Priya Narang, MS; Amar Agarwal, MS, FRCS, FRCOphth , 2025-05-05 14:52:00
Subluxation of the lens, either traumatic or congenital, poses a significant challenge as stabilization and centration of the capsular bag are of prime concern, as seen in Figure 1a.
Traumatic subluxations have a sectoral involvement of zonular dehiscence whereas congenital subluxations usually have an annular involvement that is progressive in nature. Management strategies differ depending on the kind of zonulopathy.
Images: Priya Narang, MS, and Amar Agarwal, MS, FRCS, FRCOphth
Prerequisites for bag fixation
- A perfect capsulorrhexis is essential to place the devices in the capsular bag. Therefore, every step should be taken to ensure a good rhexis. Trypan blue can be an additional tool to facilitate appropriate visualization of the capsule margin and reduce elasticity of the capsule in pediatric cases.
- Capsular hooks can be a game changer as they hold the capsular bag taut while phacoemulsification is performed. Capsular hooks provide equatorial and vertical support to the capsular bag (Figure 1b).
- Placement of an endocapsular ring into the subluxated bag distends the bag completely in the equatorial region, thereby preventing posterior capsule folds and capsular collapse.
Bag fixation devices have been documented to provide a lot of stability and are a valuable addition to achieve appropriate centralization of the capsular bag and IOL placement. Double-flanged fixation of the capsular bag has been described by Canabrava et al. A 5-0 Prolene suture is preferred for the double-flanged method of fixing a capsule fixation device. The Prolene suture is passed through the eyelet of the device, and a flange is created with low-temperature cautery at one end of the suture. The surgeon needs to make sure that the flange is the right size and that it does not slip from the eyelet of the capsule fixation device (Figure 2).
The other end of the suture is threaded into a 26-gauge needle introduced from the site where the bag-IOL complex needs to be fixed on to the sclera. The needle pierces the eye 2 mm away from the limbus as in a Yamane fixation technique. Once the suture end is withdrawn from the scleral side, the capsule fixation device is inserted into the capsular bag wherein the suture flange engages the eyelet of the device. The other end of the suture is pulled, and tension is titrated to achieve appropriate centralization of the capsular bag. The excess suture is cut, and the flange that is created is eventually buried into the scleral wall (Figure 3). Flange creation is an important aspect of this technique. The flange should be appropriate in the sense that it should be big enough not to slip inside the eye and small enough to get buried in the scleral wall. Protrusion of the flange can be a risk factor for developing endophthalmitis as the flange can serve as a route toward migration of microbes inside the eye.
After fixation of the bag, a one-piece or three-piece IOL, depending on the surgeon’s preference, can be placed into the capsular bag (Figure 4).
- Reference:
- Canabrava S, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000116.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at aehl19c@gmail.com; website: www.dragarwal.com.
- Priya Narang, MS, of Narang Eye Care & Laser Centre, Ahmedabad, India, can be reached at narangpriya19@gmail.com.
