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Maneuver to Minimize Zonular Stress During Removal of Ophthalmic Viscosurgical Devices

Dada, Vijay K. MD; Sethi, Harinder S. MD; Sharma, Namrata MD; Dada, Tanuj MD

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Journal of Cataract & Refractive Surgery: May 2003 - Volume 29 - Issue 5 - p 1045-1046
doi: 10.1016/S0886-3350(03)00303-1
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Complete removal of an ophthalmic viscosurgical device (OVD) from the eye after intraocular lens (IOL) implantation prevents not only an early postoperative rise in intraocular pressure1 but also the occurrence of capsule distension syndrome.2 To ensure complete removal of an OVD, it is desirable to aspirate it from the vicinity of the IOL in the capsular bag and the anterior chamber. While removal from the anterior chamber is easy, retropseudophakic OVD aspiration, especially with the increasing use of new-generation high-viscosity agents such as Healon GV® (sodium hyaluronate 1.4%) and Healon®5 (sodium hyaluronate 2.3%), is technically difficult.3

To facilitate retropseudophakic aspiration of the OVD, we gently depress the superior edge of the IOL posteriorly, under the cushion of the exiting OVD, and then slide an automated irrigation/aspiration (I/A) probe (port facing anteriorly) along its side beneath the IOL; this is followed by aspiration of the OVD.1,4 However, this maneuver may cause stress on the subincisional zonule−capsule apparatus, which may be strong enough in normal cases to withstand the stress. In cases with weak or compromised zonules, this force may lead to zonular dehiscence, indicated by a change in the contour of the round anterior capsulorhexis to a D shape, with the flat part of the D in the area of the decompensated zonules. We have encountered this complication in 2 cases of hypermature cataract; the zonular dehiscence occurred while the automated I/A port was slid beneath the edge of the IOL in the retro IOL compartment.

In cases in which decompensated zonules are anticipated, we recommend a different method of OVD removal. Slight inferior sliding of the IOL with the Lester hook inserted from the side port may be done to create a crescentic gap between the convex margin of the IOL and the concave border of the capsulorhexis (Figure 1). Following this maneuver, the automated I/A probe (aspiration port facing anteriorly) is inserted through the gap and the OVD is aspirated. Signs of complete OVD removal include the aspiration and exit of the Healon GV bolus due to the difference in the refractive indices of the balanced salt solution and the viscoelastic agent and the appearance of jerky IOL movements, which were muffled earlier by the presence of the viscoelastic tamponade.1

Figure 1.
Figure 1.:
(Dada) The superior edge of the IOL is inserted from the side port with a Lester hook. PC IOL = posterior chamber intraocular lens; I/A cannula = automated irrigation/aspiration probe; ACCC margin = anterior central curvilinear capsule margin.

This technique prevents zonular stress on the subincisoinal capsule−zonule apparatus while the automated I/A probe is introduced behind the IOL. We recommend this method of minimizing zonular stress during OVD removal in all cases. However, it is especially relevant in cases with compromised zonules such as eyes with high myopia, hypermature cataract, pseudoexfoliation syndrome, retinitis pigmentosa, posttraumatic cataract, and cataract with uveitis. We also suggest this method for beginning/novice surgeons who are still hesitant or not well versed in one-handed insertion of the automated I/A probe behind the IOL, which can be more difficult in cases with a small anterior capsulorhexis.

Vijay K. Dada MD

Harinder S. Sethi MD

Namrata Sharma MD

Tanuj Dada MD

New Delhi, India


1. Sharma N, Dada T, Dada VK. Removal of an ophthalmic viscoelastic device [letter]. J Cataract Refract Surg 2001; 27:492-493
2. Theng JTS, Jap A, Chee S-P. Capsular block syndrome; a case series. J Cataract Refract Surg 2000; 26:462-467
3. Tetz MR, Holzer MP. Two-compartment technique to remove ophthalmic viscosurgical devices. J Cataract Refract Surg 2000; 26:641-643
4. Dada VK, Sharma N, Pangtey MS, Dada T. Modification of the aspiration port to aid OVD removal and prevent posterior capsule tear [letter]. J Cataract Refract Surg 2001; 27:341
© 2003 by Lippincott Williams & Wilkins, Inc.