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Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation
techniques Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation Robert]. Cionni, MD, Robert H. Osher, MD
ABSTRACT The endocapsular tension ring has helped in the management of patients with moderate loss of zonular support. However, the eye with profound zonular dialysis or weakness may require scleral fixation of the ring for centration and long-term stabilization. We used a new, modified endocapsular tension ring designed to provide scleral support without violating the integrity of the capsular bag in 4 patients. All patients had extreme loss of zonular support preoperatively or a significant risk of progressive zonular weakness. In each case , the new ring provided excellent support and centration of the capsu lar bag and intraocular lens intraoperatively and postoperatively. J Cataract Refract Surg 1998; 24:1299- 1306
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he loss of significant zonular support greatly increases the surgical difficulty of cataract and intraocular lens (IOL) implantation surgery. If cataract removal is successful, there may be inadequate support for an IOL. In 1993, Witschel and Legler introduced the endocapsular tension ring, a device capable of providing intraoperative and postoperative stabilization of the capsular bag and IOL (U. Legler, MD, B. Witschel, MD, et al., "The Capsular Ring: A New Device for Complicated Cataract Surgery," presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, May 1993). Yet even with
From the Cincinnati Eye Institute, Cincinnati, Ohio, USA. Presented at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 1998. Dr. Cionni has a financial interest in the modified endocapsular tension ring. Reprint requests to Robert J Cionni, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA.
successful implantation of the ring, the capsular bag and IOL may remain decentered. Moreover, the longterm stability is uncertain in patients with pseudophak.odonesis or progressive zonular disease such as pseudoexfoliation or Marfan's syndrome. We present a modified endocapsular tension ring designed to provide scleral fixation without violating the integrity of the capsular bag and describe its benefits in 4 patients with significant zonular dialysis or weakness.
Surgical Technique The modified endocapsular tension ring (Morcher GmbH) consists of an open, flexible, poly(methyl methacrylate) (PMMA) filament. Eyelets are present at the open ends as in the original capsular tension ring (Figure 1). However, a PMMA fixation element or hook is joined to the loop. This hook extends from the loop centrally and courses anteriorly into a second plane, where it turns peripherally. At the free end of the hook is an eyelet for manipulation and suture place-
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Figure 1. (Cionni) The original Morcher-style endocapsvlar tension ring introduced by Witschel and Legler in 1993.
ment (Figure 2). When the modified endocapsular tension ring is implanted in the capsular bag, the hook wraps around the capsulorhexis edge and comes to rest on the anterior surface of the anterior capsule rim (Figure 3). A suture can be secured to this eyelet to allow scleral fixation without violating the integrity of the capsular bag (Figure 4). This new ring can be implanted in the capsular bag at any time after successful capsulorhexis. Before the ring is inserted, a 10-0 polypropylene (Prolene®) suture, double-armed with CIF-4 needles, is passed through the eyelet of the fixation element (Figure 5). Each of the 2 needles is then placed through the incision and directed over the area of zonular dialysis to exit through the ciliary sulcus and scleral wall (Figure 6). Care must be taken to pass the suture posteriorly enough to avoid future contact of the hook and eyelet with the undersurface of the iris. The suture placement should be similar to techniques for suturing a posterior chamber
Figure 2. (Cionni) The modified endocapsular tension ring, shown from a front and a side view to demonstrate the hook coursing into a second plane. 1300
Figure 3. (Cionni) A modified endocapsular tension ring after placement in a cadaver eye. The hook courses around the capsulorhexis edge to rest on the anterior surface of the anterior capsular rim. The cornea has been removed for better visualization.
Figure 4. (Cionni) A modified endocapsular tension ring after placement in the capsular bag. The hook courses around !he capsulorhexis edge to rest in the ciliary sulcus, where it can be sutured to the scleral wall without violating the integrity of the capsular bag.
Figure 5. (Cionni) The 10-0 Prolene suture double-armed with CIF-4 needles is preplaced through the eyelet on the hook of the modified endocapsular tension ring.
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Figure 6. (Cionni) The CIF-4 needles are passed through the incision, over the area of zonular weakness, and through the ciliary sulcus and scleral wall.
I 0 L. The ring is then inserted in the capsular bag, and the fixation element captures itself anterior to the residual anterior capsule rim (Figure 7). Tightening the sutures causes the ring and capsular bag to center (Figures 8 and 9). The knot can be buried by rotation or placed under a scleral flap.
Case Reports Case] A 47-year-old white woman with Marfan's syndrome complained of poor vision and disabling glare in the right eye. The family history was positive; her mother had Marfan's syndrome and developed total spontaneous luxation of her cataract. Best corrected visual acuity (BCVA) measured 20/160 in the right eye and 20/20 in the left with approximately
Figure 7. (Cionni) The modified endocapsular tension ring is inserted in the capsular bag. The capsulorhexis edge captures the hook anterior to the residual anterior capsular rim.
