Dr. Kim describes his stepwise approach to handling a displaced crystalline lens and shares pearls for achieving an optimal outcome.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step1.jpg)
1. The central cornea is marked with a 6-mm corneal ring to help guide the sizing of the capsulorhexis.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step2.jpg)
2. A cystotome is used to perform a sharp puncture technique of the anterior capsule to minimize zonular stress.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step3.jpg)
3. The capsulorhexis appears to be decentered toward the right, but it is correctly centered over the capsular bag. The capsulorhexis diameter size is planned for less than 6 mm to provide adequate anterior capsular rim support for a capsular tension ring (CTR) and sutured capsular tension segment (CTS).
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step4.jpg)
4. The Kim right angle hydrodissection cannula (Katena) is placed into the capsular fornix with the tip pointed downward, and a consistent and easy flowing dissection wave occurs. The lens is then massaged, and the capsular bag is decompressed to reduce the risk of capsular block.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step5.jpg)
5. The same cannula is used to simultaneously sweep underneath the anterior capsulorhexis edge while pulsing streams of balanced salt solution to loosen the lens in a controlled manner on both sides. The lens is then emulsified.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step6.jpg)
6. The phaco handpiece is withdrawn, and a cannula is used to inject balanced salt solution through a paracentesis incision in order to maintain IOP and minimize potential prolapse of vitreous into the anterior chamber.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step7.jpg)
7. Pulling cortex toward the center causes more focal stress on the zonules. The cortical remnants therefore are teased from the capsule using a gentle tangential sweeping motion from side-to-side to reduce zonular stress. An OVD is injected to prevent vitreous prolapse before the I/A handpiece is withdrawn.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step8.jpg)
8. A CTR is loaded into the injector and inserted through the main incision. The leading eyelet of the CTR is grasped with the Sinskey hook through a paracentesis incision and, as the CTR is delivered, the Sinskey hook is used to pull the CTR toward the surgeon to minimize torsional traction on the zonules.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step9.jpg)
9. A three-piece IOL is placed within the capsular bag. A Maltzman hook is used in attempt to gently dial the haptics into the bag. The lens remains decentered.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step10.jpg)
10. The zonules are inadequate on the left side. A traction suture is used to rotate the eye toward the right to better expose the left side of the sclera for suture fixation. A peritomy is then performed, and light cautery is applied to the area.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step11.jpg)
11. A diamond blade is used to create a partial-thickness scleral groove parallel to the limbus. A 7-0 (CV-8) Gore-Tex suture needle is threaded through the eyelet of a CTS and carefully placed through the main incision with microforceps.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step12.jpg)
12. A micrograsper is placed through a contralateral paracentesis incision to hold and tuck the CTS underneath the anterior capsule edge and into the capsular bag. A micrograsper is then placed straight down through the sclerotomy before turning toward the center to avoid hitting the ciliary body. A second micrograsper is placed through the main incision and, with a handshake technique, one suture end is passed to the forceps within the sclerotomy to externalize the suture end.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step13.jpg)
13. The handshake technique is performed with the other end of the suture. It is passed from the main incision to the other sclerotomy, and the suture end is externalized.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step14.jpg)
14. A single-throw slipknot allows the suture tension to be adjusted. After the appropriate tension is determined, a few more throws are passed and cinched tightly to lock the suture. The knot is buried through the sclerotomy, and the sclerotomies are closed with 8-0 polyglactin (Vicryl, Ethicon) sutures in an interrupted fashion on each side. The conjunctiva is then closed with the same 8-0 polyglactin sutures.
![](https://crstoday.com/wp-content/uploads/sites/4/2022/01/Kim_Step15.jpg)
15. Irrigation and aspiration are performed a second time, and the OVD is removed. The I/A tip is used to tap the IOL to confirm the stability of the capsular bag. Finally, the wounds are hydrated.