For cataract surgeons, pseudoexfoliation frequently poses the intraoperative challenge of weak zonules and a small pupil. This complicates virtually every step of cataract surgery. Besides the need to avoid posterior capsular or zonular rupture, there is the additional problem of providing adequate long-term IOL fixation in light of the progressive zonulopathy that continues to occur over time.

If the capsular bag is preserved, the surgeon must decide whether to use a capsular tension ring, which is often but not always indicated. These videos cover the spectrum of zonular instability when the IOL is implanted into the capsular bag.

In cases of severe diffuse zonular weakness, preservation of the capsular bag does not assure long-term IOL fixation if the zonules progressively weaken with pseudoexfoliation. One option is sulcus fixation of a 3-piece IOL, as demonstrated in this video series.

With insufficient centrifugal zonular tension, the posterior capsule is abnormally lax. The pliant posterior capsule will tend to be aspirated by the IA tip, increasing the risk of capsular rupture during cortical cleanup.

These videos address the intraoperative management of a zonular dialysis. Whether and when to place a capsular tension ring is a difficult decision, and these videos demonstrate some of the options. Capsule retractors provide more support to the capsular bag and do not impede cortical cleanup.

The 4+ nucleus makes zonular dehiscence or capsular rupture much more likely with pseudoexfoliation. The challenges associated with rock hard nuclei are compounded by zonular weakness. In particular, the greater nuclear size and rigidity more directly transmit the forces of every surgical maneuver to the zonular complex. Although the zonules may be intact in many eyes with pseudoexfoliation, the presence of a brunescent nucleus is typically associated with advanced zonulopathy. These videos demonstrate a number of pearls for tackling such cases.

The presence of a brunescent nucleus in eyes with pseudoexfoliation is associated with a much higher risk of zonular dehiscence, capsular rupture, and vitreous loss. Whenever performing phaco in these eyes, the surgeon should mentally rehearse and be prepared to convert to a manual ECCE technique if necessary. If severe zonular dehiscence is diagnosed early enough, manual extraction of the nucleus with a lens loop can prevent a dropped nucleus.

Eyes with markedly abnormal zonules carry the risk of delayed in-the- bag IOL dislocation, often occurring many years later. Pseudoexfoliation is the most common associated cause of progressive zonulopathy. If the capsular bag is completely dislocated, it can be challenging to remove. It may look deceptively accessible at the slit lamp, but with the patient supine in the operating room, the IOL complex often drops farther posteriorly.

A number of conditions besides pseudoexfoliation and trauma can be associated with weak or deficient zonules. These include retinopathy of prematurity, retinitis pigmentosa, scleritis, and prior surgery, such as trabeculectomy or vitrectomy. The principles of surgical management and IOL fixation previously discussed apply to these situations as well. Two examples are presented.

A second major cause of zonulopathy is trauma. In addition to the zonular problems, these eyes often suffer from anterior segment co-morbidity such as secondary glaucoma, traumatic mydriasis, iris trauma, and anterior capsular tears from penetrating injury. Iridodialysis is typically accompanied by zonular dialysis, and in some cases, vitreous prolapse into the anterior chamber. These videos present a representative sample of approaches to the myriad of problems associated with traumatic cataracts.

Traumatic mydriasis may be as functionally bothersome as the cataract itself. In addition to the cosmetic issues, the functional problems include photophobia, glare, and loss of contrast sensitivity. There is currently no artificial iris technology that is FDA approved.

In contrast to pseudoexfoliation, traumatic zonular dialysis is often localized but associated with an iridodialysis. The same principles of using capsule retractors to stabilize and support the capsular bag apply. Long- term support of the IOL must also be considered. Options include bag implantation with or without a CTR, ciliary sulcus implantation, or use of implantable capsular devices sutured to the sclera.

In addition to extensive iris trauma, penetrating injuries may be associated with tears in the anterior capsule that might not be appreciated initially. These two cases illustrate the unique surgical challenges posed by these eyes, and the principles for repairing the iris defects.