9.5 diopters (D) of myopia in both. Intraocular pressure (lOP) was normal. The right lens showed mature nuclear sclerosis with dense posterior subcapsular opacification. The cataract was decentered superonasally with thinly stretched wnules from 5 to 8 o'clock, and mild phakodonesis was present (Figure 10). Vitreous prolapse was absent. The left lens showed moderate posterior subcapsular opacification without extensive lens decentration or phakodonesis. After the risks of surgery were explained, the patient consented to allow us to implant the modified endocapsular tension ring if necessary. She was given retrobulbar and Van Lint anesthesia. A superotemporal conjunctival peritomy was made and wet-field cautery used for hemostasis. A similar peritomy was made at the site of zonular weakness. A 3-plane scleral tunnel incision was made with a diamond blade followed by entry into the anterior chamber. Sodium hyaluronate (Healon G\f®) was instilled and a bent 22 gauge needle used to perform a continuous tear capsulorhexis, slightly off center in the direction of the lens decentration. Gentle hydrodissection was performed, and a side-port incision was made. Phacoemulsification was completed with the Alcon Legacy 20,000 unit and a Kelman tip using "slow motion" parameters and a nuclear divide technique. 1 Aspiration of cortex was accomplished manually using a 27 gauge cannula and Healon GV. A 10-0 Prolene suture, double-armed with CIF-4 needles, was passed through the fixation eyelet of the modified endocapsular ring. The needles were then passed through the incision and pupillary space, between the residual annular anterior capsule rim and posterior iris surface, and through the scleral wall, exiting 2.0 mm posterior to the corneoscleral junction at the area of wnular weakness. The capsular bag was inflated with Healon GV and the modified endocapsular tension ring inserted in the capsular bag through the main incision. The fixation element remained over the anterior capsule rim and was dialed toward the area of wnular weakness using a Sinskey hook and gentle tension on the sutures. Once the capsular bag appeared to be centered,
Figure 8. (Cionni) The modified endocapsular tension ring remains decentered before the suture connected to the hook of the ring is tightened.
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Figure 9. (Cionni) The modified endocapsular tension ring and capsular bag center nicely after the suture connected to the hook of the ring is tightened.
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Figure 10. (Cionni) Case 1 with Marfan's Syndrome prior to surgery (surgeon's view).
Figure 11. (Cionni) Case 1 after placement of the modified endocapsular ring and IOL (surgeon's view).
the sutures were tightened and tied, and the knot was buried. The incision was extended to 6.0 mm, and a Pharmacia 730A PMMA lOL was implanted in the capsular bag. Healon was removed and the incision was closed. At the end of the procedure, the pupil was round and the lOL was centered and stable (Figure 11). On the first postoperative day, uncorrected visual acuity (UCVA) had improved to 20/25 and lOP measured 18 mm Hg. The cornea was clear and the anterior chamber deep with mild cell. The lOL was well centered and the capsular bag appeared stable without pseudophakodonesis. The patient was discharged to her ophthalmologist, who reported that she had maintained a small amount of asymptomatic anterior chamber cellular reaction. There had been no iris chafing or elevation of pressure, and the lOL remained stable and centered for 8 months.
risks as well as the possible use of the modified endocapsular tension ring were explained, the patient consented to surgery. Retrobulbar and Van Lint anesthesia were used. The conjunctiva was opened temporally as well as nasally at the site of the zonular dialysis. A 3-plane scleral tunnel incision was made temporally, and sodium hyaluronate (Amvisc Plus®) was injected into the anterior chamber, displacing vitreous posteriorly. A bent 22 gauge needle was used to perform a continuous anterior capsulorhexis, which was made off center toward the direction of the lens decentration. Gentle but thorough hydrodissection was performed followed by low-flow phacoemulsification. Removal of the cataract was facilitated by viscodissection, and a space was created between the anterior capsule rim and the iris with Amvisc Plus. After the ClF-4 needles and 10-0 Prolene suture were preplaced as described in the first case, a modified endocapsular tension ring was inserted in the capsular bag. A brief "dry" vitrectomy was necessary for the limited vitreous prolapse. 2 The ring was secured by tying the Prolene suture, ;md the behavior of the capsular bag was normal. Cortical ~emoval was accomplished with an automated irrigation/aspiration (IIA) handpiece followed by polishing and vacuuming the posterior capsule with the same handpiece. An ORC-C430 posterior chamber lOL was placed in the capsular bag and it centered spontaneously. Viscoelastic material was removed, and acetylcholine chloride (Miochol®) was instilled. The incision was closed, and conjunctiva was reapproximated with the coaptation cautery. On the first postoperative day, visual acuity had improved to 20/60 and lOP was 1 mm Hg because of aqueous leakage through the Prolene suture track nasally. The capsular bag and lOL were stable and well centered. The leak sealed
Case2 A 34-year-old white woman was referred with a history of blunt trauma to the left eye resulting in cataract formation 19 years earlier. She described having poor vision since the trauma. lntracapsular cataract surgery had been contemplated in 1986 because of significant zonular dialysis and vitreous prolapse. Best corrected visual acuity was 20/15 in the right eye and 201100 in the left, and lOP was normal. The left eye showed multiple sphincter tears, and the undilated pupil measured approximately 5.0 mm. The left lens demonstrated significant anterior and posterior cortical opacification. Five hours of absent zonules between 8 and 1 o'clock and vitreous prolapse into the anterior chamber were observed (Figure 12). The cataract showed inferotemporal decentration, yet there was no obvious phakodonesis. Mter the surgical 1302
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Figure 12. (Cionni) Preoperative photograph of Case 2 show-
ing inferotemporal lens decentration because of absent zonules.
within the first postoperative week, and visual acuity improved to 20/20 with a normal lOP. The lens position appeared stable during the 2 month follow-up (Figure 13).
