JACOB PAPERCLIP CAPSULE STABILIZER (GLUED CAPSULAR HOOK)

Soosan Jacob, MS, FRCS, DNB

Subluxated cataracts may be iatrogenic, post-traumatic, or secondary to ocular or systemic conditions. They can be classified according to etiology as progressive or nonprogressive. Progressive causes include congenital and developmental causes such as Marfan syndrome, homocystinuria, Ehlers-Danlos syndrome, hyperlysinemia, sulfite oxidase deficiency, Weill-Marchesani syndrome, simple primary ectopia lentis, and congenital aniridia syndrome. It also includes degenerative conditions such as pseudoexfoliation, high myopia, prior vitreoretinal surgery, and uveitis. Nonprogressive subluxation may be secondary to trauma or iatrogenic damage during surgery.^1–7

Clinical Examination

The extent of subluxation, integrity of the remaining zonules, prolapse of vitreous into the anterior chamber around the subluxated lens, and degree of dilation of the pupil should be assessed preoperatively. The presence of any other ocular or systemic comorbidities should be ruled out. A dangling cataract may sometimes be seen only when supine. All routine cataract investigations should be performed. Both phakic and aphakic refraction should be performed to assess visual potential depending on if the intraocular lens (IOL) is in the visual axis.

Management Algorithm for Subluxated Cataract

Management may vary from observation to phacoemulsification to pars plana lensectomy. Mild subluxation can cause astigmatism and induced aberrations, whereas more severe subluxation can cause glare, halos, monocular diplopia, and decreased vision. Surgical or nonsurgical management is chosen depending on the patient’s symptoms, the extent of subluxation, and the presence or absence of any complications secondary to subluxation, such as defective vision or glaucoma. A patient with large subluxation not systemically fit or not willing to have surgery may be managed by aphakic correction with spectacles or contact lenses. Miotics may be useful for patients with moderate subluxation. Once surgery is decided upon, an appropriate management plan should be worked out, always keeping in mind and being prepared for any changes in surgical strategy that may have to be made intraoperatively. The following factors should be considered when planning surgery.

EXTENT OF SUBLUXATION

For the sake of management, subluxations may also be classified according to the severity of zonular dehiscence. Dehiscence up to 3 clock hours or 1 quadrant may be managed with capsular expansion with a capsular tension ring (CTR).^8,9 Zonular dehiscence between 4 to 7 clock hours needs capsular expansion together with scleral fixation.^10–15 Greater than 8 clock hours of subluxation may be managed by 1 of 3 ways:

1. Lensectomy16–20/intracapsular cataract extraction^21,22 with anterior chamber IOL/scleral-fixated IOL/iris-fixated IOL
   
2. Capsular expansion with more than 1 point of scleral fixation
   
3. Phacoemulsification followed by a supracapsular glued IOL²³ (Figure 12-1)

Dangling cataracts generally have very tenuous support left, which is likely to give way with minimal intraoperative manipulation, and these are best tackled with lensectomy or intracapsular cataract extraction and the surgeon’s choice for IOL fixation in the absence of a capsular bag.

NATURE OF ZONULOPATHY

Having permanent, stable fixation and avoiding late subluxation of the IOL is important. Therefore, it is necessary to identify the cause of subluxation before deciding on the choice of treatment. In nonprogressive zonulopathy, the bag is retained and fixated to the scleral wall if required. In progressive causes, 1 of the 3 techniques is recommended:

1. Lensectomy/intracapsular cataract extraction with anterior chamber IOL/scleral-fixated IOL/iris-fixated IOL
   
2. Capsular expansion with more than 1 point of scleral fixation
   
3. Phacoemulsification followed by a supracapsular glued IOL

Advantages of Retaining the Capsular Bag

The advantages of retaining the capsule are many. The retention of an intact capsular barrier during surgery allows a purely anterior chamber approach to cataract extraction. Avoiding entry into the vitreous cavity and the ensuing vitreous disturbance are always desirable in cataract surgery. Maintaining the barrier decreases vitreous prolapse and unintended vitreous traction during surgery. Retaining the capsule allows a stable anterior chamber for phacoemulsification, less risk of vitreous aspiration into the phaco probe, and less risk of nuclear fragments or lens material falling into the vitreous during surgery. In the postoperative period, it decreases endophthalmodonesis and thereby the chances of posterior segment complications such as retinal detachment and cystoid macular edema. Avoiding a vitrectomy is especially desirable in eyes that are already at a higher risk of retinal detachment, such as high myopes and Marfan syndrome.^24–29

Devices Available

There are various devices available for the cataract surgeon to choose from. These include the following:

• CTRs
  
• Capsular hooks and retractors
  
• Sutured scleral-fixation devices: Cionni ring, Ahmed segment, Assia anchor, Malyugin CTR, Yaguchi’s T-shaped capsule stabilization hooks
  
• Sutureless scleral-fixation devices: Jacob paperclip capsule stabilizer and the glued capsular hook technique that had been described by the author

For cataracts with greater than 4 clock hours of subluxation, the author’s preference is the paperclip capsule stabilizer.

Device Description

The Jacob paperclip capsule stabilizer is a paperclip-type uniplanar device made of flexible blue polymethylmethacrylate that has a central rounded extension that continues as a flange on either side. It was designed by the author and is manufactured by Morcher GmbH. The width of the device is 2.8 mm and the length is 2.5 mm. The central extension measures approximately 1.9 mm. It also has a 13-mm-long haptic with indentations that allows for a firm grip within a scleral tunnel (Figure 12-2). The body of the device is meant to fixate onto the rhexis rim in a paperclip fashion, and the haptic passes outward through a sclerotomy and is tucked into a 26-gauge scleral tunnel to obtain sutureless fixation of the capsular bag to the scleral wall.

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