CASE PRESENTATION
A 37-year-old patient presented with a traumatic predominantly posterior subcapsular cataract that occurred from a tennis ball injury 12 years previously. There is approximately an 180º area of zonular weakness visible (Figure 1). At the slit lamp, the nucleus looks rather soft.
What strategy would you plan concerning machine settings, viscoelastic choice, capsulorhexis formation, use of extra devices and IOL choice, positioning, and fixation?

JOHAN BLANCKAERT, MD
The danger in this case obviously lies in the zone of zonular weakness. Since trauma provoked the weakness, I would be concerned about the zonular strength in the other zones as well. Therefore, my course of action would be to perform gentle surgery to avoid anterior chamber shallowing. Topical anesthesia is possible.

I would opt for coaxial surgery through a 2.6 mm-clear corneal incision and a 1-mm sideport incision. This technique is largely decided by my IOL choice (ie, three-piece IOL). I would not use bimanual surgery because a higher bottle height is needed for anterior chamber stability, and there is too much risk to compromise the integrity of the remaining intact zonules. During the coaxial procedure, I would fill the anterior chamber with Viscoat (Alcon Laboratories, Fort Worth, Texas), using the sideport incision to carefully avoid anterior chamber shallowing. This will maximally coat the endothelial cells, minimizing surgical damage to the young patient's eye. Ideally, the amount of viscoelastic needed is exactly the amount necessary to counteract the vitreous pressure. Therefore, stress on the zonules is relieved. Take care not to overfill the anterior chamber.

The best point to start the capsulorhexis is in the zone with any presumed undamaged zonules, since ripping forces are needed to make the first tear for the capsulorhexis. I would continue to guide the rhexis by shearing the capsule instead of using ripping force. By shearing the capsule, you reduce the pulling forces on the compromised zonules. Next, I would perform a gentle hydrodissection, placing the irrigation needle in the region of the intact zonules and gently hydrodissecting from this area. If I create a good subcortical wave, I do not insist any further. It is, however, imperative to free the cortex from the capsule, this helps considerably during emulsification and aspiration of the nucleus and cortex.

Since this is a young patient, the crystalline lens will be very soft, and emulsification and aspiration can be done using low phaco parameter settings. I would opt for a low bottle height and matched reduction in the vacuum and aspiration flow rate.

This is a case where you depend on the fluidics of the phaco machine, because surge would be devastating for the remaining zonules. The Infiniti vision system (Alcon Laboratories) has excellent fluidics and is appropriate for this case. I would use the technique of nucleus rotation, which reduces the strain on the capsule and the zonules. During emulsification, I would have Healon 5 (Advanced Medical Optics, Santa Ana, California) on standby in case the vitreous needs to be pushed back. If needed, inject the Healon 5 through the sideport without retracting the emulsification needle. It is also important to have Diamox (acetazolamide; Wyeth Pharmaceuticals, Radnor, Pennsylvania) or mannitol available in the operating theater in case accidental vitreous hydration happens through the zone of zonular loss. Either substance would soften the eye.

The remaining cortex needs to be addressed gently, as aspiration of the cortex can further damage the zonules. One trick that may be helpful is to put the aspiration cannula at the periphery of the capsule and aspirate from that position, thus avoiding capsule collapse by pulling the cortex to the center. This maneuver can be difficult if there is insufficient pupillary dilation.

I would choose a three-piece hydrophobic acrylic IOL with a 6.5-mm square edge optic (ie, Acrysof [Alcon Laboratories]) because of the reduced risk of capsular fibrosis. A larger optic is advantageous if there is postoperative displacement of the capsular bag. The haptic position is in the weak zonular area, so scleral fixation of the haptic is possible, if the IOL is dislocated in the future. Next, gentle aspiration of the remaining viscous material in the anterior chamber and behind the IOL would be performed to avoid capsule aspiration. To hydrate the incisions, I would use balanced salt solution, and subsequently inject cefuroxime into the anterior chamber—a recommendation from the ESCRS endophthalmitis study. I would also check the wound leakage and pressure of the eye. Finally, I hope she will recover vision to play tennis again.

LUCIA SCOROLLI, MD
I would perform a 0.2-mm clear cornea incision followed by an injection of a low-density viscoelastic substance. I would start the capsulorhexis using the cystotome, and then after opening the capsule, I would insert a capsular tension ring. Now, I would enlarge the rhexis (ie, 6 mm to 6.5 mm) with forceps, which will push the nucleus out to avoid counterpush.

