During this lecture, various surgical strategies on dealing with cataract complicated by a wide spectrum of zonular pathology will be discussed, from weakness to partial and severe loss of zonular support.
Lecturer: Dr. Boris Malyugin, Professor of Ophthalmology and Deputy Director General, S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia
DR MALYUGIN: Hi, everybody. My name is Boris Malyugin. I’m from Moscow, Russia, and I will be happy to share with you today some of my techniques that I use in patients with zonular deficiency and more specifically with zonular dialysis. I would also be happy to answer your questions. So as you can see here, there’s a variety of clinical cases with large zonular defects. And they usually present very significant challenges for every cataract surgeon. And they vary from more or less insignificant, like zonular weakness, towards the more significant, when the lens is significantly displaced. And here is the list of the hereditary conditions, leading to zonular deficiency, including Marfan, Weill-Marchesani syndrome, including others, and also risk factors associated with zonular pathology, such as trauma, including surgical, intraoperative trauma, previous eye surgery, some other comorbidities. We should be careful in assessing these cases quite carefully. Because we need to find out whether or not the lens is malpositioned. Sometimes it’s possible to directly visualize the zonular defect. Anterior chamber depth anomalies may help us to judge whether or not there is a zonular deficiency, as well as irido and phacodonesis. Sometimes it’s possible to visualize vitreous in the anterior chamber, and also pupil abnormalities. Before surgery, it’s quite helpful to understand the significance of the zonulopathy. The extent of the zonular dialysis can be judged in low powers, and that may help you to build your proper surgical plan. And also, you have to assess the condition of the zonules that were not directly ruptured. But may be weakened during the course of the disease. And also, we need to find out the localization of the zonular weakness. Anterior segment OCT might be quite helpful, as you can see here. There is an anomaly of the iris. This portion of the iris is lifted. Because it’s pushed from behind by the dislocated lens. And sometimes it can be pushed from behind by vitreous. Specifically in traumatic cases. Ultrasonic biomicroscopy may also help us to define the reasons for dislocation. Such as stretched zonules, such as localized zonular defect, and also we can observe hyperprolate anterior lens surface, which is a good indicator of zonular weakness and deficiency. Intraoperative examination may also be quite helpful. When you see that the lens is not very stable, it’s a good idea to find out the reason by retracting the iris and examining this area of the possible zonular defect. And also you can assess the mobility of the lens, by pushing on the lens by the instrument. Intraoperative examination, as shown in that case, may also be very helpful with external compression. So external compression sometimes is quite helpful in assessing the zonular weakness before you were actually starting to do any kind of surgery. So you can be prepared and have proper measures and proper instrumentation and lenses. There are several surgical challenges. In these cases. As shown here. And my question would be for you. So what are the substances that may help you to visualize vitreous strands located in the anterior chamber? These are Trypan blue, indocyanine green, triamcinolone acetonide, or prednisolone acetate. We will wait for the answers. Okay. So I think the majority of the people who responded, 78%, did it well. However, there is still a little bit of confusion, whether or not the dyes that we are using usually for staining the capsule may help us in staining the vitreous body, such as Trypan blue or indocyanine green. And obviously the question here is that triamcinolone acetonide is the best solution to help us in visualizing the vitreous. Here is the anterior vitrectomy. And you see that the vitreous strands are located in the anterior chamber. And there is some vitreous there. And I’m injecting triamcinolone acetonide into the anterior chamber. Usually you need to wash out the excessive amount of triamcinolone, in order to leave only the stained portion of the vitreous in the anterior chamber. And as soon as it is done, so you actually can really visualize previously invisible vitreous in the chamber. Anterior vitrectomy can be done not only with a vitrectomy probe, like in that case, there is a single strand of vitreous that is coming from the area of the zonular defect. So basically you have to be careful not to aspirate it into the ultrasonic needle. And then you can utilize 25-gauge scissors, in order to cut the single vitreous strand, and that will help you to complete the case successfully. Without the need of any kind of vitrectomy. The other surgical challenge here is capsulotomy. Because it is very hard to initiate sometimes the puncture in the anterior capsule, because there is lack of resistance from the capsule. And this resistance is generated by zonules, zonular fibers, that help to provide tension to the anterior capsule. So basically here, bimanual capsulotomy technique is being used, when the second instrument is utilized to keep the lens in place, and to prevent the lens from being moved with the instrument, as shown here. So in these cases, sometimes capsular hooks may be quite helpful to stabilize the lens. But we will show this technique later on. Capsulotomy is a very critical step of that kind of surgery. This is the animation showing how the capsulotomy is being done. And the second instrument, which is stabilizing the lens in place. We should keep in mind that high-tech equipment may be also helpful in creating very nice round capsulotomy, as shown here. This is the laser capsulotomy done. It is slightly eccentric, as you can judge by the center of the pupil. However, the capsulotomy here is not centered on the pupil, but rather on the center of the — decentered natural lens. And that’s why we can see it right here. Lens aspiration. If the lens is quite soft, it’s usually not a big issue to remove it. The contents of the capsular bag. However, if there is association of zonular instability with the harder lens, and these cases usually are presenting much more challenges. In these cases, we need some special techniques to be