When zonular compromise or capsular tear is suspected, steps should be taken to facilitate nuclear delivery while minimizing stress on these structures. If nuclear delivery is hindered by a small pupil, then the pupil should be enlarged. This can be accomplished with bimanual pupillary stretching, iris hooks, or relaxing sphincterotomies. If the capsular opening is too small, this too should be enlarged, as described above. The scleral tunnel should also be widened as needed to minimize resistance to nuclear prolapse [29, 32]. In cases of known or suspected posterior capsular tear, cortex removal should be performed with low irrigation, under the cover of viscoelastic, to avoid extension of the tear. In cases of mild to moderate zonular instability, placement of a capsular tension ring (CTR) can be considered, provided that the capsular bag is intact. If zonular dehiscence is more extensive (4 clock hours or more), a scleral-fixated capsular tension segment (CTS) or modified capsular tension ring (MCTR) is indicated [33]. In these cases, attempts should not be made to dial the nucleus out of the bag as this may result in total dislocation of the lens to the posterior pole. Lenses with severe zonular dehiscence are most safely addressed by a vitreoretinal surgeon via a pars plana approach. Where retina support is unavailable, intracapsular extraction with ACIOL or secondary placement of an iris or scleral-fixated IOL is an option.

Alternative nucleus delivery techniques may also employed to reduce stress on weak zonules or a compromised capsule. Venkatesh described a bimanual prolapse technique using a Sinskey hook and a cyclodialysis spatula. The Sinskey hook is placed through the scleral tunnel and used to gently displace the nucleus toward 6 o’clock. Once the superior pole of the nucleus is visualized, the cyclodialysis spatula is positioned beneath the nucleus via the side port incision. Employing the spatula as a fulcrum, the Sinskey hook is used to dial the nucleus out of the capsular bag. This method allows rotational forces to be absorbed by the cyclodialysis spatula, minimizing stress on the capsule and zonules [29]. Variations of this method have been described using different instruments. Fry described a similar technique known as phaco sandwich, utilizing an irrigating vectis for his supporting instrument rather than a cyclodialysis spatula [34].