Photographs suggest nearly 12 hours of weakened zonular support in both eyes. This raises the specter of an underlying systemic condition associated with compromised zonular fibers. Marfan's syndrome, Weill-Marchesani syndrome, Ehlers-Danlos syndrome, Crouzon syndrome, homocystinuria, hyperlysinemia, and spherophakia should all be excluded based on physical examination and laboratory testing. The trauma related to the automobile accident may have exacerbated the situation in the left eye, but the symmetrical bilaterality depicted in the photographs suggests this was likely superimposed on a substrate of a preexisting zonular defect. Based on the normal posterior segment examination and media status, I suspect the potential acuity meter has underestimated the left eye's potential acuity.
The conjunction of moderately severe zonular weakness with a posterior polar cataract in the left eye creates an extreme challenge for even the most skillful ophthalmic surgeon. Hydrodissection is contraindicated in the face of the posterior polar cataract, thereby increasing the odds of stressing the remaining zonular support during phacoemulsification as well as increasing the difficulty of cortical cleanup. Furthermore, should the posterior polar involvement result in a frank defect in the posterior capsule after cataract extraction, placement of a CTR would be contraindicated. A less experienced or risk-averse surgeon could not be faulted for performing ICCE with AC IOL implantation in this eye or for referring the patient for pars plana lensectomy by a vitreoretinal colleague. The latter procedure has the advantage of maintaining a small incision, and a foldable PC IOL could be sewn to the iris during the same or a subsequent surgical sitting.
I would use a temporal clear corneal approach to the left eye. The zonular weakness mandates beginning the capsulorhexis with a sharp cystotome before switching to a forceps. In this case, a larger capsulorhexis would facilitate cataract extraction and help prevent anterior capsule contraction postoperatively. If necessary, Mackool hooks (Mackool Cataract Support System) could be placed under the capsulorhexis margin to support the lens complex intraoperatively. In lieu of hydrodissection, extensive hydrodelineation would then be performed subincisionally with a J-shaped cannula and then nasally with a flat cannula. An excellent “golden ring” sign denotes fluid separation of the endonucleus from the epinucleus and should be achieved before proceeding further. I still use the Kelman–Mackool angled microtip of the Legacy 20000 unit (Alcon Laboratories); nuclear density in this case would warrant use of the 45-degree tip. I would create a wide, deep central groove. Next, I would use a Beckert nucleus rotator to produce a vector force opposite to that imparted by the phaco tip and at a mirror image location from the phaco tip relative to the center of the nucleus to create a balanced torque-couple, producing only rotational forces without translational forces on the nucleus. If the endonucleus rotated easily, nuclear removal could be completed with a cracking or chopping technique. If not, I would crack the nucleus in situ and use vacuum to extract and elevate the distal pole of each half of the endonucleus out of the capsular bag for emulsification at or just anterior to the iris plane; I would use “slow-motion” settings and frequent supplementation with OVD. Next, I would inject Viscoat just under the anterior capsule rim to viscodissect the epinucleus and cortex from the capsule and bring it anteriorly, away from the posterior capsule, for removal. In my experience, frequent supplementation with OVD to keep the capsular bag inflated and use of slow-motion techniques and settings are mandatory during this stage to prevent inadvertent trauma to the capsule and/or zonules resulting from capsule flacidity.
Assessment of zonular and capsular integrity would dictate subsequent steps. Should the posterior capsule remain intact, I would place a CTR. Should severe zonular weakness warrant, I would insert and suture a Cionni modified CTR. If the posterior capsule is found to be open, after ensuring no vitreous had prolapsed anteriorly, I would place a foldable 3-piece IOL in the ciliary sulcus. I have found the ophthalmic endoscope invaluable in ensuring that both haptics are truly fixated in the sulcus rather than resting on the pars plicata. I would then capture the IOL optic posteriorly by the capsulorhexis to compartmentalize the eye, stabilize the capsule, and ensure optic centration. Should the IOL require further stabilization, I would suture the haptics to the iris.