Chopper-Capsular fornix hook technique for severe ectopia lentis

Abstract

Purpose

To describe a simple yet effective method to access the lens in cases of severe ectopia lentis, in which over 50 % of the lens is covered by the dilated pupil. The lens-bag complex is hooked by a chopper peripheral to and just anterior to the equatorial plane and pulled toward the center. The lens-bag complex is centered by the chopper, which allows a continuous curvilinear capsulorhexis to be executed.

Observations

This technique enables access to the lens in cases of extreme subluxation with preservation of the lens-bag complex for intraocular lens placement.

Conclusions and importance

The Chopper-Capsular Fornix Hook Technique can be used to access and maintain the capsular bag by hooking and centering the lens-bag complex in cases of extreme lens subluxation.

HIGHLIGHTS

• •The Severe category of lens subluxation is defined as lens subluxation greater than 50 %.
• •Extreme cases of lens subuxation typically require sacrificing of the capsular bag, pars plana lensectomy, vitrectomy, and out-of-the bag IOL fixation.
• •Pars plana vitrectomy in young patients carries a higher risk for vitreoretinal complications.
• •The Chopper-Capsular Fornix Hook technique is used for Severe lens subluxation to reach the lens-bag complex for in-the-bag IOL placement.

1. Introduction

Ectopia lentis occurs when the crystalline lens is displaced due to poor or absent zonular integrity. In some cases there is localized weakness, and subsequent asymmetric forces on the lens-bag complex results in lens subluxation. Mild lens subluxation can be handled rather routinely; however, when the lens is severely displaced by greater than 50 %, it can be difficult to reach the lens and preserve the capsular bag for IOL implantation.

Out of necessity, in severe cases with an absence of capsule support, lensectomy, capsulectomy, and vitrectomy are performed with IOL fixation; however, this manner of IOL fixation carries a higher risk for long-term complications compared to IOL placement within the capsular bag.¹ Therefore, it is essential to preserve the lens-bag complex when managing lens subluxation.

We describe a novel technique for extreme cases of lens subluxation whereby a chopper is placed around the displaced lens-bag complex, underneath the iris, around the lens capsule just anterior to the capsule fornix and pulled toward the center to expose the lens from underneath the pupil. The lens is held in position with the chopper while the other hand is used to create a continuous curvilinear capsulorhexis. Subsequent lens removal and sutured capsule support system are utilized to achieve a well-centered in-the-bag IOL with preservation of the anterior hyaloid face.

2. Surgical technique

After incisions are made and the anterior chamber filled with dispersive ophthalmic viscosurgical device (OVD, Endocoat, Johnson and Johnson, U.S.A.), a 2.5-mm long, rounded tip, right-angled chopper (Kim Double Chopper, Corza, U.S.A.) is placed using the non-dominant hand through a limbal incision 120–180° away from the dislocated lens-bag complex. Using the non-dominant hand, the chopper is slid under the iris in the quadrant of lens-bag dislocation (Fig. 1a, Fig. 3a). The chopper is positioned just anterior to the capsule fornix and the lens-bag complex is pulled toward the center with the chopper, thereby exposing the lens from under the pupil. While the lens-bag complex is hooked and held in the center with the chopper by the non-dominant, the dominant hand is used to puncture the central anterior capsule (Fig. 2a, Fig. 4aa) either with a sharp tip capsulorhexis forceps, cystitome needle, or 27-gauge needle, and a continuous curvilinear capsulorhexis is achieved (Fig. 2a, Fig. 4ab).

Fig. 1a.

Left eye with Severe superotemporal lens subluxation with over 50 % covered by the dilated pupil. 1b: The chopper is placed through an inferior limbal incision and slid under the iris, on top of the anterior capsule, and into the superotemporal capsule fornix just anterior to the zonules.

Fig. 3a.

Right eye with Severe superotemporal lens subluxation with over 50 % covered by the dilated pupil. 3b: The chopper is placed through a limbal incision nasally and slid under the iris, on top of the anterior capsule, and into the superotemporal capsule fornix just anterior to the zonules.

