How to surgically manage iatrogenic zonular disinsertion
An approach is described for completing cortex removal and IOL implantation after intraoperative 180° zonular dialysis.
Take-home: An approach is described for completing cortex removal and IOL implantation after intraoperative 180° zonular dialysis.
Reviewed by Iqbal (“Ike”) Ahmed, MD
Toronto-When an overly aggressive attempt to remove tenacious cortex results in iatrogenic zonular dialysis, the first priority for the cataract surgeon is to maintain capsule integrity and avoid vitreous prolapse. Removal of residual cortex is also important for the final outcome.
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Options for management might include cautious endocapsular phacoemulsification, conversion to extracapsular surgery, capsular retractors, implantation of a capsular tension ring (CTR), and use of a sutured capsular tension device, reported Iqbal (“Ike”) Ahmed, MD. The decision, however, is best made through careful assessment of the situation once the eye is stabilized.
Dr. Ahmed, assistant professor of ophthalmology and vision sciences, University of Toronto, Ontario, Canada, presented his approach to managing this “disinsertion dilemma” in a case involving a 180° zonular dialysis.
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The patient did not have pseudoexfoliation or other risk factors for zonular weakness, and the surgery was uneventful until cortex removal. As the operating surgeon persisted in trying to remove residual cortex, the capsule was aspirated into the instrument tip, resulting in 180° of nasal zonular dialysis with retained cortex in the capsular bag. Fortunately, the capsular bag remained intact, Dr. Ahmed said.
Injecting OVD
After stopping the procedure and while keeping the I/A tip in the eye, a cohesive ophthalmic viscosurgical device (OVD) was instilled to reform the anterior chamber and stabilize the eye.
Dr. Ahmed offered several tips for completing this initial step.
“It is important to keep the I/A instrument in place because if the capsule has been aspirated into the tip, removing the hand piece from the eye could bring the entire capsular bag too,” Dr. Ahmed said.
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The injected OVD can displace any aspirated capsule from the tip, but before OVD is injected, infusion should be stopped or the OVD will come back out from the incision site. At the same time, surgeons should not overfill the eye–as that also will cause OVD to leak out of the incision, and vitreous prolapse may follow.
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Once the I/A tip is freed of material and the chamber stabilized, examination showed the residual cortex present in the superior area of the capsular bag, well away from the site of the zonular dialysis. Considering that use of an automated technique for completing cortex removal could create an unstable situation, Dr. Ahmed chose a manual approach to cortex aspiration, using a 27-gauge hockey stick cannula to irrigate and aspirate the residual cortex.
“It is important to add a few boluses of irrigation that will not only help with cortex removal but will also keep OVD away from the cannula,” he said.
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