CASE REPORT

Management of subluxated cataract

with capsule anchor implantation
Peter Mojzis, MD, PhD, FEBO, Peter Ziak, MD, PhD, David P. Pi~
nero, PhD

We describe a small case series that provides preliminary evidence of the usefulness of a new
capsule-anchoring device for the management of subluxated cataracts. Three eyes of 3 patients
with traumatic subluxated cataract causing a significant visual loss were enrolled. Phacoemulsi-
fication was performed in all cases with implantation of a capsule-anchoring device (AssiAnchor)
because partial zonular dehiscence was present. A significant visual improvement was achieved in
the 3 cases. The capsular bag was well centered and the anchors firmly attached to the
capsulorhexis and sclera at 12 months postoperatively. The capsule-anchoring device was helpful
in managing traumatic subluxated cataracts, enabling effective centration of the intraocular lens–
capsular bag complex and, consequently, effective visual restoration.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
JCRS Online Case Reports 2015; 3:63–67 Q 2015 ASCRS and ESCRS
Online Video

Phacoemulsification surgery in cases of subluxated (IOL).7 In more extensive cases of lens subluxation, en-
cataract following blunt injury is considered a complex docapsular rings combined with fixation hooks or cap-
and challenging procedure.1 In these cases, the surgi- sular tension segments and secured to the sclera are
cal management may lead to many complications, in- used.8 Complications such as anterior capsule tear
cluding lens dislocation into the vitreous cavity, with progression to radial tear at the posterior capsule,
vitreous loss with retinal detachment, and expulsive risk for iatrogenic zonular dehiscence, iritis, corecto-
hemorrhage.1–4 Iris hooks provide only temporary pia, and broken fixation sutures have been reported
stabilization of the lens capsule during surgery.5 with these devices.9 Recently, another capsule-
However, other devices have shown long-term effi- supporting device, the capsule anchor (AssiAnchor
cacy in preserving the capsular bag in eyes with sub- [Hanita Lenses]) (Figure 1), was developed for moder-
luxated cataracts.6 In cases with mild zonular defect, ate and severe crystalline lens subluxation. The aim of
capsular tension rings (CTRs) implanted before or after this small case series was to provide preliminary evi-
cataract surgery are able to stabilize the capsular bag dence of the usefulness of the capsule anchor in the
and enable proper insertion of the intraocular lens management of subluxated cataracts.

PATIENTS AND METHODS

Submitted: February 25, 2015. Patients
Final revision submitted: March 31, 2015. Three eyes of 3 patients were enrolled in the case series. In-
Accepted: April 1, 2015. clusion criteria were patients with significant subluxated cat-
aract (greater than 1 quadrant and approximately greater
From the Premium Clinic (Mojzis, Pi~nero), Teplice, and the Eye
than 4 clock hours with or without vitreous prolapse into
Department of Regional Hospital (Mojzis), Havlickuv Brod, Czech the anterior chamber), history of blunt trauma, visual deteri-
Republic; the Eye Clinic of Jessenius Faculty of Medicine (Ziak), oration, significant refractive astigmatism induced by a crys-
Martin, Slovakia; and the Department of Optics, Pharmacology talline lens subluxation, and age more than 18 years.
and Anatomy (Pi~nero), University of Alicante, Alicante, Spain. Exclusion criteria were patients with previous ocular sur-
gery, history of penetrating trauma including retinal detach-
Corresponding author: David P. Pi~nero, PhD, Department of Optics, ment, choroidal hemorrhage, corneal injury, and abnormal
Pharmacology and Anatomy, University of Alicante, Carretera San iris. No patient was excluded preoperatively, and only 1 pa-
Vicente del Raspeig s/n, 03690 San Vicente del Raspeig, Alicante, tient was excluded after surgery because of the presence of
Spain. E-mail: david.pinyero@ua.es. a mature luxated cataract with posterior capsule rupture

Q 2015 ASCRS and ESCRS 2214-1677/$ - see front matter 63

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcro.2015.05.003
64 CAPSULE ANCHOR IMPLANTATION FOR SUBLUXATED CATARACTS

during phacoemulsification. The nucleus density of the nu-

cleus was graded as 3 or 4 in all cases according to the
Lens Opacification Classification System III.10 All patients
were adequately informed and signed a consent form. The
study adhered to the tenets of the Declaration of Helsinki
and was approved by the local ethics committee.

