Surgery: Phacoemulsification in a Traumatic Cataract with Zonular Dehiscence

So as you can see, this is actually a traumatic cataract. This patient had a trauma around one year ago. You can see that — even without actually rotating the eye, you can see the edge of the lens is over here. So this is all the zonulysis, and you can see the edge of the lens, so by just looking at here, you can see that it’s around from 2:00 to the 4:00 or 5:00. And when you mobilize the eye, you can see that the lens actually is a little bit mobile. So we’ll be able to tell once we go into the AC if the lens moves a lot. You can see that the lens moves down a little bit. Again, I tried to actually make a long tunnel for this, because — in case we need a sclerally fixated lens, it’s better to have a longer tunnel, because the wound will be much, much bigger. You can see one sign of zonulysis or zonule dehiscence is that when we do the capsulorrhexis, there are a lot of folds on the capsule, and the counterpressure — if you do enough phaco, you’ll know that it’s different. The counterpressure. When you actually try to do the CCC, it is very unstable, the zonules. You know that. It feels different. And the capsulorrhexis is much more difficult to do. Because the zonules act as a counterpressure. The capsulorrhexis I’m doing now is slightly smaller. But I think it’s good enough for the time being. I might choose to do a hydrodissection first. It’s important to do a very thorough hydrodissection, if possible. Okay. So we can see that the ring is building up. And we’re trying to release the pressure in the posterior capsule, because you can see the water coming out. Gushing out. Okay? And I’ll try to see if we can rotate it. If we can rotate it, I think it’s better to rotate it counterclockwise. Maybe there’s a zonulysis in that region. It’s better to rotate the lens towards the zonular dehiscence. So I’m going under, and I’m still trying to isolate — you see, I’m trying to use the — the dissect the capsule away from the lens. Now, for the introduction of the CTR, it’s important that we don’t — we have to think. Okay. Where should we put the CTR, and how? In what direction should we do it? You can see the zonulysis is over here. Okay? So if we put the CTR in that direction, in fact, we are creating more trouble. Because the CTR, when it threads through here, it can cause more tension on the zonules. Okay? So in other words, we should only think about putting the CTR in that direction. So it’s an anticlockwise position. So here’s the CTR. So we think about what we do. When we introduce it, we’re trying to put it in, in the anticlockwise position. Like that. And we’ll go in through here, and then just thread through. Okay? Make sure the end of the capsular tension ring is stuck inside the bag. Okay. So hopefully everything is okay. I tried to use the hydrodelineation. I’ll try to express it a bit more. It’s always a good idea dissect a bit more. Make sure the lens is really free, away from the cataract. Okay. So we’re gonna start phaco. I usually use a divide and conquer approach. The lens is still very unstable, I can see. It’s very important to make sure you’re not pushing the lens too much. Because any pushing can cause more zonule problems. And the CTR can’t withstand zonulysis too much. So it’s still very important to have a gentle phaco. It’s easier if it’s in the AC. The lens will be easier to remove. It’s not causing damage or zonule stress. It has to be very gentle. The bag is very mobile. So everything has to be very gentle. You can see that I’m trying to do this cracking over this direction. Because the zonule is on the temporal side that has the zonulysis, so I’m not pushing the lens in another direction, so we are going down now to the last quadrant. But sometimes I can adjust with my pedal too. I’m trying to not press the pedal to the full strength. One thing with the capsular tension ring is that after the phaco, you see the capsulorrhexis is still pericentral, and circular, which is good. Because if there’s any capsular damage, you won’t see that. You’ll see a D shape, or the distortion of the capsule. So far, so good. And there seems to be no vitreous. I will just insert some OVD. Just try to block this area. Because this is where the vitreous can come out from. So when I do IA, I do it very slowly. When you do it in situ, it’s always more difficult to absorb. Because we have done a little bit of that complete hydrodissection, it’s making it easier. I won’t go very heroic. In case I can’t suck off all the capsule. Because as long as the center part of the bag is clear, I think I’m happy. Usually when the zonulysis is happening in this direction, the lens may have a little bit of injury too. So it’s not uncommon. The capsule seems to be okay. It’s good to rotate the lens so that the haptic stays where the zonulysis is. So that’s why I’ll rotate a little bit.