Case3 A 37-year-old man was referred with bilateral colobomata of the anterior and posterior segments associated with subluxated cataractous lenses. His BCVA measured 20/300 in the right eye and 20/250 in the left. Intraocular pressure was normal. The pupils measured 4.0 X 5.0 mm with bilateral inferior colobomata and some eccentricity in position. The right lens showed yellow nuclear sclerosis that was more advanced than the milky nuclear sclerotic left lens. Each lens showed severe superior displacement, and the normal curvature of the lens equator was flattened inferiorly in association with elongated inferior zonules (Figure 14). Each fundus had a large inferior chorioretinal coloboma. The patient was informed of the risks of surgery and the possible use of a modified endocapsular tension ring before consenting to surgery in the right eye. He was given retrobulbar and Van Lint anesthesia. Superotemporal and inferior conjunctival peritomies were made, and limited cautery was applied for hemostasis. A 3-plane scleral tunnel incision was made with a diamond knife and a scleral flap prepared inferiorly. A 22 gauge needle under Healon GV was used for the capsulorhexis, and phacoemulsification of the cataract was performed using a curved Kelman tip and a "slow motion" technique. Cortex was removed using the automated I/A handpiece, and the posterior capsule was vacuumed with the same handpiece. Healon GV was instilled to reinflate the capsular bag. A 10-0 Prolene suture doublearmed with CIF-4 needles was placed through the eyelet of the fixation element on the modified endocapsular ring. The
Figure 13. (Cionni) Slitlamp photograph of Case 2 6 weeks after surgery. The eye has been dilated to reveal the fixation "hook" superotemporally.
needles were then placed through the incision and directed through the pupil, exiting through the ciliary sulcus and scleral wall beneath the scleral flap. Next, the endocapsular ring was inserted in the capsular bag and the 2 Prolene sutures were tightened, which resulted in more physiologic centration of the capsular bag. The needles were cut free and the sutures tied beneath the scleral flap. An MA60 acrylic IOL (Alcon Laboratories, Inc.) with a 6.0 mm optic was folded longitudinally and placed in the capsular bag using a Y-hook to insert the trailing haptic (Storz Instrument Co.). Healon was removed, Miochol instilled, and the conjunctiva closed over the watertight wound with the coaptation cautery (Figure 15). On the first postoperative day, UCVA measured 20/50, improving to 20/30 with a pinhole. The lOP measured 28 mm Hg. The cornea showed mild edema and the anterior chamber was deep with 1-2+ cells. The capsular bag and IOL were nicely centered and stable. The following day, UCVA was 20/40 and lOP was 14 mm Hg. The anterior segment continued to look excellent and the patient was discharged to his ophthalmologist, who reported 20/25 acuity, normal IOP, and a centered IOL without pseudophakodonesis or inflammation 6 months postoperatively.
Case4 A 64-year-old white man was referred with a history of blunt trauma to the left eye resulting in multiple lid lacerations, an orbital fracture, and a cataract, which was partially sub luxated. Despite a laser iridotomy and the use of timolol (Betimol®) and dorzolamide hydrochloride (Trusopt®), lOP remained in the high 20s and low 30s. The patient's BCVA measured 20/15 in the right eye and 20/200 in the left. The left anterior chamber was shallow with iris bombe and slit to
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Figure 14. (Cionni) Preoperative photograph of Case 3 showing superior lens decentration with elongated inferior zonules and inferior iris coloboma (surgeon's view).
Figure 15. (Cionni) Case 3 after placement of the modified endocapsular tension ring and IOL. The IOL and capsular bag are nicely centered (surgeon's view). The coloboma was not repaired.
closed angles. A laser iridotomy was present at the 11 o'clock position. The lens was displaced anteriorly with 180 degrees of superior zonular dehiscence and mild vitreous prolapse through the zonular defect (Figure 16). Prior to dilation there was impressive phakodonesis. Following dilation the lens stabilized with only trace phakodonesis, the chamber deepened dramatically, and the lOP decreased to 20 mm Hg. The lens showed nuclear sclerosis and cortical opacification. The fundus appeared normal without evidence of glaucomatous cupping. The risks of surgery were discussed, and the patient was informed of the possible use of the modified endocapsular tension ring. The patient consented to surgery, which was scheduled under regional anesthesia. Conjunctival peritomies were dissected both temporally and superiorly at the site of the dialysis. A temporal 3-plane scleral tunnel incision was made, and sodium chondroitin sulfate-sodium hyaluronate (Viscoat®) was instilled to deepen the anterior chamber and for vitreous tamponade. The capsulorhexis was initiated inferiorly over intact zonules using a bent 22 gauge needle. Once the tear reached the 10 o' dock position, the lack of countertraction necessitated the use of a second dull instrument to stabilize the lens. After the 1 o'clock position was reached, the second instrument interfered with the 22 gauge needle so a nylon iris retractor was placed through the 12 o'clock stab incision and used to secure the capsulorhexis edge. A Utrata forceps was then used to complete the capsulorhexis. The nylon retractor was left in place during the hydrodissection and for the beginning of the phacoemulsification. However, it was subsequently removed to prevent its unpolished tip from possibly tearing the anterior capsule rim during phacoemulsification. Viscoat was injected between
the posterior iris surface and the anterior surface of the capsular bag. A 10-0 Prolene suture double-armed with ClF-4 needles was placed as in the previous cases, exiting through the scleral wall at the 12 o'clock position. Viscoat was injected between the remaining nucleus and posterior surface of the anterior capsule rim to create a space for the modified endocapsular tension ring. The ring was inserted in the capsular bag over the top of the remaining nucleus. The fixation hook was dialed to the 12 o'clock position by stabilizing the lens with a second instrument and using a Y-hook while placing tension on the Prolene sutures. A temporary slip knot was tied to secure the ring and capsular bag. Phacoemulsification was completed without difficulry using low-flow, low-aspiration settings and a nuclear divide technique. Automated cortical aspiration was uneventful, and the posterior capsule was vacuumed until clear. The incision was enlarged to 6.0 mm to allow implantation of an ORC-C430 posterior chamber style lOL, which was placed in the capsular bag where it centered spontaneously. The needles were cut free from the suture, the suture was tied, and the knot was buried. Viscoelastic material was removed with a miniature IIA handpiece, and Miochol was instilled. At the conclusion of the procedure, the cornea was clear, the anterior chamber was deep, the pupil was round, and the capsular bag and lOL were centered (Figure 17). On the first postoperative day, visual acuity measured 201125 and lOP, 33 mm Hg. Mild corneal edema was present and the chamber was deep with 2 + cells. The lOL was centered without any evidence of pseudophakodonesis. Twenty-four hours later, visual acuity had improved to 20/40 and lOP was 14 mm Hg. The lOL and capsular bag appeared centered and stable. The patient returned to his
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Figure 16. (Cionni) Preoperative photograph of Case 4 showing 180 degrees of superior zonular dialysis (surgeon's view, temporal approach).
