Authors: Anthony Fanous¹, Ali Salimi², Harrison Watt¹, Mohammed Abu-Nada¹, Paul Harasymowycz³.
¹Faculty of Medicine, McGill University, ²Department of Ophthalmology, Faculty of Medicine, McGill University, ³Montreal Glaucoma Institute and Bellevue Ophthalmology Clinics.

Author Disclosure Block:A. Fanous: None. A. Salimi: None. H. Watt: None. M. Abu-Nada: None. P. Harasymowycz: Any direct financial payments including receipt of honoraria; Name of for-profit or not-for-profit organization(s); Allergan, Glaukos, Ivantis, Johnson & Johnson Vision, and Alcon.. Any direct financial payments including receipt of honoraria; Description of relationship(s); Consultant.

Abstract Body:

Purpose: Intraocular surgeries in patients with zonular weakness are challenging and are at increased risk of intraoperative and postoperative complications. The prevalence of zonulopathy has been previously reported for the general population; however, the evidence among angle-closure eyes is scarce. The present study aimed to assess the prevalence of zonulopathy among a large cohort of angle-closure eyes that underwent cataract surgery as a stand-alone procedure or combined with glaucoma procedures.
Study Design: Retrospective consecutive case-series.
Methods: This retrospective case-series comprised of angle-closure eyes that underwent phacoemulsification cataract surgery at a single ophthalmology center between 2009 and 2020. Those with known risk factors for zonulopathy such as history of trauma, pseudo-exfoliation syndrome, previous intraocular surgery, retinitis pigmentosa, or connective tissue disorders were excluded. The primary outcomes included the prevalence of zonulopathy assessed intraoperatively and secondary pigment dispersion syndrome (SPDS). Secondary outcomes included postoperative best-corrected visual acuity (BCVA) changes, intraoperative complications, and postoperative adverse events.
Results: A total of 806 eyes of 465 patients with an average age of 65.7±10.7 years were included. Angle-closure diagnoses included primary angle-closure suspects (PACS) in 21%, primary angle-closure (PAC) in 43%, and primary angle-closure glaucoma (PACG) in 36% of the eyes. Intraoperative signs of zonular weakness were evidenced among 59 eyes (7.3% of the cohort), including floppy capsule (29 eyes, 3.6%), zonular laxity (22 eyes, 2.7%), and zonular dehiscence (8 eyes, 1.0%). In our cohort of angle-closure eyes, the prevalence of zonulopathy was significantly greater than the 0.6% to 2.6% range reported for the general population (p<0.001). SPDS was observed in 141 eyes (17.5%). Vision significantly improved from 0.27±0.51 logMAR preoperatively to 0.17±0.39 at the first postoperative month (p<0.001). Among the 59 eyes with zonulopathy, capsular tension ring was used in 23 eyes (39.0%), six eyes (10.2%) experienced vitreous prolapse intraoperatively and underwent anterior vitrectomy, and one eye experienced posterior capsular rupture.
Conclusions: Zonulopathy is an under-recognized pathology that poses an increased risk of intraoperative and postoperative adverse events. The present study evidenced a high prevalence of zonulopathy among angle-closure eyes. Awareness about the prevalence of this pathology in angle-closure coupled with a careful preoperative examination can help minimize or prevent the adverse events associated with zonulopathy.