Stepwise Management of Zonular Instability

A practical intraoperative sequence for restoring capsular stability while minimizing additional zonular stress.

J. Morgan Micheletti, MD, FACS, and Evan Dackowski, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Zonular instability turns routine cataract maneuvers into stress tests for the capsular bag, so stabilization should precede rotation, chopping, and cortical removal Small, repeated ophthalmic viscosurgical device additions and capsule retractors can restore chamber control and capsular centration without abruptly deepening the anterior chamber Horizontal chop, tangential rotation, bimanual cortical cleanup, and timed capsular tension ring or segment placement reduce zonular stress while preserving fixation options Zonular instability during cataract surgery exists on a spectrum that ranges from diffuse weakness to focal or extensive dialysis. Regardless of the etiology, once instability is present, even routine maneuvers such as nuclear rotation and cortical removal can place additional stress on the remaining zonules. When we encounter zonular instability, we slow down and stabilize the capsular bag before proceeding. Rather than rely on a single maneuver or device, we manage these cases in a deliberate sequence that progressively restores capsular stability while minimizing additional zonular stress. RECOGNIZING INSTABILITY Zonular instability may be recognized preoperatively or discovered intraoperatively. Preoperative Recognition In select eyes with preexisting dialysis or zonular instability, we consider performing the capsulotomy with a femtosecond laser because it can create a centered, reproducible opening without relying on zonular countertraction, which can be helpful when the capsule is unstable. Intraoperative Recognition and Capsulorhexis Strategy Sometimes, zonular instability becomes apparent intraoperatively—often during the capsulorhexis. In these eyes, the capsule frequently moves with the tearing force because the zonules cannot provide adequate countertraction. The capsulorhexis may be smaller than intended because the capsule follows the vector of the tear. We try to maintain chamber stability with an OVD, frequently regrasp the capsule with forceps, and deliberately direct the tear outward to compensate for this tendency.

From Complication to Innovation

Kendall E. Donaldson, MD, MS

Cataract and Refractive Surgery Today

We ophthalmologists strive for precision and predictability. Advances in imaging, diagnostics, and surgical technology have elevated the standard of care to remarkable levels. Cataract and refractive surgery now routinely deliver outcomes that would have seemed extraordinary only a few decades ago. Despite these advances, complications remain an inevitable part of surgical practice. No amount of experience or technology can eliminate them. What matters most is how we respond. A complication in the OR can disrupt a carefully constructed plan, but it can also become a moment when preparation, judgment, and creativity intersect. Difficult situations often yield the most valuable lessons. When we remain calm, reassess the situation, and consider alternative strategies, we may still achieve a successful outcome. Preparation is essential.

Spotlight on UNITY® VCS: UNITY for All

Sarwar Zahid, MD, FASRS; John Kitchens, MD and Matthew Cunningham, MD, FASRS

Eyetube

Centered on the UNITY® VCS platform, this RetinaLIVE episode features Sarwar Zahid, MD, FASRS moderating a discussion with John Kitchens, MD and Matthew Cunningham, MD, FASRS. The panel shares firsthand experiences with UNITY® VCS. Listeners will discover practical insights on how the technology support both seasoned surgeons and fellows. For Important Product Information, visit https://unityvcs.com. Featured surgeons are paid Alcon consultants. The views expressed are their own. Disclaimers: 1:52: Based on bench data 3:28: MSLP(4) is 3 times faster than SSLP 8:53, 9:16: For posterior segment surgeries/poster cassette pack. (P