utilized. So what do we need to help these patients? Iris retractors may sometimes be helpful. As shown here. And this is an iris retractor, catching the anterior capsular edge. And it stabilizes the lens, which is now in place. And by stabilizing the lens, it is possible to evacuate the cortical contents. Again, as shown here, vitrectomy is being done. And as I mentioned to you earlier, capsulotomy is quite challenging in these cases, because the lens is very mobile. And we need to be quite careful. It is a good idea to initiate capsulotomy at the area adjacent to the zonular weakness and create some tractions towards the zonules that are intact. Again, here is the hooks that are utilized to keep the lens in place, and as shown here, you have to be quite careful, because there is a possibility for the collapse of the equator of the capsular bag, as shown here. So this is the area in between two hooks that is not supported. The equator of the lens is not really supported. That’s why there’s a significant risk of aspiration of the capsular bag. That’s why capsule retractors are quite useful. Because as shown here, they are having elongated fixation elements that rest on the equator of the capsular bag, and help you to stabilize the capsular bag more effectively. This is a double threaded design of the CTR that helps you to avoid rotation. They are a little bit more bulky than the regular iris hooks that we get used to expand the pupil. So they require a little bit of more extensive manipulations, in order to implant and to remove it from the eye. In cases where there is an insufficient mydriasis associated with the zonular weakness, it is possible to simultaneously expand the pupil and catch the edge of the capsule with these capsular expanders, and then suspend the lens by fixating it to the limbal area. Here is the clinical case. During capsulotomy, it’s possible to judge the weakness of the zonules. Actually, from the first puncture of the zonules, you can see how the lens is mobile. And whether or not you will be having difficulties. So if you see radial folds on the anterior capsule, that may bring you the idea that there is a significant zonular weakness. So here is the association of the zonular weakness with small pupil. And by expanding the pupil and catching the edge of the rhexis, you will actually be able to stabilize the lens. Remove the nucleus safely. And implant the IOL directly into the capsular bag. As shown here. And this is evacuation of the cortical material. Lens is in place. And what we’ll be doing now is just removing these hooks. And this is done quite gently, in order to avoid trauma to the endothelium, which may be caused by these elongated elements of the hooks. If you will manipulate them not very carefully. Capsular tension rings are very helpful in expanding the equator of the capsular bag by providing tension. And by redistributing the forces that are caused on the equator of the capsular bag, and helping the residual zonular apparatus to work properly. So my second question to you is: In which of the following cases you will consider suturing CTR to the scleral wall? First if the zonular defect is extending from 0 to 30 degrees. Second, when the zonular defect is from 30 to 60 degrees. Third, when the zonular defect is from 60 to 90 degrees. And the fourth option, when the zonular defect is exceeding 90 degrees. Okay. So most of the respondents consider suturing CTR in patients when the zonular defect is extending three clock hours. Which is right. However, it sometimes can be considered even in the smaller zonular defects, depending on the health, on the status of the residual zonular apparatus. So these are different CTRs. Classical one, designed first by Hara. Then Cionni CTR, which is designed for scleral suturing. And we have a lot of evidences in the literature that suturing the CTR to the scleral wall is a very helpful technique that can help us to manage patients with subluxated lenses. And as having the reason of hereditary conditions, such as in this paper you by Vasavada, you see that there is a fixation element of the CTR going out of the capsular bag, outside of the bag, and it is sutured to the sclera by the 9-0 polypropylene suture. So our idea was to a little bit modify the CTR designed by Cionni. Because with the Cionni CTR, it’s quite… Not so easy, when you try to inject the ring. Because you see that this is the portion of the ring that keeps the equator of the capsular bag on the right angle, when you try to inject the CTR in place. So our design modification was actually quite simple, and getting rid of that portion of the CTR that makes the ring completely retractable, inside the injector tube, as shown here, that makes the passage of the CTR into the capsular bag quite easy and atraumatic. And this is the animation showing how the 9-0 polypropylene is attached to the eyelet of CTR, with a co-hitch type suture. And then the ring is injected into the capsular bag. The fixation element is repositioned on top of the anterior capsule, and the needle is passed through the ciliary sulcus, in order to fixate CTR to the sclera. As shown here. So this modification is having certain advantages. First it can be fully retracted in the injector tube. And subsequently implanted through the sub-2 millimeter corneal incision. The fixation element is moved to the tip of the ring. And gives you a very smooth gliding along the equator of the capsular bag. And sometimes the duplicating of this area gives you additional strength of the area of the most significant zonular defect. Because actually, you position the fixation element at the very center of the zonular defect during the surgery. And this is proud by Morcher. So these are some clinical examples. Here is the case of the patient having blunt trauma. And as you can see here, there is a fibrotic area on the anterior capsule. Shown here. And the radial folds. Again proving that the zonules are quite loose. And the triamcinolone is injected into the anterior chamber. And this is the area we can see of the vitreous that goes through the zonular defects, into the anterior chamber. So you do not necessarily need to cut the vitreous strands from the very beginning. Because by utilizing the dispersive OVD, it can actually displace the vitreous back into the posterior chamber. Anterior capsulotomy is initiated with a sharp bent needle. Then microforceps are used to pass the tear around the area of the capsular