Preoperative and Postoperative Examination

Preoperatively, all patients had a complete ophthalmo-
logic examination including uncorrected (UDVA) and cor-
rected (CDVA) distance visual acuity, Goldmann
applanation tonometry, slitlamp examination with assess-
ment of the zonular defect, corneal topography and ocular
aberrometry (OPD Scan III, Nikek Co., Ltd.), optical
biometry (IOLMaster v.4.3, Carl Zeiss Meditec AG), and fun-
doscopy. Postoperatively, patients were evaluated at 1 day,
1 month, 6 months, and 12 months. In some cases, a longer
follow-up was achieved. At 1 day, only the UDVA, intraoc-
ular pressure (IOP), and integrity of the anterior segment
were evaluated. The postoperative examination protocol
was identical to the preoperative protocol, with additional
analysis of the IOL position by optical coherence tomogra-
phy (OCT) (Visante, Carl Zeiss Meditec AG).

Surgical Technique
All surgeries were performed by the same experienced
surgeon (P.M.) using a standard technique of sutureless co-
axial phacoemulsification with the Infiniti Vision System
and the Ozil handpiece (Alcon Surgical, Inc.). A combination
of topical drops and retrobulbar anesthesia was used in all
cases. Adequate dilation was obtained with preoperative
mydriatic drops, and a 2.6 mm clear corneal incision was
performed. Trypan blue was injected into the anterior cham-
ber to improve visualization during creation of the capsulo-
rhexis and to facilitate insertion of the capsule-anchoring
device beneath the anterior capsule. A careful anterior vitrec-
tomy with the Ultravit system (Alcon Surgical, Inc.) was per-
formed to release the vitreous traction in the area of zonular
dialysis. After the vitrectomy, the anterior chamber was
filled with a cohesive ophthalmic viscosurgical device
(OVD) (sodium hyaluronate 1%–chondroitin sulfate 4%
[Provisc]) to maintain an adequate anterior chamber depth
during surgery and a curvilinear capsulorhexis with a diam-
eter between 4.0 mm and 5.0 mm was made using a forceps.
At the location of the cataract subluxation, a peritomy was
performed and a scleral flap created. A double-armed
10-0 polypropylene (Prolene) suture was inserted through
the scleral wall to the anterior chamber. Polypropylene
10-0 was selected for its easy manipulation, knotting, and
biocompatibility. Before the capsule-anchoring device was
secured, a partial-thickness scleral flap was created to avoid
exposing suture knots; this prevented conjunctival irritation.
The flap was created with a diamond blade at a depth of one
third the scleral thickness. A 27-gauge needle was used as
a guide to externalize the suture through a paracentesis in
the opposite side. In the same manner, a suture needle was
Figure 1. Implantation of the capsule-anchoring device in a conven- reinserted into the anterior chamber to create a loop. The cor-
tional phacoemulsification procedure. Top: Insertion of the device tical separation from the anterior capsule by hydrodissection
through a 2.5 mm corneal incision. Middle: Clipping of the device facilitated insertion of the device (Video 1).
to the capsule. Bottom: Phacoemulsification surgery with implanta- The capsule-anchoring device was implanted through the
tion of the IOL after implantation of the device. 2.6 mm clear corneal incision (Figure 1). Before implantation