Fig. 2a.

The chopper is used to pull the lens-bag complex toward the center and hold it in place while a cystitome needle is used to puncture the anterior lens capsule. 2b: The lens-bag complex is held with the chopper while continuous curvilinear capsulorhexis is completed.

Fig. 4a.

The chopper is used to pull the lens-bag complex toward the center and hold it in place while a straight 27-gauge needle is used to puncture the anterior lens capsule. 4b: The lens-bag complex is held with the chopper while continuous curvilinear capsulorhexis is completed.

(Video 2) The lens is aspirated using an automated irrigation and aspiration (I&A) handpiece (Veritas, Johnson and Johnson, U.S.A.). Cohesive viscoelastic is used to inflate the capsular bag. A pre-placed 8–0 Goretex (W.L. Gore and Associates, U.S.A.) suture is threaded through the central eyelet of a capsule tension segment (CTS, MicroSurgical Technology, U.S.A.) ab externo, or the CTS can be placed through the main temporal incision and the suture placed ab interno. With the needle cut, the CTS-Goretex suture complex is positioned with microforceps (23 gauge MST, U.S.A.) within the capsular bag over the area of zonulopathy. A 5-0 silk traction suture is placed contralateral to the area of zonulopathy and the eye is rotated to improve exposure of the conjunctiva in the area of zonulopathy. A peritomy and 3–4 mm partial thickness scleral groove is placed parallel to the limbus and 1.5–2.0 mm posterior to the limbus over the area of zonulopathy. The ends of the scleral groove are made full-thickness with a 1-mm blade. A microforceps is used to grasp one end of the Goretex suture through the main incision and another microforcep is placed through one of the sclerotomies and the suture is hand-shaked and pulled out of the sclerotomy. The same procedure is performed with the other end of the Goretex suture and the suture ends are tightened over the sclerotomy to center the lens-bag complex. More cohesive viscoelastic is injected into the capsular bag and the appropriately sized capsule tension ring (CTR) is injected into the capsular bag. The I&A handpiece is used to remove any remaining cortical material. A single piece acrylic IOL is then injected into the capsular bag. The Goretex suture is tied using a 1-1-1-1 square knot to more easily titrate the suture tension and ensure good centration. The suture should not be overly tight, which can cause erosion of the sclera. The suture knot is then buried within the sclerotomy and the sclerotomies and conjunctiva are closed with 8–0 vicryl suture.

2.1. Case

An 18-year-old Caucasian male with long-standing ectopia lentis in both eyes presented with worsening vision in both eyes. Past medical history was significant for Marfan syndrome, mitral valve prolapse, hypertension, and refractive amblyopia in both eyes. Both father and paternal grandmother had Marfan syndrome. Examination revealed severe ectopia lentis (over 50 % of lens covered under the pupil) in both eyes. Uncorrected distance visual acuity (UCDVA) was 20/400–1 in the right eye and 20/400 in the left eye. Manifest refraction was +4.50 + 4.50x096 in the right eye with 20/100 and + 3.00+4.00x080 in the left eye with 20/200. Intraocular pressure was 13 in the right eye and 11 in the left eye.

Lens removal with in-the-bag IOL placement was performed in the left eye using the Chopper-Capsular Fornix Hook technique to access the lens for CTR, scleral-sutured Goretex CTS, and in-the-bag single piece acrylic IOL. The same procedure was performed one month later in the right eye. Postoperatively, UCDVA was 20/200 in the right eye and 20/200 in the left eye. Manifest refraction was −4.50 + 5.00x096 with 20/200 in the right eye and −6.00 + 5.00x089 with 20/200 in the left eye. Intraocular pressure was 12 in the right eye and 17 in the left eye. The patient has had 1 year of follow-up with stable IOLs and no sign of complication.

