followed postoperatively for at least 2 years. All eyes had phacoemulsification and aspiration using an ordinary capsule expander and in-the-bag implantation of an intraocular lens (IOL). Capsule expanders were removed after the residual cortex was removed, and the capsular bag was fixated to the scleral wall via the ciliary sulcus using the modified capsule expander stabilization hook. Preoperative findings, intraoperative complications, and postoperative courses were examined.

RESULTS

The mean age of the 11 patients (11 eyes) was 72.2 years ± 10.5 (SD); 5 patients were men. The mean postoperative follow-up was 48.6 ± 13.6 months. The zonular dialysis range was 90 to 180 degrees in 1 eye, 180 degrees in 4 eyes, and 180 to 270 degrees in 1 eye. In 5 eyes, severe phacodonesis was observed without obvious zonular dialysis. In all eyes, the capsular bag and IOL were well centered without severe intraoperative or postoperative complications.

CONCLUSION

The modified capsule expander stabilization hook provided good centration and stabilization of the capsule-IOL complex in eyes with severely weak zonular fibers.

FINANCIAL DISCLOSURE

Dr. Yaguchi, who is the inventor of the modified capsule expander, has received financial support from Handaya, Tokyo, Japan. No other author has a financial or proprietary interest in any material or method mentioned.

All about capsular tension rings

PURPOSE OF REVIEW

To discuss capsular tension devices and recent evidence regarding their use.

RECENT FINDINGS

The capsular tension ring, modified capsular tension ring, and capsular tension segment are well established tools for use during phacoemulsification when zonular instability is present. Recent research has provided additional evidence of their benefits in decreasing intraoperative and postoperative complications.

SUMMARY

Endocapsular support devices allow for cataract surgery success in the setting of zonular instability.

Iris retractors: the saviours in cataract surgery for cataract in lens coloboma

A 67-year-old woman presented with features of bilateral cataract and lens coloboma. The lens coloboma was from 1 to 8 o'clock and from 5 to 9 o'clock positions in right and left eye, respectively. With some modifications, phacoemulsification was performed in both eyes at an interval of 1 month. A smaller (4.5 mm) anterior capsulorrhexis was made due to poor peripheral lenticular support. Three iris retractors were used to stabilise anterior capsulorrhexis margin to the limbus. Phacoemulsification was performed by direct chop technique under low phacodynamics. A capsular tension ring was placed in a bag followed by tangential cortical clean up and implantation of a foldable intraocular lens (IOL). One month following surgery, both eyes had a visual acuity of 20/20 with a stable IOL. This case report highlights the rarest malformation of the lens with cataract and its successful management by phacoemulsification using iris retractors as capsule supporting device.

Cionni ring and in-the-bag intraocular lens implantation for subluxated lenses: a prospective case series

PURPOSE

To report the intraoperative performance and postoperative outcomes of the Cionni-modified capsule tension ring (CTR) implantation in eyes with subluxated lenses.

DESIGN

Prospective, observational case series.

METHODS

This study was carried out at Iladevi Cataract & IOL Research Centre, Ahmedabad, India. The study population comprised 41 eyes with subluxated lenses that underwent lens extraction, capsular bag fixation with modified CTR, and in-the-bag single-piece AcrySof intraocular lens (IOL) implantation. Main outcome measures were intraoperative performance and postoperative best-corrected visual acuity (BCVA), IOL centration, and complications.

RESULTS

The mean age was 29.46 ± 16.16 years (3-68 years). Mean extent of subluxation was 6.1 ± 1.0 clock hours. Preoperatively, vitreous was detected in the anterior chambers of 5 eyes (12.2%). Two-port anterior chamber vitrectomy was performed in 2 eyes. Mean follow-up was 45.8 ± 2.9 months. Mean preoperative BCVA was 0.66 ± 0.22 logMAR (35 eyes). Mean postoperative BCVA at final follow-up was 0.33 ± 0.21 logMAR (41 eyes) (P < .001). BCVA improved in 35 eyes (85.4%) at the last follow-up. In 3 eyes (7.3%) IOL decentration was noted and repositioning was required in 2 eyes. Posterior capsule opacification developed in 14 eyes (34.2%); 12 eyes (29.3%) required Nd:YAG capsulotomy. Other complications included cystoid macular edema in 1 eye (2.4%), posterior synechiae in 1 eye (2.4%), and retinal detachment in 1 eye (2.4%).

CONCLUSION

In-the-bag implantation of a Cionni-modified CTR with IOL appears to be a safe option in eyes with subluxated cataract, ensuring a stable IOL with few complications.

Complete spontaneous posterior luxation of capsular bag-intraocular lens-capsular tension ring complex

We describe the case of a monocular 72-year-old man who presented with spontaneous acute visual decrease in the left eye 2 years after uneventful phacoemulsification with intraocular lens (IOL) and standard capsular tension ring (CTR) implantation. Dilated fundoscopy revealed aphakia and complete vitreous luxation of the entire capsular bag-IOL-CTR complex.