referring ophthalmologist, who reported 20/30 visual acuity, normal lOP, and a centered IOL without phakodonesis or inflammation 5 months after surgery.
Discussion Adequate stabilization of the capsular bag and IOL implantation in patients with poor zonular support has been a difficult challenge for the cataract surgeon. The endocapsular ring has greatly improved our ability to stabilize the capsular bag while providing the necessary countertraction to facilitate phacoemulsification and IOL implantation. The ability to successfully complete small incision cataract surgery eliminates the need to extend the incision to the large size needed for delivery of the entire cataract within its capsular bag. Surgery is therefore safer; it induces less astigmatism, and it allows a quicker visual recovery. Additionally, maintaining the capsular bag for IOL support with an endocapsular ring is more physiologic, may prevent the need for a vitrectomy, and is easier than suturing an IOL through the ciliary sulcus. Moreover, the endocapsular ring reduces asymmetric capsular forces, stabilizes the vitreous base, and prevents severe contraction of the posterior capsule following surgery. Yet, the endocapsular ring may fail to stabilize the capsular bag in cases with extensive zonular loss, and the prognosis for maintaining stability in cases of
Figure 17. (Cionni) Case 4 at the conclusion of surgery after placing the modified endocapsular tension ring and IOL (surgeon's view, temporal approach).
progressive zonular loss is uncertain. 3 In our first reported case, the endocapsular ring was inserted in a patient with 240 degrees of zonular dialysis ("New Approaches to Zonular Cases," Audiovisual Journal of Cataract and Implant Surgery 1993; Vol 9; Issue 3). The surgery was successful, but the IOL was slightly decentered at the 5 month postoperative visit. 4 In another case, a patient with microspherophakia who received bilateral endocapsular rings and IOLs showed significant irido/pseudophakodonesis several years after surgery. There have been reports of late spontaneous total lens dislocation in patients with or without known pseudoexfoliation, 5- 7 although we know of no such cases involving an endocapsular ring. Osher has developed a technique for creating "synthetic zonules" to secure the endocapsular tension ring and capsular bag to the scleral wall for better centration and long-term support ("Cataract Surgery: Tough Cases," Video Journal of Cataract Implant Surgery 1997; Vol8; Issue 1). However, this technique involves passing a needle through the capsular bag and distorting the configuration of the capsulorhexis with the other end of the suture. The 4 cases described herein demonstrate the modified endocapsular tension ring's ability to provide stability and centration of the capsular bag without violating its integrity. Each case had significant zonular weakness characterized by phakodonesis and/or preop-
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erative lens decentration. Postoperatively, each patient achieved capsular bag and IOL centration. Additionally, there was complete absence of iridodonesis and pseudophakodonesis postoperatively, confirming the increased level of stability. One patient has maintained an asymptomatic, lowgrade level of inflammation in the anterior chamber that appears to be indolent. The ring model used in this case was an earlier prototype with a 0.5 mm anterior return of the fixation hook, while the current mode~ has a 0.25 mm anterior return. The etiology of the cellular reaction is uncertain; however, there is no evidence of iris chafing. Although not seen in these 4 cases, patients with even more significant generalized zonular weakness could theoretically develop decentration or IOL tilt resulting from weakness at the pole opposite the fixation hook. A second ring could be placed, securing the hook at the opposite pole in such patients. Additionally, model 2-L, a 2-hook model of the ring (Morcher GmbH), should help manage these even more challenging patients. We believe that this new modified endocapsular
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tension ring represents a significant improvement in the management of the patient with severe zonular damage or progressive zonular weakness.