JCRS ONLINE CASE REPORTS - VOL 3, JULY 2015

 CAPSULE ANCHOR IMPLANTATION FOR SUBLUXATED CATARACTS 65

was started, a safety suture through the proximal hole was Case 2
used. After successful fixation, the safety suture was ex-
tracted. The proximal part (handle) of the anchor was maneu- A 55-year-old man attended our clinic after blunt injury to
vered beneath the capsulorhexis edge, which was one of the his right eye. He complained of decreased visual acuity
most complex steps of the surgical procedure. After this, the immediately after the trauma. On examination, the CDVA
distal part (base) was placed in the loop to center the lens. A was 0.30 logMAR (objective refraction, 0.50 2.00  121;
Sinskey hook and a 23-gauge vitreoretinal forceps were used keratometry, 44.75 @ 178/45.50 @ 88) and the IOP was
to facilitate insertion of the anchoring device. After this, the 27 mm Hg. The anterior chamber was deeper in the nasal
device was sutured at 1.5 mm from the corneal limbus. region, and iridophacodonesis was present with prolapsed
A gentle flow of a balanced salt solution from the syringe vitreous into the anterior chamber. The traumatic cataract
was used to release the trapped cortex, and then the cortex was displaced temporally and decentered, with nasal zonu-
was carefully aspirated using bimanual irrigation/aspira- lar dehiscence extending from 12 o’clock to 6 o’clock
tion cannulas. After uneventful phacoemulsification, a CTR (Figure 2). The subluxated capsular bag was centered using
(Tensiobag, Carl Zeiss Meditec AG) was inserted to restore 2 capsule-anchoring devices placed at 1 o’clock and 4 o’clock.
the contour of the capsule. An IOL (1-piece or 3-piece Acry- At 19 months, the CDVA was 0.00 logMAR (objective
sof IOL, Alcon Surgical, Inc., or 1-piece CT47S, Carl Zeiss refraction, 0.50 0.75  143; keratometry, 44.75 @ 175/
Meditec AG) was implanted in the capsular bag through 45.75 @ 85) and the IOP was 18 mm Hg. At the last postop-
the main incision using the Royal injector (ASICO LLC) erative visit, an insignificant corectopia was present, the
and cartridge “B” or “C” or the AT.Smart cartridge set IOL implanted in the capsular bag was well centered
(Carl Zeiss Meditec AG) and the AT.Shooter A1-2000 injector (Figure 3), and the 2 anchors were firmly attached to the cap-
(Carl Zeiss Meditec AG). At the end of surgery, the OVD was sulorhexis and sclera (Figure 2).
evacuated using bimanual aspiration cannulas. Postopera-
tive topical therapy included a combination of topical antibi- Case 3
otic and steroids. A 45-year-old man attended our clinic with a recommen-
dation for cataract extraction. The cataract had been induced
by blunt trauma to the left eye and generated poor vision and
Capsule-Anchoring Device elevated IOP. On examination, the CDVA was 0.50 logMAR
The AssiAnchor is made of poly(methyl methacrylate) (objective refraction, C0.25 1.25  23; keratometry, 41.25 @
(PMMA) (Figure 1). The shape is similar to that of a paperclip, 179/43.25 @ 89) and IOP was 28 mm Hg. On slitlamp exam-
consisting of 2 proximal arms (handle) allowing firm grasp- ination, a mild reaction in the anterior chamber with signifi-
ing of the capsulorhexis edge beneath the anterior capsule cant iridophacodonesis was present. The traumatic
and 2 distal arms (base) with a hole securing the transscleral subluxated cataract was displaced and decentered, with ex-
fixation using a 9-0 or 10-0 polypropylene suture. The prox- tension of the zonular dehiscence from 1 o’clock to 5 o’clock
imal hole is used as a temporary safety suture to prevent cap- (Figure 2). To maintain the proper position of the capsular
sule dislocation into the vitreous cavity. The single-piece bag, a capsule-anchoring device was implanted at the
device has an overall length of 3.00 mm and a width of 3 o’clock position. A mild postoperative inflammation was
2.48 mm. The anchor can be implanted before or after re- present in the initial postoperative period, resulting in
moval of the crystalline lens. Depending on the magnitude posterior synechiae in the upper part of the iris. At 12 months,
of the crystalline lens subluxation, 1 or more devices can be the CDVA was 0.10 logMAR (objective refraction, C0.75
inserted. The capsule-anchoring device enables cataract sur- 1.25  21; keratometry, 41.25 @ 177/42.75 @ 87) and the
gery of a subluxated lens, centers the subluxated capsule, IOP was 14 mm Hg. Significant fibrosis of the anterior cap-
and provides wide contact between the device and the ante- sule was observed, although the IOL–capsular bag complex
rior capsule. was well centered. The anchor was not visible because of the
posterior synechiae (Figure 2).

CASE REPORTS DISCUSSION

The capsule anchor was developed to manage sublux-
Case 1
ated cataracts. It faciliates creation of a centered IOL–
A 60-year-old woman with a history of blunt injury to her capsular bag complex and therefore effective visual
left eye 6 months earlier attended our clinic with complaints
of blurred vision. On examination, the CDVA was 0.30 log- restoration. Intraocular lens decentration has been
MAR (objective refraction, 1.25 2.75  56; keratometry, shown to be associated with a significant degradation
43.25 @ 17/43.75 @ 107) and the IOP was 16 mm Hg. On sli- of the retinal image.11 The combination of IOL decen-
tlamp examination, a clear cornea, deep anterior chamber, tration and tilt induces an unpredictable refractive er-
and iridophacodonesis with prolapsed vitreous into the an- ror that depends on the relationship between the
terior chamber were observed. A traumatic cataract slightly
displaced anteriorly and decentered was observed, with geometric axes of the decentration and tilt.12 Further-
temporal zonular dehiscence from 2 o’clock to 5 o’clock more, IOL tilt influences the level of ocular coma-like
(Figure 2). A capsule-anchoring device was implanted at aberrations.13 The current small case series describes
the 3 o’clock position. No postoperative inflammation was 3 cases of subluxated cataract in which the use of the
observed. At 24 months, the CDVA was 0.00 logMAR (objec- capsule anchor provided a successful outcome. To
tive refraction, 0.00 0.50  10; keratometry, 43.00 @ 7/44.15
@ 97) and the IOP was 19 mm Hg. The IOL and the capsular our knowledge, this small case series is the first scien-
bag were well centered (Figure 3), and the anchor was firmly tific evidence of the usefulness of the capsule anchor
attached to the capsulorhexis and sclera (Figure 2). for the management of subluxated cataracts.

