-: Dr. Yehia Mostafa from Egypt encounters
a patient with long anterior zonules.
-: This was a normal day, routine cataract surgery.
A 67-year-old lady with nothing alarming preoperatively.
Aside from nicking the anterior
capsule during my paracentesis,
I noticed very long insertion of anterior zonules.
This was my first time to see such an abnormality,
Leaving very small area for capsulorhexis.
My first and only worry was how to do
a continuous capsulorhexis without extension.
By bypassing this anteriorly inserted zonules.
So, very carefully I tried to do my capsulorhexis
to get a continuous circular one, thinking that
this should be my only problem in such a case.
Moving forward, I could get away with a nice
circular continuous capsulorhexis.
But if I look carefully here with high magnification,
you can see that I was stripping the anterior zonules.
But again, this did not ring any bells in my head.
So carrying on with my technique of hydrodissection
then vertical chopping, normal settings,
Just looking around for any abnormalities,
but not really worried about anything serious
as I got my continuous rhexis.
Now I start to notice some wobbling of the whole bag.
So I decided just to go out carefully
with replacement of viscoelastic to alleviate the situation.
Probably it looks like there is zonulysis all around,
but being in a state of denial, I started
to inflate the bag, thinking I can go away with this.
So I started to try to get the cortical material,
nuclear fragments outside of the bag.
And thought I could to phaco aspiration for it,
preserving the bag waiting for the help of capsular hooks
or capsular tension rings.
After all, I had to admit that all my attempts
had failed to preserve the bag completely.
So I start to do visco expression of the cortical contents.
And then I thought I have to get the whole bag
with the contents outside of the eye,
and my focus was to keep an intact
anterior vitreous face at this point.
I thought iris claw lens was a good idea.
So I started to inject Miochol to get the pupil down.
Finally I got the lens in good position,
I closed the wound with 1 suture
and left some vitreous hemorrhage
hoping to clear soon.
Postoperatively, the vitreous hemorrhage cleared in 10 days,
but the intraocular pressure was not controlled
by medications, so filtering surgery had to be done.
Reviewing literature showed that this case
is called long anterior zonules.