References 1. Osher RH. Slow motion phacoemulsification approach (letter).] Cataract Refract Surg 1993; 19:667 2. Cionni RJ, Osher RH. Intraoperative complications of phacoemulsification surgery. In: Steinert RF, ed, Cataract Surgery: Technique, Complications, and Management. Philadelphia, PA, WB Saunders Co, 1995; 327340 3. Osher RH. Response. In: Masket S, ed, Consultation Section. J Cataract Refract Surg 1998; 24:437-445 4. Cionni RJ, Osher RH. Endocapsular ring approach to the subluxated cataractous lens. ] Cataract Refract Surg 1995; 21:245-249 5. Fischel JD, Wishart MS. Spontaneous complete dislocation of the lens in pseudoexfoliation syndrome. Eur J Implant Refract Surg 1995; 7:31-33 6. Nishi 0, Nisho K, Sakanishi K, Yamada Y. Explantation of endocapsular posterior chamber lens after spontaneous posterior dislocation. ] Cataract Refract Surg 1996; 22:272-275 7. Davison JA. Capsule contraction syndrome.] Cataract Refract Surg 1993; 19:582-589
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ABSTRACT The endocapsular tension ring has helped in the management of patients with moderate loss of zonular support. However, the eye with profound zonular dialysis or weakness may require scleral fixation of the ring for centration and long-term stabilization. We used a new, modified endocapsular tension ring designed to provide scleral support without violating the integrity of the capsular bag in 4 patients. All patients had extreme loss of zonular support preoperatively or a significant risk of progressive zonular weakness. In each case , the new ring provided excellent support and centration of the capsu lar bag and intraocular lens intraoperatively and postoperatively. J Cataract Refract Surg 1998; 24:1299- 1306
T
he loss of significant zonular support greatly increases the surgical difficulty of cataract and intraocular lens (IOL) implantation surgery. If cataract removal is successful, there may be inadequate support for an IOL. In 1993, Witschel and Legler introduced the endocapsular tension ring, a device capable of providing intraoperative and postoperative stabilization of the capsular bag and IOL (U. Legler, MD, B. Witschel, MD, et al., "The Capsular Ring: A New Device for Complicated Cataract Surgery," presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, May 1993). Yet even with
From the Cincinnati Eye Institute, Cincinnati, Ohio, USA. Presented at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 1998. Dr. Cionni has a financial interest in the modified endocapsular tension ring. Reprint requests to Robert J Cionni, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA.
successful implantation of the ring, the capsular bag and IOL may remain decentered. Moreover, the longterm stability is uncertain in patients with pseudophak.odonesis or progressive zonular disease such as pseudoexfoliation or Marfan's syndrome. We present a modified endocapsular tension ring designed to provide scleral fixation without violating the integrity of the capsular bag and describe its benefits in 4 patients with significant zonular dialysis or weakness.
Surgical Technique The modified endocapsular tension ring (Morcher GmbH) consists of an open, flexible, poly(methyl methacrylate) (PMMA) filament. Eyelets are present at the open ends as in the original capsular tension ring (Figure 1). However, a PMMA fixation element or hook is joined to the loop. This hook extends from the loop centrally and courses anteriorly into a second plane, where it turns peripherally. At the free end of the hook is an eyelet for manipulation and suture place-
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Figure 1. (Cionni) The original Morcher-style endocapsvlar tension ring introduced by Witschel and Legler in 1993.
ment (Figure 2). When the modified endocapsular tension ring is implanted in the capsular bag, the hook wraps around the capsulorhexis edge and comes to rest on the anterior surface of the anterior capsule rim (Figure 3). A suture can be secured to this eyelet to allow scleral fixation without violating the integrity of the capsular bag (Figure 4). This new ring can be implanted in the capsular bag at any time after successful capsulorhexis. Before the ring is inserted, a 10-0 polypropylene (Prolene®) suture, double-armed with CIF-4 needles, is passed through the eyelet of the fixation element (Figure 5). Each of the 2 needles is then placed through the incision and directed over the area of zonular dialysis to exit through the ciliary sulcus and scleral wall (Figure 6). Care must be taken to pass the suture posteriorly enough to avoid future contact of the hook and eyelet with the undersurface of the iris. The suture placement should be similar to techniques for suturing a posterior chamber
Figure 2. (Cionni) The modified endocapsular tension ring, shown from a front and a side view to demonstrate the hook coursing into a second plane. 1300
Figure 3. (Cionni) A modified endocapsular tension ring after placement in a cadaver eye. The hook courses around the capsulorhexis edge to rest on the anterior surface of the anterior capsular rim. The cornea has been removed for better visualization.
Figure 4. (Cionni) A modified endocapsular tension ring after placement in the capsular bag. The hook courses around !he capsulorhexis edge to rest in the ciliary sulcus, where it can be sutured to the scleral wall without violating the integrity of the capsular bag.
Figure 5. (Cionni) The 10-0 Prolene suture double-armed with CIF-4 needles is preplaced through the eyelet on the hook of the modified endocapsular tension ring.
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Figure 6. (Cionni) The CIF-4 needles are passed through the incision, over the area of zonular weakness, and through the ciliary sulcus and scleral wall.
I 0 L. The ring is then inserted in the capsular bag, and the fixation element captures itself anterior to the residual anterior capsule rim (Figure 7). Tightening the sutures causes the ring and capsular bag to center (Figures 8 and 9). The knot can be buried by rotation or placed under a scleral flap.
Case Reports Case] A 47-year-old white woman with Marfan's syndrome complained of poor vision and disabling glare in the right eye. The family history was positive; her mother had Marfan's syndrome and developed total spontaneous luxation of her cataract. Best corrected visual acuity (BCVA) measured 20/160 in the right eye and 20/20 in the left with approximately
Figure 7. (Cionni) The modified endocapsular tension ring is inserted in the capsular bag. The capsulorhexis edge captures the hook anterior to the residual anterior capsular rim.