fibrosis. Luckily, the area of the capsular fibrosis was quite limited. So there was really a possibility to create very nice round capsulotomy. These are more or less final steps of the anterior capsulorrhexis, as shown here. And now the anterior capsular flap will be removed from the anterior chamber. Followed by injection of the CTR in place. And there are different options we can think about. We can think about first injecting CTR into the bag, and suturing the bag to the sclera. And then proceeding with phacoemulsification. While the other option will be to use capsular hooks. At that point. To stabilize the lens. And then remove it. And then inject CTR. So very much depending on the preference of the surgeon. So here is the CTR, which is injected into the capsular bag. As the decision here was to first inject CTR. In spite of the fact that the lenses are still in place and it’s filling the capsular bag. So you can watch actually the vitreous that is herniating from the posterior chamber through the area of the zonular defect. So this is a very challenging portion of the procedure, because you actually need to rotate the fixation element to move it and position at the area of the most significant zonular defect. Here’s the technique of passing the needle. So I’m using here the zigzag suture. We’ll explain that suture technique a bit later on. During my lecture. And as shown here, the needle is passed, after going out of the eye, the needle is passed parallel to the sclera, four or five times, and sometimes the knot is created. Sometimes not. Because the original technique was actually based on just passing the needle four or five times and leaving the end of the suture trimmed. Now you see that the CTR is in place. And now phacoemulsification is in progress. As shown here. Phaco chop is being utilized. And you need to be quite careful not to rotate — not to cause significant stress on the zonules. As phacoemulsification in situ is the most zonular-friendly approach that will help to avoid unzipping of the residual zonular apparatus, which is very, very important in these cases. Because you want to keep the rest of the zonules in place. So these are the final steps. Of phacoemulsification. The lens is now almost completely removed from the bag. Sometimes it’s a good idea to inject some viscoelastic behind the lens. Or residual cortical material, to lift it into the anterior chamber. Rather than emulsifying it inside the bag. To avoid some trauma. To the capsular bag. Because of the CTR, which is now located in the bag, so it’s sometimes possible to see the vitreous that herniates here, so actually you have to be quite careful, because here I’m not any more aspirating the cortical material, which is located here, but rather, aspirating the vitreous. Because in spite of the fact that there is a CTR, which is sutured here, there is a significant zonular defect. And the vitreous may still pass through the zonules and go out into the anterior chamber. So actually, at that moment, it’s a good idea to stop, and to stain the vitreous with triamcinolone. Because we need to avoid any traction on the vitreous body. And we see that there is a relatively small vitreous amount that is located in the chamber. So it’s again possible to reposition this vitreous back into the posterior chamber, implant the IOL, as shown here, you have to be quite careful, and you watch carefully here, and you can see that sometimes vitreous is going backwards, with the manipulations, so you have to be quite careful not to cause a lot of stress on the zonules. And on the vitreous. And now it’s time to remove this vitreous away, in order to avoid any kind of incarceration of the vitreous body in the wound. So here, this is the end of that case. There are different clinical cases shown here. This is a giant iridodialysis, associated with a zonular dialysis. And in many of these cases, not only suturing of the CTR to the sclera was needed, but also pupilloplasty. Because in these cases, when there is a significant zonular defect, usually sphincter muscle is also damaged, as shown here. And this is transillumination, which is the result of the blunt trauma and the significant impact on the iris. Again, I see that multiple pigment defects… That is the result of the blunt trauma. And you need to make a pupilloplasty, either by interrupted sutures like here, four sutures were being used, or by using three sutures, as shown here, or the other option will be to use the pupillary cerclage. Hereditary zonular pathology. Usually in these cases, the capsules — capsular bag is more elastic. And more resistant to any kind of surgical trauma, as shown here again. As soon as I was trying to inject some mydriatic in the anterior chamber, there was some vitreous present. You have to be quite careful not to cause any stress. And you need to stain this vitreous. This is the area of the vitreous going into the anterior chamber. You can visualize it quite easily. And it is possible to sequester this vitreous with dispersive viscoelastic, in order to avoid any excessive vitreous to go out. At this particular moment, it is a good idea to make the dry vitrectomy. Dry vitrectomy is done without irrigating the anterior chamber. And it helps you to avoid hydration of the residual vitreous. That is a very useful technique, in order to avoid the significant amount of vitrectomy. Sometimes scissors vitrectomy can be done. Helping you to avoid a lot of manipulations. And in that case, the pupil was not big enough, and that’s why the idea was to implant the pupil expansion device, in order to have a good access to the anterior capsule. And also, while implanting the pupil expander, it is possible to visualize the equator of the capsular bag, and visualize how significant is the zonular defect, and how the lens is displaced. So it’s now a good idea to displace a little bit the pupil expansion device, to create very nicely centered capsulotomy, as shown here. And this is the Sharpoint needle, which I’m using now to create this capsulotomy. And after initiating the capsulorrhexis, microforceps being used, to continue with creating this tear, and this is a time when the capsular hooks might be helpful, because you need to stabilize the lens. And the capsular hooks are introduced into the capsular bag. You don’t have to overextend the capsule significantly, in order to avoid the radialization of the tear. So you have to be quite gentle. However, as soon as the capsular