Reversible ımplantation of capsular tension rings in zonular ınstability using 10-0 nylon sutures

Background: Zonular instability complicates cataract surgery and creates uncertainty about choosing sutureless or sutured capsular tension rings (CTRs). Sutureless CTRs are preferred for mild zonulopathy, while sutured CTRs or segments are favored in advanced cases. Borderline situations, however, lack clear guidelines. This video presents a reversible CTR implantation technique using a temporary 10-0 nylon suture threaded through the trailing eyelet. After CTR and intraocular lens implantation, capsular stability is evaluated. If stable, the suture is removed, leaving the CTR in place; if unstable, the CTR can be safely retrieved. This reversible approach enhances flexibility, safety, and real-time surgical decision-making. Purpose: Management of zonular instability during cataract surgery remains challenging. Current literature suggests employing a sutureless capsular tension ring (CTR) in cases of mild diffuse zonular weakness or focal zonular weakness extending fewer than 3 clock hours. 1 However, in scenarios with eyes with advanced zonular weakness, more than 4 clock hours of zonular loss, or progressive zonulopathy, or sutured CTR or segments are recommended to enhance stability. 2 Nevertheless, precise criteria defining indications for sutured versus sutureless CTR are often ambiguous, complicating intraoperative decision-making. Synopsis: This video introduces a reversible implantation technique of CTRs, particularly beneficial in borderline cases. Initially, an appropriately sized, sutureless CTR is selected based on the white-to-white and axial length. A 10-0 nylon suture is threaded through the CTR’s trailing terminal eyelet before implantation. The CTR is gently implanted into the capsular bag utilizing a push–pull maneuver to minimize mechanical stress on compromised zonules, thereby aiming to reduce the risk of further zonular damage. Following insertion, capsular stability is carefully evaluated. If the capsular bag demonstrates sufficient stability, an intraocular lens (IOL) is subsequently implanted. Stability is then reassessed post IOL implantation. Provided adequate stability is maintained, the temporary 10-0 nylon suture is easily removed by severing one end and gently extracting the suture from the CTR. The reversible nature of this method significantly enhances surgical safety. If capsular instability is encountered after CTR and IOL placement, the nylon suture allows effortless removal of both implants without additional trauma. Consequently, this approach provides valuable intraoperative flexibility, enabling dynamic decision-making based on real-time capsular stability assessments. In addition, in some cases, it may be necessary to implant a CTR in the early stages of surgery. 1 It may also be necessary to remove these CTRs due to a complication that may occur after implantation (posterior capsule rupture, disruption of the CCC). Highlights: Suture-guided CTR insertion has been described with variations in suture placement and purpose. Sethi and Naik proposed forceps-assisted, 10-0 nylon suture-guided insertion for controlled distal eyelet placement and safe retrieval in subluxated cataracts. 3 Similarly, Oudjani et al . 4 introduced CTRs with a knotted thread to permit removal at the end of surgery. In conclusion, this reversible CTR implantation technique offers ophthalmologists a practical and safe way to manage variable cases of zonular instability. It facilitates intraoperative decision-making and reduces potential complications associated with zonular compromise. Video Link: https://youtu.be/u5aS-RpkjJ8