Intraocular lens optic capture and zonular impairment

Abstract

Devranoğlu et al.1 described their surgical approach in cases of marked zonular impairment. In these cases, they suggested a combination of previously described techniques, including the use of flexible nylon retractors for temporary capsule support, the use of a capsular tension ring (CTR), and the implantation of a sulcus-fixated foldable 3-piece intraocular lens (IOL) with the optic capture technique through the anterior continuous capsulorhexis. Besides arguing that 3-piece IOLs of any geometry can be implanted in this way (and not only those with an “asymmetric biconvex optic”), we noticed that the authors did not describe exactly when during surgery they suggest placement of the CTR. It is also appropriate to mention that in cases of marked zonular impairment, CTR insertion might be challenging and risk further damage to the already altered zonule. The fish-tail technique could be useful in these cases.2 We also read that the technique they described for cases with marked zonular instability was “validated” in a series of 70 cases with no visible phacodonesis that presented with only “predisposing factors” for late IOL dislocation. We highlight that there is no need for capsule hooks in cases without phacodonesis as the hooks can lead to complications.3 The use of a CTR does not prevent late in-the-bag IOL dislocation,4 and capsular bag distension syndrome can occur with this technique.5 In this respect, the authors did not detail how they ensure complete ophthalmic viscosurgical device removal from behind the IOL. Finally, we might agree that in a few selected cases, this fixation method could be beneficial, although we must consider that generally, endocapsular placement of the IOL ensures a reduced rate of postoperative complications and more predictable refractive outcomes. Apart from cases of posterior capsule rupture, we call for this technique only in cases of moderate to marked intraoperative phacodonesis, extending the indication also to young patients with phacodonesis secondary to previous intraocular surgery, high myopia, or a combination of these conditions.