bag is repositioned, then you actually may go on and complete the capsulotomy. Sometimes it’s a good idea to displace the pupil expander, in order to pass the tear around, and then finish it right near the capsule hook. So other than that, the procedure was more or less similar to the previous one that I showed you. So we also should be quite careful when we are dealing with patients having weakened zonular apparatus, as shown here. This is a patient having pseudoexfoliative syndrome. And you see that the capsulorrhexis was initiated by the forceps, and the lens is being fragmented. With the phaco chop technique. And usually combination of the zonule and vertical chop is quite helpful, in small pupil cases, because you don’t want to go behind the iris. And you want to visualize all that is happening. And see what is going here… Blind aspiration maneuver in the area behind the iris actually resulted in unzipping of the zonule. So there is a zonular defect which should be repaired for sure. So it should be recognized properly. And you have to stop aspiration of the residual cortical material. And you need to reposition the capsule, the equator of the capsular bag, with the help of viscoelastic back. And then it’s a good idea to inject the capsular tension ring, in order to restore the equatorial contour of the capsular bag. You have to be sure that you’re injecting it directly into the capsular bag. Not into the sulcus, which is sometimes challenging, because of the smaller pupil. So this is another clinical case. In this patient, the pupil is rather good. However, during irrigation/aspiration, there was a suspicion of zonular dialysis. As shown here, there was some equatorial cortical material. It’s located here. So that was a not very pleasant surprise. And the idea here was to inject the CTR suture in place. And then continue with the rest of the surgery. So you actually see that the CTR is injected in the direction of the zonular defect. And now you will see how the fixation element slides along the equator, expanding the equator of the bag, and helping to restore the contour of the capsular bag. Which is now done. So the fixation element is repositioned on top of the anterior capsule. You need to rotate the CTR to position the fixation element at the very center of the zonular defect, as shown here. And this is the suture that is passed through the ciliary sulcus, outside of the sclera, and then fixated to the sclera in a zigzag manner. So there are some other devices that should be mentioned, and that can be used for supporting of the capsular bag. This is Ahmed capsular tension segment, which is a portion of the CTR with the fixation element, as shown here. It is sutured through the eyelet, and can cause equatorial support… Localized equatorial support to the capsular bag. This is another useful device. Which is more or less half of the CTR, with the two eyelets that may help you again to restore all the localized area of the zonular defect. Assia Anchor is another option. This is the older version. There is the newest one, that is available in some countries. And it’s also a good idea to combine this device with CTR, because it’s a good idea not only to support the area of the zonular defect, but also support the full equator of the capsular bag. This is another device, which was designed by Dr. Sergienko from Ukraine. This area goes out of the bag, and it is designed to be sutured to the sclera. Another option is the Yaguchi-Kozawa capsular hooks. It can be used to permanently fixate the bag to the scleral wall. This is another option that is designed by me. This is the capsular hook or anchor. As shown here. We call it anchor because it’s very much similar to the marine anchor, and this fixation element is used to fixate the device to the sclera, and again cause the localized support to the area of the missing zonules, as shown here. The bag is centered, and IOL is implanted into the bag. And as you can see here, there was CTR also used in that particular case. If there is no support to the capsular bag, so you may consider utilizing scleral flaps, and passing the suture and then fixating the IOL to the scleral wall, as shown here, this is a very classical technique that was described by Malbran, Lewis, and Girard, utilizing the polypropylene suture that passes through the scleral wall. And you see how one needle goes into another needle. Both externalized from the eye and now the loop of the suture will be created by catching this suture with the hook. And then the ends of the suture will be attached to the eyelets of the rigid PMMA IOL, and the IOL will be implanted and fixated to the sclera. So there are other options that you may consider. So-called Hoffman pockets, that do not require any conjunctival dissection. Because the dissection goes from the limbal area towards the fornix. And by creating this type of pocket, it is quite easy to suture the IOL or CTR to the scleral wall. Without conjunctival dissection. Which is sometimes very useful. You can cover the knot without any kind of rotation. And it’s more comfortable for the patient, because there is no conjunctival sutures here. I already mentioned to you the zigzag suturing, which was proposed by Peter Szurman, and this is passing the needle parallel to the limbal area. And as shown here, this is the area of the sutured lens. Sutured CTR. And actually sometimes you can visualize the polypropylene suture through the sclera. However, in most of the cases, it does not cause any cosmetic defect. There are some considerations to be kept in mind. First of all, you need the wide scleral exposure. By creating L-shaped fornix-based conjunctival flap. And the second thing is that actually you have to avoid the areas of the rectus muscles. So it’s better to place the suture in the oblique meridian. So these are two major things to be kept in mind. And with that technique, as shown here, these are the tips of the CTR, located in the bag, as well as the IOL is there, and this is the UBM picture, showing white dots. These are sutures that are located inside the sclera. So my question to you now is: Which of the following suturing materials is the most appropriate for the CTR scleral suturing? There are five options here. 10-0 nylon. 10-0 polypropylene. 