9.5 diopters (D) of myopia in both. Intraocular pressure (lOP) was normal. The right lens showed mature nuclear sclerosis with dense posterior subcapsular opacification. The cataract was decentered superonasally with thinly stretched wnules from 5 to 8 o'clock, and mild phakodonesis was present (Figure 10). Vitreous prolapse was absent. The left lens showed moderate posterior subcapsular opacification without extensive lens decentration or phakodonesis. After the risks of surgery were explained, the patient consented to allow us to implant the modified endocapsular tension ring if necessary. She was given retrobulbar and Van Lint anesthesia. A superotemporal conjunctival peritomy was made and wet-field cautery used for hemostasis. A similar peritomy was made at the site of zonular weakness. A 3-plane scleral tunnel incision was made with a diamond blade followed by entry into the anterior chamber. Sodium hyaluronate (Healon G\f®) was instilled and a bent 22 gauge needle used to perform a continuous tear capsulorhexis, slightly off center in the direction of the lens decentration. Gentle hydrodissection was performed, and a side-port incision was made. Phacoemulsification was completed with the Alcon Legacy 20,000 unit and a Kelman tip using "slow motion" parameters and a nuclear divide technique. 1 Aspiration of cortex was accomplished manually using a 27 gauge cannula and Healon GV. A 10-0 Prolene suture, double-armed with CIF-4 needles, was passed through the fixation eyelet of the modified endocapsular ring. The needles were then passed through the incision and pupillary space, between the residual annular anterior capsule rim and posterior iris surface, and through the scleral wall, exiting 2.0 mm posterior to the corneoscleral junction at the area of wnular weakness. The capsular bag was inflated with Healon GV and the modified endocapsular tension ring inserted in the capsular bag through the main incision. The fixation element remained over the anterior capsule rim and was dialed toward the area of wnular weakness using a Sinskey hook and gentle tension on the sutures. Once the capsular bag appeared to be centered,
Figure 8. (Cionni) The modified endocapsular tension ring remains decentered before the suture connected to the hook of the ring is tightened.
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Figure 9. (Cionni) The modified endocapsular tension ring and capsular bag center nicely after the suture connected to the hook of the ring is tightened.
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Figure 10. (Cionni) Case 1 with Marfan's Syndrome prior to surgery (surgeon's view).
Figure 11. (Cionni) Case 1 after placement of the modified endocapsular ring and IOL (surgeon's view).
the sutures were tightened and tied, and the knot was buried. The incision was extended to 6.0 mm, and a Pharmacia 730A PMMA lOL was implanted in the capsular bag. Healon was removed and the incision was closed. At the end of the procedure, the pupil was round and the lOL was centered and stable (Figure 11). On the first postoperative day, uncorrected visual acuity (UCVA) had improved to 20/25 and lOP measured 18 mm Hg. The cornea was clear and the anterior chamber deep with mild cell. The lOL was well centered and the capsular bag appeared stable without pseudophakodonesis. The patient was discharged to her ophthalmologist, who reported that she had maintained a small amount of asymptomatic anterior chamber cellular reaction. There had been no iris chafing or elevation of pressure, and the lOL remained stable and centered for 8 months.
risks as well as the possible use of the modified endocapsular tension ring were explained, the patient consented to surgery. Retrobulbar and Van Lint anesthesia were used. The conjunctiva was opened temporally as well as nasally at the site of the zonular dialysis. A 3-plane scleral tunnel incision was made temporally, and sodium hyaluronate (Amvisc Plus®) was injected into the anterior chamber, displacing vitreous posteriorly. A bent 22 gauge needle was used to perform a continuous anterior capsulorhexis, which was made off center toward the direction of the lens decentration. Gentle but thorough hydrodissection was performed followed by low-flow phacoemulsification. Removal of the cataract was facilitated by viscodissection, and a space was created between the anterior capsule rim and the iris with Amvisc Plus. After the ClF-4 needles and 10-0 Prolene suture were preplaced as described in the first case, a modified endocapsular tension ring was inserted in the capsular bag. A brief "dry" vitrectomy was necessary for the limited vitreous prolapse. 2 The ring was secured by tying the Prolene suture, ;md the behavior of the capsular bag was normal. Cortical ~emoval was accomplished with an automated irrigation/aspiration (IIA) handpiece followed by polishing and vacuuming the posterior capsule with the same handpiece. An ORC-C430 posterior chamber lOL was placed in the capsular bag and it centered spontaneously. Viscoelastic material was removed, and acetylcholine chloride (Miochol®) was instilled. The incision was closed, and conjunctiva was reapproximated with the coaptation cautery. On the first postoperative day, visual acuity had improved to 20/60 and lOP was 1 mm Hg because of aqueous leakage through the Prolene suture track nasally. The capsular bag and lOL were stable and well centered. The leak sealed
Case2 A 34-year-old white woman was referred with a history of blunt trauma to the left eye resulting in cataract formation 19 years earlier. She described having poor vision since the trauma. lntracapsular cataract surgery had been contemplated in 1986 because of significant zonular dialysis and vitreous prolapse. Best corrected visual acuity was 20/15 in the right eye and 201100 in the left, and lOP was normal. The left eye showed multiple sphincter tears, and the undilated pupil measured approximately 5.0 mm. The left lens demonstrated significant anterior and posterior cortical opacification. Five hours of absent zonules between 8 and 1 o'clock and vitreous prolapse into the anterior chamber were observed (Figure 12). The cataract showed inferotemporal decentration, yet there was no obvious phakodonesis. Mter the surgical 1302
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Figure 12. (Cionni) Preoperative photograph of Case 2 show-
ing inferotemporal lens decentration because of absent zonules.
within the first postoperative week, and visual acuity improved to 20/20 with a normal lOP. The lens position appeared stable during the 2 month follow-up (Figure 13).
