Background: Marfan’s syndrome is an inherited connective tissue disorder with characteristic ocular manifestations, including lens subluxation, high myopia, and retinal detachment. Severe zonular weakness often leads to inadequate capsular support, making cataract surgery particularly challenging. The use of modified Cionni capsular tension ring (CTR) enhances capsular stabilization through scleral fixation of the capsular bag, thereby allowing in-the-bag intraocular lens (IOL) implantation even in cases with severe zonular weakness. Purpose: To demonstrate the surgical technique and outcomes of phacoemulsification with scleral-fixated modified Cionni CTR in a patient with near 360-degree zonular weakness. Synopsis: A 38-year-old female with Marfan syndrome presented with progressive bilateral blurring of vision and diplopia for six months. Best-corrected visual acuity (BCVA) was 6/60 in both eyes. Anterior segment examination revealed a cataractous lens with nearly 360° zonular weakness, while fundus evaluation was within normal limits. Capsulorhexis was performed using rhexis forceps, followed by placement of capsular hooks to support the capsular bag. Phacoemulsification was done to remove the cataractous lens. A modified Cionni CTR was inserted into the capsular bag, and the ring’s eyelet was pre-sutured using 6-0 Prolene suture and externalized using a 26-gauge needle. The suture was flanged and buried within the scleral tract. This maneuver provided a capsular bag, stabilization, allowing successful in-the-bag implantation of a posterior chamber IOL. The postoperative course was uneventful. The fellow eye was operated on with the same technique. At one-month follow-up, the patient achieved unaided visual acuity of 6/6 in both eyes. Discussion: Cataract surgery in Marfan syndrome is challenging due to severe zonular weakness and lens instability. The modified Cionni CTR allows preservation and stabilization of the capsular bag—an advantage not shared by alternative fixation methods. Cionni CTR redistributes zonular tension and anchors the capsule to the sclera, enabling safe in-the-bag IOL placement with long-term centration. Maintaining the native capsular support, it offers more physiological lens positioning and prevents vitreous disturbance. 1 In comparison, the glued IOL provides excellent stability in the absence of capsular support but sacrifices the natural bag and carries risks of haptic extrusion or tilt. The iris-claw IOL, particularly in the retropupillary position, achieves good centration but depends on iris tissue, with risk of disenclavation or chronic inflammation. The Yamane technique offers sutureless scleral fixation with good outcomes but lacks capsular preservation, increasing the risk of IOL tilt or vitreous traction. It also has a learning curve. 2-4 Highlights: The video demonstrates a minimally invasive technique for achieving stable, in-the-bag IOL placement in a case of cataract with severe zonular weakness. Integrity of the capsular bag is preserved along with IOL centration, preventing vitreous disturbance. Video Drive Link: https://youtu.be/mqmfO9t7bgc
Kelkar et al. (Thu,) studied this question.