9-0 polypropylene, 8-0 nylon, or 6-0 Gore-Tex. Okay. Let’s have a look. What is the result? So most of the respondents think that 9-0 polypropylene is the most appropriate. This is 42%. Followed by 10-0 polypropylene, and some even consider using nylon. So let’s go and have a look at what the literature says. So 10-0 polypropylene sutures. In the mean of 50 months post-op will break in about 30% of cases, so this is not the best suture material to be utilized. This is our publication showing biodegradation of the 9-0 polypropylene suture, as shown here. This is intact polypropylene suture, 9-0, and this was the portion that was located intrasclerally. And you see how significantly it was biodegraded. And these are two ends of the same suture that were attached to the scleral fixated CTR. So there was mechanical issue here. And the suture was broken. So 9-0 polypropylene is not the best suture material as well. So our current preference is Gore-Tex. Which we do think is one of the best materials. So this is the technique of utilizing Gore-Tex. Together with the modified CTR. In this case, laser capsulotomy was done. Prior to lens removal. And the lens is stabilized with three capsular hooks. As shown here. The nucleus is rather dense here. So it needs some efforts to remove this suture. And again, I’m injecting a little bit of viscoelastic. Because as I mentioned to you before, you have to be quite careful. Even if the capsular hooks are in place, there is still a gap in between them, where you can accidentally aspirate the equator of the capsular bag, so it’s quite challenging sometimes, because while breaking the capsule, you’re completely changing the surgical plan of saving the capsular bag. So at that point, I decided to stop and inject CTR into the capsular bag, as shown here, and the CTR will now be sutured to the sclera, with the help of the Gore-Tex suture. As shown here. I’m using 25-gauge forceps. In order to pass the suture, and this is the 25-gauge needle that will be passed through the ciliary sulcus, outside of the eye, and this is the whole needle, with the lumen containing the cortex suture. This is one part of the suture being externalized. And this is another one that is also being externalized, as shown here. And after externalization of both ends, so we are actually creating a loop, we will tie the knot, and then fixate it to the sclera. And it’s very important to rotate this knot, after trimming the ends. In order to bury this knot inside the sclera, to avoid the exposure of that suture. As shown here, IOL is injected into the capsular bag. As shown here. And positioned exactly in place. More or less the end of the procedure. And it’s again very important to mention to bury the knot inside the sclera. In order to avoid exposure in the late postoperative period. So this is the last clinical case that I want to show you. This is showing the breakage of the suture. You see that the CTR was sutured to the sclera with a 9-0 polypropylene. However, 9-0 was broken. And this happened five years postoperatively. So I’m removing the old 9-0 polypropylene suture. Because it’s not holding the CTR in place anymore. And in that case, it was possible to use the Gore-Tex suture to refixate the CTR to the sclera. And again, I’m using 25-gauge forceps to pass the Gore-Tex suture through the eyelet of the CTR, which is now located outside of the bag. It’s sometimes not so easy, because the suture is quite pliable. It was needed to repeat this maneuver several times, in order to be sure that it goes directly into the eyelet of the CTR. And now I’m catching the tip of that suture, and retracting the thread. And in that case, I’ll be using 27-gauge needle, which is a little bit shorter than the 25, so that’s why I’ll be using this short needle through this paracentesis, which is located 90 degrees to the area of the sclera, where I want the suture to exit the eye. Rather than 25-gauge needle, which I can pass through the whole anterior chamber. You see here the suture goes out of the sclera, and I will be retrieving the suture here, because again, the needle is thinner, but it’s shorter. So it’s basically — there is a need to pass both ends of the suture here. It’s a good idea to expand the sclerotomy a little bit, because when you will be trying to bury the knot, a very tight sclerotomy will not give you the opportunity to pass the suture inside the eye. To rotate the suture. Basically, these are the final steps of the procedure. The tips of this suture are trimmed. And I will be using forceps. And then sometimes spatula. In order to pass this knot inside the eye, to avoid exposure of this knot through the sclera in the late postoperative period. I’m checking the stability of this suture, CTR, IOL, capsular bag complex. And it was quite okay. So my conclusions. That severe zonular deficiency presents one of the major challenges for the cataract surgeon. The successful management of this condition is based on careful preoperative planning and utilization of an adequate surgical technique and instrumentation. And obviously the best results can be achieved with the devices allowing to simultaneously restore the lens equator circular shape and creating the synthetic zonular apparatus. And I thank you very much for your kind attention.
>> Thank you very much, Dr. Malyugin. If you can stop your screen share, perhaps we can take a look at the Q and A questions that have come in. I see 24 questions in the queue.
DR MALYUGIN: Okay. So we have a couple of questions here. I will try to answer them one by one. First is what are the best techniques that I use to detect zonular weakness preoperatively so there are no surprises in the operating room. Obviously we should keep in mind different visualization techniques. Such as classical one — biomicroscopy. Because irregularities of the anterior chamber may help us to judge whether or not there is a zonular weakness. OCT may be also helpful. However, to my experience, the best is the ultrasonic biomicroscopy. Because it helps you to visualize what’s happening behind the iris. And to visualize the zonular apparatus, which is sometimes very, very important to understand how severely the zonules are affected. How many clock hours of detected zonular weakness should be referred to a retina surgeon by a beginning or intermediate cataract surgeon? I think I will be recommending to think about… For the younger surgeons, to think about the threshold of 60 degrees or two clock hours. To be more or less acceptable. Because you actually can utilize conventional CTR. Something that is closer to 90 degrees might be more challenging. And it should be