New sign of anterior zonular dehiscence
A 65-year-old man presented with reduced vision due to a cataract in the left eye. He had sustained a squash ball injury to this eye 20 years previously, which had resulted in a retinal tear, which was treated with laser retinopexy. No further ophthalmic issues arose until he presented with reduced vision. There was no previous occupational exposure that would predispose to anterior capsular abnormalities or any personal or family history of syndromes associated with zonular compromise.

Preoperative uncorrected distance visual acuity was 20/40 in the right eye and 20/80 in the left, improving to 20/30 and 20/40 through a pinhole, respectively. Spherical equivalent was +2.125 diopters (D) and +2.00 D, respectively. The anterior chambers appeared symmetrically deep; there was no pseudoexfoliation material visible. A grade 1 to 2 nuclear cataract was present in the right eye and a grade 3 nuclear cataract in the left, commensurate with the visual acuity. No phacodonesis, iridodonesis, iridodialysis, or abnormality of the anterior capsule was evident. The left pupil was 1 mm less dilated than the right despite pharmacological mydriasis. There was an area of peripheral chorioretinal atrophy in the left eye, consistent with a previous retinal tear, and a partial-thickness (lamellar) macular hole associated with a mild epiretinal membrane. The examination was, otherwise, normal, as was the intraocular pressure. The mean keratometry was 44.65 D and 43.51 D, axial lengths were 24.32 mm and 24.46 mm, anterior chamber depth was 2.96 mm and 2.89 mm, and lens thickness was 4.86 mm and 5.0 mm in the right and left eyes, respectively.

Under the operating microscope, prior to commencement of planned phacoemulsification surgery, a circular, 6.5 mm diameter lesion was noted in the anterior capsule. It was visualized best when trypan blue was irrigated from the anterior chamber. Full-thickness redundancies of the capsule billowed back and forth in response to the jet of irrigation from the paracentesis, but they retained an approximately circular disposition. Phacodonesis and capsular striae were observed during continuous curvilinear capsulorhexis. No splitting or undue friability of the capsule was noted. Furthermore, mild phacodonesis was observed during hydrodissection and nuclear disassembly. The operation, otherwise, proceeded normally. Given the absence of more serious evidence of zonular compromise, it was decided not to use endocapsular support devices or a 3-piece intraocular lens. A 1-piece acrylic aspheric monofocal intraocular lens was inserted in the capsular bag. Care was taken to orient the haptics vertically in the eventuality that scleral fixation was subsequently required.

The patient's postoperative recovery was prolonged by cystoid macular edema that required an additional course of topical corticosteroids and nonsteroidal anti-inflammatory drugs. No similar abnormalities in the anterior capsule were observed at the time of right cataract surgery, which was performed 2 years subsequently. Left uncorrected distance visual acuity at 2 years postoperatively was 20/30 with a spherical equivalent of -0.25 D; the intraocular lens remained stable with no undue development of capsular phimosis.