JCRS ONLINE CASE REPORTS - VOL 3, JULY 2015

66 CAPSULE ANCHOR IMPLANTATION FOR SUBLUXATED CATARACTS

Figure 2. Frontal image of the anterior segment in the 3 cases obtained by slitlamp biomicroscopy preoperatively and postoperatively.

In the 3 cases evaluated, the capsule anchor The first scientific evidence of the usefulness of a cap-
achieved centration of the capsular bag and, conse- sule anchor for management of a subluxated lens was
quently, of the IOL, which was easily visualized and reported by Ton et al.14 The authors developed and
confirmed by OCT. The proximal arms of the capsule tested experimental models of a PMMA 1-plane intra-
anchor were in contact with the capsulorhexis edge, ocular anchoring device consisting of 2 handles that
and the distal arms were secured to the scleral wall. grasp the edges of the capsulorhexis and a base for
The lateral arms of the proximal part of the anchor cre- scleral fixation with a single 10-0 or 9-0 polypropylene
ated a large contact area with the capsule, and the tips suture. They implanted this device in porcine eyes and
supported the capsule equator. Transscleral fixation living rabbit eyes in which lens subluxation was
enabled stabilization of the anterior capsule. The achieved by tearing about one third of the zonular fi-
mechanism of action of the capsule anchor provided bers. The study confirmed the safety and efficacy of
effective centration of the IOL–capsular bag complex. the device in the experimental animal models.14 Two
In more severe or complex cases, CTRs can be im- years later, the same research group reported the
planted along with the capsule anchor to restore and outcomes of implanting a similar anchoring device in
maintain the circular contour of the capsular bag. 2 patients with traumatic subluxated lenses and 2 pa-
tients with Marfan syndrome.15 They found that the
capsule-anchoring device was effective in fixating the
lens capsule to the scleral wall in those cases of signifi-
cant zonular dehiscence. We also observed successful
management of subluxated cataracts caused by blunt
trauma using the new capsule-anchoring device. In
our 3 cases, no significant complications occurred dur-
ing the follow-up period. Therefore, the capsule anchor
can be considered an additional option for the manage-
ment of subluxated cataract. Future studies evaluating
the performance of these devices in larger sample sizes
and during a longer follow-up should be conducted.
In our 3 cases, effective centration of the IOL–capsu-
lar bag complex was the main factor in the excellent vi-
sual outcomes. This is consistent with the results in
Figure 3. Position of the IOL in Cases 1 and 2 visualized by OCT. previous case reports and case series evaluating the

JCRS ONLINE CASE REPORTS - VOL 3, JULY 2015

 CAPSULE ANCHOR IMPLANTATION FOR SUBLUXATED CATARACTS 67

management of subluxated cataract with various tech- 2. Chee S-P, Jap A. Management of traumatic severely subluxated
niques or devices.2–5,7,9 Chee and Jap2 preserved the cataracts. Am J Ophthalmol 2011; 151:866–871