referred either to an experienced surgeon, or sometimes to the vitreoretinal colleague. The other question: How does zonular weakness affect your biometry, IOL planning, and IOL choice? Whether or not it’s a good idea to use multifocal or toric IOL? Basically optical biometry is not very much affected by lens malpositioning. However, when we are thinking about the IOL, I will not recommend using multifocal lenses in this case. In general, toric lenses are also not recommended in zonular weakness and deficiency. Specifically the extensive one. Because sometimes, as in pseudoexfoliative syndrome, this is a progressive condition, and a progressive condition that may worsen within years, so there is a significant concern about the stability of the implant, if it’s not… If the CTR is not sutured to the sclera. The next question is… If there is no vitrectomy probe, how we will stabilize the vitreous, and how we will do IOL implantation. So it’s quite challenging, I think. Vitrectomy probe should be always in our surgical armamentarium, because sponge vitrectomy or Weck-Cel vitrectomy is not really sufficient enough to help us, when there is a massive vitreous loss. So that’s basically, I think, there is a need for that equipment in every operating room. You should not start the surgery if there is no such kind of equipment. Especially when you anticipate the zonular weakness. So again, there is a question about the detection of the weakness. And the technique. So I mentioned already UBM, which is my preference. Should you do hydrodissection prior to placing capsular retractors in the anterior capsule? No. I will not recommend hydrodissection before you place capsular retractors. And the reason with hydrodissection — you’re losing visualization. And you are having difficulties to find the edge of the capsular bag in that case. So it’s better to place hooks and then to start hydrodissection. The same applies to the CTR. If you want to inject CTR at the earlier stage of the procedure, do it before hydrodissection. Otherwise it’s quite tricky to visualize the edge of the capsule, which is very important. Because you need to be sure that you go directly into the capsular bag. What should we do if after placing CTR we have a complication like posterior capsular rent? Should we just leave the CTR? Do we have to explant it? Can we place three piece IOL in the sulcus if this condition happens? Thank you so much. So it depends very much on the extent of the posterior capsular defect. Because sometimes very small defects — usually that occurs during irrigation/aspiration, when you aspirate the capsule into the aspiration needle — it can be converted into the posterior capsulorrhexis. I did it many times, and it’s quite helpful. In that case, the CTR may stay. However, if there is a significant zonular defect, there is a high risk that the CTR will be dislocated into the vitreous cavity. You should consider removing it from the eye. Although that might be quite challenging. Specifically in patients with a not perfect mydriasis. So that’s why some surgeons proposed attaching 10-0 polypropylene suture to the eyelet of the CTR prior to implantation. Specifically that may help in patients with very unstable zonules. When you’re not sure that you can save the capsular bag. So by having the safety suture, it might be a good idea, in order to be able to retrieve the CTR quite easily, when it is supported or attached to the suture. How long we wait after we inject to the anterior chamber triamcinolone, before we wash it out? I do it immediately. Because there is an immediate staining. So as soon as you inject, you place the syringe with the triamcinolone, you take the syringe with BSS, and you immediately start washing it out. So there is no need to wait. The next one… In cases with vitreous prolapse, do you suture the wound at the end of the case? What about pediatric cases like Marfan’s? What type of surgery do you recommend? In many of my cases, I do like to suture the wound at the end of the case. And that’s specifically true for pediatric cases. Because in these patients, I do like to suture all my wounds, because it’s sometimes not very predictable. Kids may rub the eye. And that may happen. So the loss of the self-healing properties of the wound. Basically I want to be sure that at the end of the surgery, the eye is firm, the eye of the patient is firm, and there is no leakage. If I have any doubts, I do not hesitate to place the suture. Can you use iris hooks in the capsule if you don’t have capsule hooks? I know many surgeons doing that. However, you can do it only if you don’t have capsule hooks. Because basically it’s a little bit risky technique. Because when you extend the capsular hooks too much, so it is a very significant risk of tearing the capsule, and also, you don’t have support of the equator of the capsular bag. So you can easily aspirate the equator of the bag, because the zonules are loose, and they can easily go to the center of the bag, so basically it’s a risky technique. The next question is: In mature intumescent cataract with zonular dialysis, do you suggest linear capsulotomy or can opener capsulotomy instead of CCC? So this question relates on what technique do you — of cataract extraction — you are planning to use. If you are thinking about phacoemulsification, obviously it is not possible to proceed with can opener capsulotomy or linear capsulotomy, because you cannot suspend the capsular bag with the iris hooks. However, if you consider using small incision cataract surgery, that might be another issue, and you can try the other type of capsulotomy, and sometimes that may work with very, very hard brown and white cataracts. Can the orientation of IOL haptics stabilize areas of capsular loss, or should we avoid excessive IOL rotation in the bag when there is zonular loss? I think the answer to this question is that we should rather stabilize areas of zonular loss by implanting conventional CTR rather than by haptical element of the IOL. However, if the CTR is not available for whatever reason, it might be a good idea to try to use three piece IOL, and orient the haptical element, directly to the area of the zonular defect. Although if the defect is very long, it’s sometimes not so easy to reposition the equator of the capsular bag. So my preference will be definitely CTR. Okay. So there are some — a couple of hellos from the colleagues. At which stage of phaco would you recommend to insert