Suture-guided CTR technique useful in complex surgery cases

Advances in intraocular prosthetic devices in cataract surgery, such as capsular tension rings, capsular tension devices and capsule support hooks, have helped cataract surgery move to a higher level of surgical excellence. Surgeons can perform safe surgery in the presence of zonular weakness, zonular lysis or capsular instability and safely place a posterior chamber IOL within the capsular tension ring-stabilized capsular bag, with usually a favorable surgical outcome. In the past, such cases could end up with intracapsular cataract extraction and an anterior chamber IOL, an iris-claw IOL, a scleral-fixated posterior chamber IOL or an iris-sutured posterior chamber IOL, possibly with an anterior vitrectomy. While pseudoexfoliation and ocular trauma top the list of etiologies contributing to zonular compromise, there are other causes including hypermature cataract, intraocular neoplasms, Marfan syndrome, Weill-Marchesani syndrome, homocystinuria, retinitis pigmentosa, lens coloboma, microspherophakia and multiple vitrectomies.Preoperative evaluation of zonular integrity should include observing the lens position and lens periphery and checking for phacodonesis. Flattening of equatorial lens capsule may reflect focal zonular weakness, while a more spherical or rounded lens margin may represent extensive zonular compromise. Surgical modifications or additions to augment safety may include a laser-assisted capsulorrhexis, lower fluidics parameters, viscodissection, multiple quadrant hydrodissection, limited nuclear rotation, micro-capsulorrhexis forceps use, and capsular tension rings or capsular hooks.