3. Gonza  lez-Castan
~o C, Castro J, Alvarez-S  nchez M. Subluxa-
a
capsular bag in a group of eyes with traumatic sublux- tion of the lens: etiology and results of treatment. Arch Soc
ated cataract with the aid of a Cionni modified CTR in Esp Oftalmol 2006; 81:471–478. Available at: http://www.
36 eyes (87.8%) and a combination of a capsular ten- oftalmo.com/seo/archivos/maquetas/0/3CCFFA43-B97E-8328-
sion segment (CTS) and a CTR in 2 eyes. In that case DAB2-00007189AE80/articulo.pdf. Accessed April 2, 2015
series, only 9 of the 41 eyes (22.0%) had a preoperative 4. Praveen MR, Vasavada AR, Singh R. Phacoemulsification in
subluxated cataract. Indian J Ophthalmol 2003; 51:147–154
CDVA of 20/40 or better compared with 38 eyes at the 5. Santoro S, Sannace C, Cascella MC, Lavermicocca N. Sublux-
last visit (92.7%, P ! .001). Santoro et al.5 evaluated ated lens: phacoemulsification with iris hooks. J Cataract
the outcomes in 5 cases of subluxated cataract that Refract Surg 2003; 29:2269–2273
was managed using 4 or 5 disposable nylon iris hooks 6. Taskapili M, Gulkilik G, Kocabora S, Yilmazli C, Ozsutcu M. The
placed on the capsulorhexis edge. The mean decimal capsular tension ring in eyes with traumatic subluxated cata-
racts: a comparative study. Ann Ophthalmol 2008; 40:147–151
visual acuity improved significantly with surgery, 7. Ma X, Li Z. Capsular tension ring implantation after lens extrac-
from 0.26 G 0.18 (SD) to 0.68 G 0.33 (P ! .001).5 Va- tion for management of subluxated cataracts. Int J Clin Exp
savada et al.9 reported that the CDVA improved in Pathol 2014; 7:3733–3738. Available at: http://www.ncbi.nlm.
35 of 41 eyes (85.4%) in which phacoemulsification nih.gov/pmc/articles/PMC4128984/pdf/ijcep0007-3733.pdf. Ac-
surgery was combined with implantation of Cionni cessed April 2, 2015
8. Moreno-Montan ~e
s J, Sainz C, Maldonado MJ. Intraoperative
modified CTRs for the management of subluxated cat- and postoperative complications of Cionni endocapsular ring im-
aracts. In our 3 cases, a significant improvement in plantation. J Cataract Refract Surg 2003; 29:492–497
CDVA was achieved, with 2 of the cases achieving 9. Vasavada AR, Praveen MR, Vasavada VA, Yeh R-Y,
0.00 logMAR postoperatively and 1 achieving 0.10 Srivastava S, Koul A, Trivedi RH. Cionni ring and in-the-bag in-
logMAR. Therefore, adequate centration of the IOL traocular lens implantation for subluxated lenses: a prospective
case series. Am J Ophthalmol 2012; 153:1144–1153
was achieved in all 3 cases. As previously stated, 10. Chylack LT Jr, Wolfe JK, Singer DM, Leske MC, Bullimore MA,
IOL decentration or tilting would have induced a sig- Bailey IL, Friend J, McCarthy D, Wu S-Y; for the Longitudinal
nificant deterioration of the visual acuity and Study of Cataract Study Group. The Lens Opacities Classification
quality.11,12 System III. Arch Ophthalmol 1993; 111:831–836. Available at:
The aim of our small case series was to provide ev- http://www.chylackinc.com/LOCS_III/LOCS_III_Certification_files/
LOCS_III_Reprint_pdf.pdf. Accessed April 2, 2015
idence of the clinical usefulness of capsule anchors in 11. Kumar S, Miller D. Effect of intraocular lens decentration on
cases of subluxated cataract. The potential benefit of retinal image contrast. J Cataract Refract Surg 1990; 16:712–714
these devices over others, such as CTRs, is being eval- 12. Korynta J, Bok J, Cendelin J, Michalova K. Computer modeling
uated and should be clarified in future studies compar- of visual impairment caused by intraocular lens misalignment.
ing the results obtained with the capsule anchor and J Cataract Refract Surg 1999; 25:100–105
13. Taketani F, Matsuura T, Yukawa E, Hara Y. Influence of intraoc-
those obtained with devices such as CTRs. This clarifi- ular lens tilt and decentration on wavefront aberrations.
cation will allow the clinician to know the advantages J Cataract Refract Surg 2004; 30:2158–2162
and disadvantages of each device for the management 14. Ton Y, Michaeli A, Assia EI. Repositioning and scleral fixation of
of subluxated cataract. It should be mentioned that the the subluxated lens capsule using an intraocular anchoring de-
main advantage of the AssiAnchor from our perspec- vice in experimental models. J Cataract Refract Surg 2007;
33:692–696
tive is that it provides stabilization of the capsular 15. Assia EI, Ton Y, Michaeli A. Capsule anchor to manage sublux-
bag before the phacoemulsification process, enabling ated lenses: Initial clinical experience. J Cataract Refract Surg
successful insertion of the IOL in the subluxated cap- 2009; 35:1372–1379
sular bag, even one with a CTR.
First author:
REFERENCES Peter Mojzis, MD, PhD, FEBO
1. Hoffman RS, Snyder ME, Devgan U, Allen QB, Yeoh R, Braga- Premium Clinic, Teplice, Czech
Mele R; for the ASCRS Cataract Clinical Committee; Challeng- Republic
ing/Complicated Cataract Surgery Subcommittee. Management
of the subluxated crystalline lens. J Cataract Refract Surg 2013;
39:1904–1915

JCRS ONLINE CASE REPORTS - VOL 3, JULY 2015