Eyeworld

24 | EYEWORLD | SEPTEMBER 2020 SKILL FOCUS ATARACT C by Ellen Stodola Editorial Co-Director W hen preparing to inject a single- piece IOL, there are several potential issues that may arise during the process. Experts dis- cussed some of these and how they routinely handle them. What's the best way to stabilize the eye during injection? Do you prefer twist injectors or push injectors? According to D. Brian Kim, MD, the best way to stabilize the eye is to use a second instrument inside the sideport incision to provide counter- traction to inject the IOL. The sideport is ideal because it is about 90 degrees away from the main incision and allows him to move the eye to assist with IOL injection. "I don't recommend grasping the limbal tissue with 0.12 forceps since this could cause trauma," Dr. Kim said. Dr. Kim thinks surgeons make decisions based on which IOL they prefer, not which injector they prefer. In addition, some surgeons may not have a choice if the ASC or hospital only offers certain IOLs. John Davidson, MD, noted that he has preferred the single-handed injector to the two-handed screw-type twist injector for nearly 20 years because the single-handed injector al- lows him to stabilize the eye with the non-dom- inant hand with a second instrument in the secondary incision. This keeps the eye in the primary position while you're injecting the lens, he said, and gives control over the eye. You can watch the lens glide under the nasal leaflet of the anterior capsule, ensuring placement in the bag. With the two-handed injector, Dr. David- son said, you can't stabilize the eye and end up having to push the globe nasally and often cannot visualize delivery of the lens in the bag, which is especially important in small pupil cases. Robin Vann, MD, said stabilizing the eye depends on the kind of IOL injector being used. He has experience with the Alcon UltraSert. The plunger is advanced best with the thumb, he said, but this can also induce torque. "I've found using a second instrument in my sideport incision helps stabilize the eye from the torque motion when I use my thumb to advance the plunger for injecting it into the eye," he said. Discussing different injector types, Dr. Vann said the push injector is nice, but if thumb-driven, he doesn't like the torque. "From a stabilization standpoint and ability to get the lens into the eye as easily as possible, I prefer a twist injector," Dr. Vann said. He noted that the twist injector plunger advancement doesn't come preloaded in the monofocal lens that he prefers, so that's why he often uses the push injector. Alcon has a pre- loaded injector, AutonoMe, that advances the Pearls for injecting single-piece IOLs About the doctors John Davidson, MD Director of refractive/ lens replacement surgery Miramar Eye Specialists Medical Group Ventura, California D. Brian Kim, MD Partner Professional Eye Associates Clinical assistant professor of ophthalmology Medical College of Georgia Augusta, Georgia Robin Vann, MD Medical director Duke Eye Center Operating Rooms Durham, North Carolina How much larger than the cartridge should the corneal incision be? Dr. Kim provided general guidelines for the Alcon SN60WF AcrySof IOL using the Monarch injector system, A being the largest cartridge and D being the smallest: D cartridge: 2.2–2.6 incision C cartridge: 2.6–3.0 incision B cartridge: 3.0–3.2 incision A cartridge: 3.2–3.4 incision The only exception to this rule, he said, is for high-powered IOLs 28 D or great- er, which require the B cartridge. Since these high powered IOLs are thicker, the surgeon will need to widen the incision if it is less than 3.0 mm. Dr. Kim makes a 2.6-mm incision and pri- marily uses a D cartridge. "Every surgeon should consult the manufacturer's recom- mendations and allow the phaco rep to give some guidance when choosing the best cartridge for a given incision size," he said.

• Blank Page
• Blank Page (1)