the CTR? There is a very nice wording. That you have to inject CTR as late as possible, but as early as you need it. So the meaning of that wording is that you want to implant the CTR when the capsular bag is completely free from the cortical material. Because in that case, there is no compression of the cortical material towards the equator of the capsular bag, and you don’t have any difficulties in removing the residual cortical material. However, if the bag starts to collapse, even if there is some nucleus or cortical material in the bag, so you should implant CTR to avoid aspiration of the capsular bag, or equator of the capsular bag, so do it as late as possible, but as early as you need it. The next question is: In significant zonular dialysis, where there is risk of IOL displacement in postoperative period, is it not better to have scleral fixated IOLs. So there are many options. Scleral fixated IOLs is one of them. Anterior chamber IOLs is another. Iris fixation is the third option, with sutures or iris claw. So I think these are all alternatives. Of course some surgeons prefer to — like me — to preserve the capsular bag. And make a lot of efforts to keep it in place. However, if you are comfortable with utilizing iris fixated lens, why not to use it? Or scleral fixated lens. That’s another option. What’s the best way to practice scleral suturing or Yamane technique? Wet lab? Which eyes are the best? I tried the bionic eyes. I have no financial interest in these eyes. I tried the scleral suturing on these eyes, plastic model eyes, and it was quite helpful. I think you should definitely practice this technique, prior to going to the OR, because it’s not an easy technique to master. And there are some devices that help you. For instance, Yamane — I believe with Geuder, he created a special guide for the needle, because you need to pass the needle under a certain angle. So it may help. MST made a special set of all instruments that you need, starting from marker to needles to special pens, to mark the area of the exit of the needle. So there are some companies that are working on that. The Michael Amon created very nice needle forceps with Geuder I believe as well. So 30-gauge needle with the forceps at the end. So you can actually grab the tip of the haptic with this very tiny elegant forceps. And externalize it. There are some instruments that are on the market that may help you to conquer these challenging cases. What’s your opinion about Carlevale lens? I have no experience with that lens. However, I’ve seen the surgeons using it. I’ve seen a couple of videos. And it looks like it’s a nice option. And a good option because it does not need any suturing to the sclera. So it’s haptical elements that are fixated to the sclera. So it might be a nice option. And I think that’s a good one. Okay. Size of the needle to deliver Gore-Tex. Brand of Gore-Tex — there is only one company that is manufacturing Gore-Tex. So there is no other company that I believe — the name of the company is easy to remember. The Gore and Co. And the needle — I mentioned to you that I used 27-gauge needle and 25-gauge needle. 27 is shorter, a little bit. So you need to consider introducing it through the paracentesis located 90 degrees from the area of the needle exit, while 25-gauge is a longer one. So it’s a little bit easier to pass through the sulcus, from the opposite meridian. Okay. Ab interno… I’m not sure I can understand. Gore-Tex is a little bit too thick? Yes, it’s thicker, but what is good with Gore-Tex is it is not absorbable. That is the major advantage of that suture. I think that the surgeon is thinking about blind needle passing behind the iris. There is a concern about that. I understand that might come with certain experience. However, I tried different techniques. I even used at some point in my career endoscopy. So the needle was attached to the endoscopic probe. And I passed the needle with the help of the endoscopic probe. So you may think about using that technique. Although endoscopes are quite expensive machines. Okay. What about irrigation/aspiration techniques? IA coaxial or bimanual? I think bimanual is more suitable for the challenging cases. For the challenges with small pupils and big zonules. The next question is the question about the patient having IOL capsular bag complexes dislocated, due to zonular instabilities, 70 years later. Edge of the IOL is in the pupil. If there is a CTR in the bag, that is very useful to have it, because you can easily catch the IOL capsular bag complex and stabilize it with either 9-0 polypropylene, or now my preference is Gore-Tex. If there is no CTR, that is very much dependent on the type of the lens. If it is possible to catch the haptical element, and circle the suture around the haptical element, it’s possible to attach it to the sclera. However, sometimes I’m even using the technique of passing the iris fixating the IOL-capsular bag complex with 9-0 polypropylene, and a long needle. And that is quite helpful. Okay. How many throws do you need while suturing the ring? I create the loop. Gore-Tex suture loop. And I do 2-1-1, while creating the knot. And I take precautions in order to avoid overtying the suture. Because otherwise the IOL capsular bag complex will be displaced into the area of the sutures. So that’s the thing you want to avoid. What model of the original Cionni ring is better to use? I like to use the one with one loop. But basically I’m not using it anymore, because I like to use my modification of that device. So that’s my personal preferences. Do you use iris clipped lens? If you are talking about the lens that is not iris claw but iris clips, the lens that is fixated to the pupil, basically it’s one of the options. Some of my colleagues use it. I like to use iris claw lenses, but I reserve these cases specifically to — when I do endothelial keratoplasty, and I have to remove the lens, I remove the lens for whatever reason, and then I take the iris clips — sorry, iris claw lens — and fixate it retropupillarily, to avoid — to keep the distance between the endothelial transplant and the IOL optic. I consider it very useful. Although scleral rigidity… The question is probably about the suturing of the incisions in the pediatric cases. I agree. Because of the low rigidity, and because of the tendency for gaping, it’s better to suture the cornea in pediatric cases. Cortex is not available. Can we use 10-0 or 9-0 prolene for