3. Discussion

Ectopia lentis can vary in the degree of lens subluxation. Unfortunately, there is no gold-standard grading system. Hoffman et al.² developed the simplest and most relevant system for our technique. Hoffman categorizes 3 broad groups: Mild, Moderate, and Severe. Mild: the lens edge uncovers 0 %–25 % of the dilated pupil; Moderate: the lens edge uncovers 25 %–50 % of the dilated pupil; and Severe: the lens edge uncovers greater than 50 % of the pupil.

Based on Hoffman et al. classification, Mild lens subluxation can be handled fairly easily, similar to routine cataract surgery with preservation of the lens-bag complex. Moderate lens subluxation is more challenging, but the lens can be accessed with capsular retractors and a CTR can be placed to achieve a well-centered in-the-bag IOL.

Our case would be classified as Severe, with over 50 % of the lens covered by the dilated pupil; however, “over 50 %” is a wide range. If there is less Severe dislocation, a partial capsulotomy with placement of capsule retractors to aid capsulorhexis can be performed, along with a CTR±scleral sutured CTS. The decision to place a CTR or sutured CTS depends on the status of the zonules. Focal zonulopathy of less than 3–4 clock hours can be addressed with CTR without CTS, but if there is extensive zonular deficiency, a sutured CTS may be necessary for long-term stability. Placement of a sutured CTS without a CTR lacks circumferential support and would be a concern for future capsule contraction and late IOL decentration; however, if one wishes to place a sutured CTS without CTR, then a three-piece IOL would be favored over a single piece acrylic IOL, due to its additional support.

But in more Severe cases of dislocation like ours, when most of the lens is covered by the iris, it is impossible to reach the anterior capsule to perform continuous curvilinear capsulorhexis using current techniques. Despite special instrumentation, such as iris hooks or capsule retractors, it is a challenge to reach the lens, and any attempt may be met with a peripheral tear in the capsular bag with subsequent vitreous loss and dropped nucleus. As a result, these patients are typically referred to a vitreoretinal surgeon for pars plana lensectomy and vitrectomy. Unfortunately, this strategy in younger patients with a well-formed vitreous carries a higher risk for retinal detachment,³ and other potential complications, including IOL dislocation,4, 5, 6 pupil capture,^6,7 and late IOL decentration.⁸

We describe a novel technique, the Chopper-Capsular Fornix Hook Technique, which is utilized for Severe lens subluxation to preserve the lens-bag complex and anterior hyaloid face. For instrumentation, this method requires only a long, right-angled, rounded tip chopper.

Nonetheless, there are important considerations and nuances to this technique, which involve proper patient selection, planning, and execution. This technique works best for cases of congenital ectopia lentis because these patients are typically younger and, except for the quadrant(s) of zonulopathy, have very strong zonules. Having strong zonules is important for this technique because the chopper is placed in the quadrant of greatest zonular strength, hooking and pulling the lens-bag complex toward the center to overcome the zonular forces that pull the lens-bag complex peripherally. This technique would be less applicable for lens subluxation in the face of diffuse zonulopathy, such as in pseudoexfoliation.

Another reason why this technique is better suited for younger congenital ectopia lentis patients is because the anterior hyaloid face is intact with a solid vitreous, which helps to support the lens-bag complex from underneath, maintaining a stable antero-posterior position. In other words, the technique would be less effective when there is a lack of vitreous support such as after vitrectomy. Hooking the lens-bag complex with the chopper in this context could further strip the remaining zonules, and the lack of zonular stability and vitreous support could cause the lens-bag complex to tilt posteriorly. We were fortunate not to have encountered vitreous loss during our cases, but in the case of vitreous loss, it is important to perform thorough anterior vitrectomy to prevent traction on the retina.

The final reason why this technique is better suited for younger congenital ectopia lentis patients is because their anterior capsules are thicker, stronger, and more elastic than older patients.⁹ Observe the striae within the anterior capsule as the chopper is hooking and pulling the lens-bag complex (Video 1 and 2). The stronger and more elastic anterior capsule in younger patients can tolerate this manipulation; however, utilizing this technique on older patients with thinner, more friable capsules could carry a higher risk for capsule tears from the force of the chopper.