In the aspiration phase—without using ultrasound because they could determine fluids vibration—I would pay attention to position the capsular tension ring well at the opposite site. I would also advise performing all surgical steps without viscoelastic substance and to choose a balanced salt solution height at 15 cm to 20 cm over the patient's head.

If capsular residues remain in the bag, I think it is better to use a viscoelastic substance like Healon (Advanced Medical Optics) and/or Charlet's needle. I would choose an acrylic single-piece IOL with injector (Alcon Laboratories) to better distribute weight and centrifugal force. The posterior aspiration would be performed using only the Charlet's needle.

CARLOS VERGÉS, MD, PhD
Assuming that there is no increase in IOP and that it is only a cataract with zonular rupture, I would consider performing microincisional cataract surgery with low parameters. I would also use a capsular tension ring fixed at the sclera and implant a three-piece acrylic IOL.

Follow-up steps are described herein. (1) Create a 1.2-mm clear cornea incision on the opposite side of the zonular fracture if the location of the rupture allows it. (2) Make a second 1.2-mm incision—90º from the first one—to perform the microincisional cataract surgery technique. (3) Introduce a mixed dispersive-cohesive viscoelastic (eg, Healon 5, and check that there is not vitreous inside the anterior chamber. (4) Proceed in performing a 5-mm capsulorhexis with the forceps, avoiding the traction maneuvers. (5) I would then insert the capsular tension ring before performing the hydrodissection and emulsification, as the cataract material in a 37-year-old is soft.

For advanced cataracts with high hardness levels, I would rather perform the nucleus emulsification and insert the ring in to the bag before finishing the cortex emulsification. If this is the case, take care of tractions that would induce more zonular rupture.

After inserting the ring, (6) I would proceed with the phacoemulsification following the microincisional cataract surgery technique. I prefer the Sovereign Whitestar ICE (Increased Control and Efficiency) system (Advanced Medical Optics) because the parameters may be reduced during an aggressive surgery. The setting would be 5% ultrasound power, flow of 20 mL/min and vacuum of 350 mm Hg with a chamber stabilization environment of 200 mm Hg, with micropulsed mode and a duty cycle of 80%. (7) Once the emulsification is finished, I would fix the ring to the sclera by means of a 10/0 prolene suture, perforating the capsule to extract the needle through the sclera at 3 mm from the limbus (ie, previous opening in that zone of the conjunctiva). (8) The surgery procedure will end with the implant of a foldable three-piece acrylic IOL, directly injected in the capsular bag. I use this lens because of its stability inside the capsular bag, and because it is feasible to perform a suture in one of its haptics to the sclera. In this case, it was necessary.

Johan Blanckaert, MD, is a cataract surgery consultant in the department of ophthalmology at the University Hospital UZ Leuven and in private practice at The Eye & Refractive Center, in Belgium. Dr. Blanckaert discloses that he has no financial interest in the products or companies mentioned. He may be reached at oogartsen@pandora.be; phone, +32 57 202300; or fax, +32 57 221656.

Lucia Scorolli, MD, is the director of pathophysiological optics at the University of Bologna, in Italy. Dr. Scorolli did not provide financial disclosure information. She may be reached at amb.santalucia@libero.it.

Carlos Vergés MD, PhD, is professor of ophthalmology at the Instituto Universitario Dexeus Universitat Autonoma de Barcelona, in Spain. Dr. Vergés discloses that he has no financial interest in the products or companies mentioned. He may be reached at verges@attglobal.net. Dr. Vergés is a member of the CRST Europe Editorial Board.

Khiun F. Tjia, MD is an anterior segment surgery specialist at the Isala Clinics, in Zwolle, Netherlands. He is a research consultant for Alcon Laboratories, but he states that he holds no financial interest in any of its products. Dr. Tjia is a member of the CRST Europe Editorial Board and cosection editor of the Cataract Complications column. He may be reached at K.Tjia@Isala.nl or +31 38 424 2980.

Brian Little, MA, DO, FRCS, FRCOphth is an ophthalmologist at the Royal Free Hospital in London. He may be reached at brianlittle@blueyonder.co.uk. Dr. Little is a member of the CRST Europe Editorial Board.