suturing? That might be a good technique. However, there is a new technique called Assia technique, when you are utilizing the flange, and using 5 or 6-0 polypropylene, creating — treating the tip of the suture by creating a bulb, a flange, and it’s quite an interesting technique. You may have a look at the internet about this type of suturing. I think it’s a good option. To consider if you don’t have Gore-Tex. What type of needle for the polypropylene suture? I used to utilize 13 millimeter polypropylene needle. So the type of that suture — it’s actually in my lecture. You can see on the slide. There is a picture of that 9-0 polypropylene that I was using for many years. Is there a technique in rotating the CTR to avoid enlarging the zonulolysis? Yeah, sometimes it’s quite challenging. Because when the zonular weakness is quite pronounced, it’s quite challenging to rotate the modified CTR or CTR. In some cases I use bimanual technique when I was sketching the fixation element with one forceps, and then stabilizing the ring with the second instrument, and trying kind of bimanual rotation, and at the same time, utilizing capsular hooks to stabilize the bag. When the zonular defect — the generalized zonular defect is not very pronounced, it’s more or less okay. However, if it’s a significant zonular defect, then that might be a big challenge. In these cases, obviously you prefer peribulbar with a block. Because you cannot do that under topical. Okay. There are certain hellos from my colleagues, from different countries. Hi, guys. Nice seeing you. When did you start using Gore-Tex? I started using Gore-Tex three years ago. As soon as I started to get my patients back with the CTRs that were sutured to the sclera, with 9-0 polypropylene, that were broken. Okay. So what’s the other prolene… Yeah, we were discussing the flange. 5-0 polypropylene, with flange might be a good option to Gore-Tex. To replace Gore-Tex. Any… How to merge sutures of the CTR in case of scleromalacia. If there is a scleromalacia, is it a secondary? Around the suture? Or kind of a primary case, when there is a thin sclera? So if it’s primary, I will probably not like blue sclera, so I will not consider scleral suturing. If it’s secondary, depending on what is the reason, is it autoimmune condition or inflammation, basically it depends on the reason for that condition. With the child having large zonular dialysis, which is better, Cionni or sclerally fixated IOL? I do like the Cionni or modified capsular tension ring. That’s my preference. Again, that’s my personal preference. That’s why I do like to recommend it. However, not all surgeons are sharing my preference. That’s for sure. In complicated surgery, what is better for children? Both can be done with good success. So whatever you — for complicated surgery, scleral suturing or iris claw — I think the best technique is what you’re comfortable with. So if you are confident in scleral suturing, please do. If not, and you like and have experience with iris claw lenses, I can see no reason not to recommend it. Is Gore-Tex suture advisable in kids? I think so. Yeah. I think so. Okay. Do you adjust your phaco settings when doing phaco in patients with zonular defect? Yes, of course. It’s a good idea to lower your fluid parameters to avoid hydration of the vitreous. You need to block the area of zonular defect with dispersive OVD, which is a combination of Healon and 118. And sometimes I like to increase a little bit my ultrasound. Because I want to avoid the movements of the lens. So for that purpose, I do like to have a little bit more energy with my phaco tip. That helps me to avoid vibration of the lens. Aphakia postsurgery, best method of implantation for an 18 year old boy? I would go for scleral suturing — sorry, fixation of intrascleral haptic fixation with three piece IOL. I had recently the same case, and I think that’s the best one. What age to have in this case? I’m not sure what does that mean. The age of the patient? Or what’s the age of the surgeon? If you are asking about the age of the patient, I do it… Starting from very young patients. In pediatric cases. What about Yamane intrascleral fixation in children? I do not have experience with very young kids. The lowest intrascleral fixation age is 16 years old. After vitrectomy and lensectomy for Marfan. And that was a good success. So I’m not sure how that will be good with younger kids. We know that they may probably need some adjustment in the lens power. So I think maybe in younger patients, it’s better to avoid intrascleral fixation, like 5, 6, 7 years old. Better to use — if there is aphakia — to use aphakic contact lens to a certain age. Let’s say to 16, 18 years old. And then perform intrascleral fixation. So when the eye will be grown enough, and there will be no change in refraction. Because you will not be able to exchange the sclerally fixated lens, or it will be very traumatic. How do you manage subluxated microspherophakic lens? Again, it depends. Sometimes in patients with lens coloboma, it’s possible to remove it and to restore the equatorial contour of the bag. However, in some microspherophakia, it’s migrating from the anterior chamber, so there is no other option to make lensectomy. Do I always do dry vitrectomy? Not always. Because especially when you have 23-gauge vitrectomy, with dispersive OVD, such as Viscoat, you may have some issues. Because sometimes the vitrectomy needle may be clogging. So you need to wash it repeatedly, in order to have — to keep the effectiveness of the vitrectomy. How long does Gore-Tex last? As far as I know, it does not biodegrade. There is no biodegradation of Gore-Tex. Known so far. Modified CTR available in India? I have no idea. It is produced by Morcher, but I don’t know whether or not it is available in India. Probably yes. But I don’t know. Do you use HumanOptics lens for such preparations? Yes, the HumanOptics have specific lens models that are having three piece models that are designed for sulcus fixation. So I had experience with intrascleral fixation of the HumanOptics lens. It has a silicone element. And works well. But I was not using it for any of the HumanOptics lens for intracapsular fixation. That’s not my lens preference, currently. I think more or less we have covered most of the questions. So I thank you very much for your kind attention. I was glad to be with you today. And to share with you some of my experience on my preferred techniques. Thank you.