Supplementary video related to this article can be found at https://doi.org/10.1016/j.ajoc.2026.102523

The following is the supplementary data related to this article:

Video 1

Right eye. Using the non-dominant hand, the chopper is placed through a nasal limbal incision ∼120° away from the lens-bag complex. The chopper is then slid under the iris, over the anterior capsule, and across into the superotemporal capsule fornix taking care to stay just anterior to the equator to minimize interaction with the zonules. The chopper is used to pull the lens-bag complex toward the center. As the lens is held by the chopper, the dominant hand is used to puncture the anterior capsule with a 27-gauge straight needle mounted on a syringe full of balanced salt solution (BSS). The needle is exchanged for a 23-gauge microforcep which is used to complete a continuous curvilinear capsulorhexis.1

Video 2

Left eye. Using the non-dominant hand, the chopper is placed through an inferior limbal incision ∼180° away from the lens-bag complex. The chopper is then slid under the iris, over the anterior capsule, and across into the superotemporal capsule fornix taking care just to stay anterior to the equator to minimize interaction with the zonules. The chopper is used to pull the lens-bag complex toward the center. As the lens is held by the chopper, the dominant hand is used to puncture the anterior capsule with a 27-gauge cystitome needle mounted on a syringe full of balanced salt solution (BSS). The needle is exchanged for a microforcep which is used to complete a continuous curvilinear capsulorhexis. Hydrodissection, automated irrigation and aspiration (I&A) of the lens, and in-the bag CTR, Goretex-sutured CTS, and in-the-bag IOL are placed. Vitreous is not encountered throughout the entire case, and a well-centered IOL within the capsular bag is achieved.

Surgical planning is important. The incision for the chopper should be placed 120–180° away from the quadrant of lens-bag subluxation to maximize leverage for the chopper to hook and pull the lens-bag complex. The quadrant of lens-bag subluxation signifies the area of greatest zonular strength, which is why it takes effort to pull the lens-bag complex toward the center using the chopper and why the zonular apparatus in this quadrant can tolerate such manipulation. The decision of where to place the incision for the chopper is not always easy. This is particularly true for right-handed surgeons confronted with a superiorly displaced lens in the right eye (Video 1), since the non-dominant hand needs to be contorted in order to hold the chopper through a nasal incision while the capsulorhexis is executed through a temporal incision.

There are some nuances to the technique. As the non-dominant hand holds the chopper, the maneuvers during capsulorhexis (Video 2) cause the chopper to slip off the lens-bag complex, which then slides back under the iris. The chopper is immediately repositioned to maintain grip on the lens-bag complex. This is a dynamic process that requires constant repositioning of the chopper for control of the lens-bag complex during capsulorhexis. It is important to position the chopper just anterior to the capsule equator to reduce risk to the zonules.

Precise positioning of the chopper is necessary to hook the lens-bag complex safely. The chopper is tilted slightly sideways (Fig. 2a, Fig. 4a) which serves two purposes: to reduce the risk of stripping zonules by positioning the chopper just anterior to the equator, and to improve the grip of the chopper on the lens capsule due to increased contact surface on the anterior capsule.

The Chopper-Capsular Fornix Hook technique is not without risks. Care must be taken to maintain control of the chopper tip to avoid damaging and stripping off more zonules. This technique is best reserved for cataract surgeons experienced with horizontal chopping and comfortable with advanced anterior segment techniques involving two-handed maneuvers. Future development of instruments specifically designed for the technique would be useful to minimize zonular trauma and improve ease of use.

One may argue that the technique is not worth the risk of stripping more zonules, but in our opinion, stripping a few zonules is worth the risk if it means avoiding lensectomy, vitrectomy and the potential for vitreoretinal complications.¹

CRediT authorship contribution statement

Madeleine Eun-Ji Kim: Writing – review & editing, Writing – original draft, Visualization, Validation, Formal analysis, Data curation, Conceptualization. Dooho Brian Kim: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Conceptualization.

Patient consent

Written consent to publish this case has not been obtained. This report does not contain any personal identifying information.

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.

Funding

No funding or grant support.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.