Special precautions needed in eyes with weak zonules

Weak zonules can lead to disasters for both experienced and novice surgeons if 

they fail to take certain precautions,  Khiun Tjia MD, Zwolle, the Netherlands,  

told the 18th ESCRS Winter Meeting in Ljubljana, Slovenia. 

Dr Tjia presented an example 

of what can go wrong when appropriate precautions are not taken in such cases 

followed by an example of how to handle such cases properly.

The first example involved a very old woman with LOCS grade 4+ cataract. 

The procedure was uneventful to begin with, but capsular folds prior to 

capsulorhexis gave a clear indication of zonular weakness. The procedure 

continued but when he had half of the nucleus out of the capsule the zonule 

had a sudden 180 degrees detachment. He salvaged the case by immobilising 

the nuclear fragment and injecting viscoelastic underneath it to act as a shield 

between the lens and the vitreous.

Dr Tjia then demonstrated in another case how the complication could probably 

have been avoided by taking a few simple precautions. The first precaution is 

to create as large a capsulorhexis as possible so that manipulation of lens puts 

the least amount of stress on the zonules, the second is to perform a very careful 

hydrodissection.

Furthermore, when performing the phacoemulsification it is best to avoid 

pushing the lens with the phaco tip and move slowly using adequate ultrasound 

and gentle manipulation of the lens. In addition, instead of dividing the lens into 

quadrants it should be divided into six to eight pieces before removal from the 

capsule for further emulsification, he said.