Case3 A 37-year-old man was referred with bilateral colobomata of the anterior and posterior segments associated with subluxated cataractous lenses. His BCVA measured 20/300 in the right eye and 20/250 in the left. Intraocular pressure was normal. The pupils measured 4.0 X 5.0 mm with bilateral inferior colobomata and some eccentricity in position. The right lens showed yellow nuclear sclerosis that was more advanced than the milky nuclear sclerotic left lens. Each lens showed severe superior displacement, and the normal curvature of the lens equator was flattened inferiorly in association with elongated inferior zonules (Figure 14). Each fundus had a large inferior chorioretinal coloboma. The patient was informed of the risks of surgery and the possible use of a modified endocapsular tension ring before consenting to surgery in the right eye. He was given retrobulbar and Van Lint anesthesia. Superotemporal and inferior conjunctival peritomies were made, and limited cautery was applied for hemostasis. A 3-plane scleral tunnel incision was made with a diamond knife and a scleral flap prepared inferiorly. A 22 gauge needle under Healon GV was used for the capsulorhexis, and phacoemulsification of the cataract was performed using a curved Kelman tip and a "slow motion" technique. Cortex was removed using the automated I/A handpiece, and the posterior capsule was vacuumed with the same handpiece. Healon GV was instilled to reinflate the capsular bag. A 10-0 Prolene suture doublearmed with CIF-4 needles was placed through the eyelet of the fixation element on the modified endocapsular ring. The
Figure 13. (Cionni) Slitlamp photograph of Case 2 6 weeks after surgery. The eye has been dilated to reveal the fixation "hook" superotemporally.
needles were then placed through the incision and directed through the pupil, exiting through the ciliary sulcus and scleral wall beneath the scleral flap. Next, the endocapsular ring was inserted in the capsular bag and the 2 Prolene sutures were tightened, which resulted in more physiologic centration of the capsular bag. The needles were cut free and the sutures tied beneath the scleral flap. An MA60 acrylic IOL (Alcon Laboratories, Inc.) with a 6.0 mm optic was folded longitudinally and placed in the capsular bag using a Y-hook to insert the trailing haptic (Storz Instrument Co.). Healon was removed, Miochol instilled, and the conjunctiva closed over the watertight wound with the coaptation cautery (Figure 15). On the first postoperative day, UCVA measured 20/50, improving to 20/30 with a pinhole. The lOP measured 28 mm Hg. The cornea showed mild edema and the anterior chamber was deep with 1-2+ cells. The capsular bag and IOL were nicely centered and stable. The following day, UCVA was 20/40 and lOP was 14 mm Hg. The anterior segment continued to look excellent and the patient was discharged to his ophthalmologist, who reported 20/25 acuity, normal IOP, and a centered IOL without pseudophakodonesis or inflammation 6 months postoperatively.
Case4 A 64-year-old white man was referred with a history of blunt trauma to the left eye resulting in multiple lid lacerations, an orbital fracture, and a cataract, which was partially sub luxated. Despite a laser iridotomy and the use of timolol (Betimol®) and dorzolamide hydrochloride (Trusopt®), lOP remained in the high 20s and low 30s. The patient's BCVA measured 20/15 in the right eye and 20/200 in the left. The left anterior chamber was shallow with iris bombe and slit to
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Figure 14. (Cionni) Preoperative photograph of Case 3 showing superior lens decentration with elongated inferior zonules and inferior iris coloboma (surgeon's view).
Figure 15. (Cionni) Case 3 after placement of the modified endocapsular tension ring and IOL. The IOL and capsular bag are nicely centered (surgeon's view). The coloboma was not repaired.
closed angles. A laser iridotomy was present at the 11 o'clock position. The lens was displaced anteriorly with 180 degrees of superior zonular dehiscence and mild vitreous prolapse through the zonular defect (Figure 16). Prior to dilation there was impressive phakodonesis. Following dilation the lens stabilized with only trace phakodonesis, the chamber deepened dramatically, and the lOP decreased to 20 mm Hg. The lens showed nuclear sclerosis and cortical opacification. The fundus appeared normal without evidence of glaucomatous cupping. The risks of surgery were discussed, and the patient was informed of the possible use of the modified endocapsular tension ring. The patient consented to surgery, which was scheduled under regional anesthesia. Conjunctival peritomies were dissected both temporally and superiorly at the site of the dialysis. A temporal 3-plane scleral tunnel incision was made, and sodium chondroitin sulfate-sodium hyaluronate (Viscoat®) was instilled to deepen the anterior chamber and for vitreous tamponade. The capsulorhexis was initiated inferiorly over intact zonules using a bent 22 gauge needle. Once the tear reached the 10 o' dock position, the lack of countertraction necessitated the use of a second dull instrument to stabilize the lens. After the 1 o'clock position was reached, the second instrument interfered with the 22 gauge needle so a nylon iris retractor was placed through the 12 o'clock stab incision and used to secure the capsulorhexis edge. A Utrata forceps was then used to complete the capsulorhexis. The nylon retractor was left in place during the hydrodissection and for the beginning of the phacoemulsification. However, it was subsequently removed to prevent its unpolished tip from possibly tearing the anterior capsule rim during phacoemulsification. Viscoat was injected between
the posterior iris surface and the anterior surface of the capsular bag. A 10-0 Prolene suture double-armed with ClF-4 needles was placed as in the previous cases, exiting through the scleral wall at the 12 o'clock position. Viscoat was injected between the remaining nucleus and posterior surface of the anterior capsule rim to create a space for the modified endocapsular tension ring. The ring was inserted in the capsular bag over the top of the remaining nucleus. The fixation hook was dialed to the 12 o'clock position by stabilizing the lens with a second instrument and using a Y-hook while placing tension on the Prolene sutures. A temporary slip knot was tied to secure the ring and capsular bag. Phacoemulsification was completed without difficulry using low-flow, low-aspiration settings and a nuclear divide technique. Automated cortical aspiration was uneventful, and the posterior capsule was vacuumed until clear. The incision was enlarged to 6.0 mm to allow implantation of an ORC-C430 posterior chamber style lOL, which was placed in the capsular bag where it centered spontaneously. The needles were cut free from the suture, the suture was tied, and the knot was buried. Viscoelastic material was removed with a miniature IIA handpiece, and Miochol was instilled. At the conclusion of the procedure, the cornea was clear, the anterior chamber was deep, the pupil was round, and the capsular bag and lOL were centered (Figure 17). On the first postoperative day, visual acuity measured 201125 and lOP, 33 mm Hg. Mild corneal edema was present and the chamber was deep with 2 + cells. The lOL was centered without any evidence of pseudophakodonesis. Twenty-four hours later, visual acuity had improved to 20/40 and lOP was 14 mm Hg. The lOL and capsular bag appeared centered and stable. The patient returned to his
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Figure 16. (Cionni) Preoperative photograph of Case 4 showing 180 degrees of superior zonular dialysis (surgeon's view, temporal approach).
