Anterior capsulorhexis opening reduction after cataract surgery with subluxated lenses

Background and objective: This study sought to evaluate anterior capsulorhexis opening (ACO) reductions after surgery for a subluxated lens. Significant reduction of an ACO supports direct zonular involvement (capsular factors excluded by use of capsular tension rings [CTRs] and modern intraocular lens [IOLs]), and these findings question the long-term efficacy of subluxated lens surgery by means of cataract surgery. A small ACO due to lens mobility, non-enlargement of the ACO, and no lens epithelial cell washing due to an additional risk of further zonular damage were left as additional features to evaluate the possible outcomes of this simplified but still complicated surgery.
Materials and methods: Data from 30 patients were used in the final analysis of this prospective study. Phacoemulsifications of subluxated lenses were performed in all patients, and iris/capsule hooks and CTRs or Cionni rings were used as stabilisers of the lens. Photography of the anterior parts (performed at 1 day, 1 week, 1 month, 3 months and 6 months after surgery) was used to evaluate the anterior capsulorhexis openings.
Results: Small initial anterior capsulorhexis openings (13.54 mm²) were achieved, and the area reduction at 6 months was 16.70% (mean area at month 6: 11.28 mm², P < 0.001). The reduction of the ACO area in the pseudoexfoliation (PEX) syndrome patients was 20% relative to the initial size (13.49 mm² vs. 10.92 mm², P < 0.001). Two patients exhibited marked ACO reductions, and both were referred for anterior laser capsulotomy treatment.
Conclusions: A weak or partially absent zonule does not markedly affect the reduction of the anterior capsule opening if appropriate surgical techniques, support materials and IOLs are used, even in the presence of a small initial capsulorhexis opening area. Therefore, a cataract surgery approach on the subluxated lens should be used. Ocular comorbidities, particularly PEX syndrome, play more significant roles in ACO reduction, and appropriate ACO size reducing inhibitors (e.g., anterior laser capsulotomy) or other types of surgery should be used.