• Kelman Lecture: Compromised Zonules

    Change for the sake of change usually doesn’t work, said Robert J. Cionni, MD, during the 14th Charles Kelman, MD, Lecture, “Managing Compromised Zonules.” But change that is designed to address an unmet need—or intended to make a product or procedure better, safer, quicker, or less expensive—is another matter, he said.

    Dr. Cionni’s own innovation, the Cionni capsular tension ring (CTR), was sparked by an unmet need for additional support of compromised zonules. “There’s no doubt that when challenged with weakened zonules, we have an unmet need,” he said. “When the zonules are weak, it’s hard to get a good capsulotomy.” And even if you do get a good capsulotomy, “it’s difficult to remove all of the cataract safely without losing nucleus down into the vitreous space, having vitreous prolapse, losing support for any intraocular lens, and running the risk of choroidal effusion, choroidal hemorrhage, and perhaps even expulsive hemorrhage.”

    Helpful innovations. These include modern capsulorrhexis and hydrodissection techniques, foldable IOLs, the femtosecond laser, and myriad hooks, rings, and segments. Ophthalmic viscoelastic devices (OVDs) have proved essential—as Dr. Cionni pointed out, “Probably most of the surgeons here today have never done surgery without an OVD.”

    General principles of management. These include the following:

    • Never let the chamber collapse.
    • Use a dispersive OVD.
    • Create an intact capsulotomy, and generally make it larger than you would for normal zonules.
    • Use generous hydrodissection.
    • Don’t ramp the fluidic parameters up to the roof; instead, use “just enough flow and aspiration to get the job done.”
    • Use hooks, rings, and segments.
    • Make sure to use resilient sutures.

    Additional nuances. Dr. Cionni addressed some common questions—including indications for using a CTR or a sutured modified CTR, contraindications to usage, and timing of placement during surgery—and discussed recent CTR developments and modifications. With regard to sutures, he noted, “One of the things we have learned is that we no longer use Prolene sutures” because of the risk of breakage. “We now use Gore-Tex sutures, even though this certainly is an off-label use.”

    Finally, he said, “Expect the unexpected—be prepared”; and he reminded the audience that all patients hope for an excellent refractive outcome, even those with weakened zonules.—Jean Shaw 

    Watch online. Dr. Cionni’s Kelman Lecture, as well as the rest of the Spotlight on Cataract Complications session, is available online via the Virtual Meeting. First sign in at aao.org/virtual-meeting (you will need your Academy login credentials), click “Sessions,” and then click “Archived Sessions” to find the “SPO2: Spotlight on Cataract Complications.” You will be able to access archived sessions until Jan. 31, 2019. 

    Financial disclosures. Abbott Medical Optics: C; Alcon: C,L; Carl Zeiss: C; Glaukos: C; Mile High Ophthalmics: S; Morcher: P; Ocumetics: C; Omeros: C; RVO: C.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

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