Cataract surgery with traumatic zonular loss

Issue: February 2020

ByUday Devgan, MD

The patient is a relatively young construction worker who sustained a blunt traumatic ocular injury that was fortunately nonpenetrating. This resulted in the development of a focal lens opacity initially, which then progressed to a visually significant cataract requiring surgery. He is part of our charity surgery program given his inability to afford the cost of surgery.

The case starts out normally, with a successful capsulorrhexis and minimal evidence of zonular instability. The first clue of an abnormality is the focal lens opacity noted at the pupil margin at the 10 to 11 o’clock position from the surgeon’s view. The next warning sign is the inability of the nucleus to rotate after hydrodissection (Figure 1). When watching the video of this case, we can see that the fluid waves propagate normally across the center of the nucleus, but not along the area of trauma.

We are able to perform phaco chop and bring each nuclear half out of the capsular bag and into the iris plane for aspiration. This is done by chopping the nucleus in the capsular bag and then bringing the pieces up into the iris plane. This can be accomplished without having to rotate the nucleus if the surgeon is able to pivot the instruments sufficiently.

Figure 1. The patient sustained an ocular injury that induced a focal lens opacity and damaged the zonular structures. The inability to rotate the nucleus after hydrodissection is an important warning sign.

When we switch to the irrigation/aspiration probe for cortex removal, we really start to notice issues. During attempted cortex removal from the area of traumatic injury, extensive zonular loss becomes evident. The round capsulorrhexis morphs into a D shape, which indicates loss of zonules along the flat surface (Figure 2). The ideal next step would be to implant a capsular tension ring to bolster the weak area and to provide stability for IOL implantation. We could also further support the area by using a Cionni ring or an Ahmed segment.

Figure 2. With the nucleus removed, the capsular bag equator at the site of trauma becomes visible. Approximately 3 clock hours of zonular loss appear, and this causes the previously round capsulorrhexis to change to the D shape shown. Care must be taken during cortex removal not to further damage the weakened zonular structures.

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In this situation, we do not have access to these devices so we must rely on the haptics of the IOL to provide support. We can implant the IOL so that one haptic is placed along the area of zonular weakness. This haptic will exert an outward force that will support the capsular bag equator and help keep the optic centered. This results in a well-centered optic, and the capsulorrhexis returns to a rounder appearance with resolution of the D shape (Figure 3). A three-piece IOL may provide more support than a single-piece IOL, but either will work. If the surgeon decides to place a three-piece IOL in the sulcus, note that it must be placed so that both haptics are 90° away from the area of zonular loss.

Figure 3. Ideally, a capsular tension ring would be placed to help distribute forces and support the area of zonular loss. But even without this device, we can proceed by placing the IOL in the capsular bag so that one of the haptics pushes toward this area so that it acts as a strut to support the capsular bag equator. Note that the capsulorrhexis has returned to a more normal configuration instead of the D shape seen in Figure 2.

With the IOL in position and the capsule equator supported, the viscoelastic can be removed from the anterior segment. In this case, going behind the optic to remove viscoelastic is a risky maneuver and I avoid doing so. A small amount of retained viscoelastic can be managed conservatively with pressure-lowering medications for the week or so after surgery.

I am happy to report that the patient has done very well and has a stable and well-centered IOL with excellent vision. Let’s hope that he is able to avoid future trauma.

For more information and the complete surgical video, please see www.CataractCoach.com.

For more information:
Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.CataractCoach.com.

Disclosure: Devgan reports no relevant financial disclosures. He reports he owns and runs the CataractCoach.com website, which is free and noncommercial.

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Disclosures: Devgan reports no relevant financial disclosures. He reports he owns and runs the CataractCoach.com website, which is free and noncommercial.