referring ophthalmologist, who reported 20/30 visual acuity, normal lOP, and a centered IOL without phakodonesis or inflammation 5 months after surgery.
Discussion Adequate stabilization of the capsular bag and IOL implantation in patients with poor zonular support has been a difficult challenge for the cataract surgeon. The endocapsular ring has greatly improved our ability to stabilize the capsular bag while providing the necessary countertraction to facilitate phacoemulsification and IOL implantation. The ability to successfully complete small incision cataract surgery eliminates the need to extend the incision to the large size needed for delivery of the entire cataract within its capsular bag. Surgery is therefore safer; it induces less astigmatism, and it allows a quicker visual recovery. Additionally, maintaining the capsular bag for IOL support with an endocapsular ring is more physiologic, may prevent the need for a vitrectomy, and is easier than suturing an IOL through the ciliary sulcus. Moreover, the endocapsular ring reduces asymmetric capsular forces, stabilizes the vitreous base, and prevents severe contraction of the posterior capsule following surgery. Yet, the endocapsular ring may fail to stabilize the capsular bag in cases with extensive zonular loss, and the prognosis for maintaining stability in cases of
Figure 17. (Cionni) Case 4 at the conclusion of surgery after placing the modified endocapsular tension ring and IOL (surgeon's view, temporal approach).
progressive zonular loss is uncertain. 3 In our first reported case, the endocapsular ring was inserted in a patient with 240 degrees of zonular dialysis ("New Approaches to Zonular Cases," Audiovisual Journal of Cataract and Implant Surgery 1993; Vol 9; Issue 3). The surgery was successful, but the IOL was slightly decentered at the 5 month postoperative visit. 4 In another case, a patient with microspherophakia who received bilateral endocapsular rings and IOLs showed significant irido/pseudophakodonesis several years after surgery. There have been reports of late spontaneous total lens dislocation in patients with or without known pseudoexfoliation, 5- 7 although we know of no such cases involving an endocapsular ring. Osher has developed a technique for creating "synthetic zonules" to secure the endocapsular tension ring and capsular bag to the scleral wall for better centration and long-term support ("Cataract Surgery: Tough Cases," Video Journal of Cataract Implant Surgery 1997; Vol8; Issue 1). However, this technique involves passing a needle through the capsular bag and distorting the configuration of the capsulorhexis with the other end of the suture. The 4 cases described herein demonstrate the modified endocapsular tension ring's ability to provide stability and centration of the capsular bag without violating its integrity. Each case had significant zonular weakness characterized by phakodonesis and/or preop-
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erative lens decentration. Postoperatively, each patient achieved capsular bag and IOL centration. Additionally, there was complete absence of iridodonesis and pseudophakodonesis postoperatively, confirming the increased level of stability. One patient has maintained an asymptomatic, lowgrade level of inflammation in the anterior chamber that appears to be indolent. The ring model used in this case was an earlier prototype with a 0.5 mm anterior return of the fixation hook, while the current mode~ has a 0.25 mm anterior return. The etiology of the cellular reaction is uncertain; however, there is no evidence of iris chafing. Although not seen in these 4 cases, patients with even more significant generalized zonular weakness could theoretically develop decentration or IOL tilt resulting from weakness at the pole opposite the fixation hook. A second ring could be placed, securing the hook at the opposite pole in such patients. Additionally, model 2-L, a 2-hook model of the ring (Morcher GmbH), should help manage these even more challenging patients. We believe that this new modified endocapsular
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tension ring represents a significant improvement in the management of the patient with severe zonular damage or progressive zonular weakness.
References 1. Osher RH. Slow motion phacoemulsification approach (letter).] Cataract Refract Surg 1993; 19:667 2. Cionni RJ, Osher RH. Intraoperative complications of phacoemulsification surgery. In: Steinert RF, ed, Cataract Surgery: Technique, Complications, and Management. Philadelphia, PA, WB Saunders Co, 1995; 327340 3. Osher RH. Response. In: Masket S, ed, Consultation Section. J Cataract Refract Surg 1998; 24:437-445 4. Cionni RJ, Osher RH. Endocapsular ring approach to the subluxated cataractous lens. ] Cataract Refract Surg 1995; 21:245-249 5. Fischel JD, Wishart MS. Spontaneous complete dislocation of the lens in pseudoexfoliation syndrome. Eur J Implant Refract Surg 1995; 7:31-33 6. Nishi 0, Nisho K, Sakanishi K, Yamada Y. Explantation of endocapsular posterior chamber lens after spontaneous posterior dislocation. ] Cataract Refract Surg 1996; 22:272-275 7. Davison JA. Capsule contraction syndrome.] Cataract Refract Surg 1993; 19:582-589
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