Eyeworld

28 | EYEWORLD | SEPTEMBER 2023 ATARACT C rotated to the wrong axis, I will routinely use a CTR. I place the CTR at the first sign of zonular instability," he said. Methods for best placement CTRs can be placed with an inserter or man- ually, Dr. Hart said. He added that there are reusable inserters, and there are preloaded disposable inserters. The reusable inserters are made to insert the CTR in a clockwise manner. The disposable inserters can insert the CTR in a clockwise or counterclockwise manner. Dr. Hart added that the direction of inser- tion can be important, depending on where the zonular weakness is localized in relation to the main incision. "If the CTR encounters resistance during insertion, the surgeon should remove it and attempt insertion in the opposite direction," he said. "There are other ways to insert a CTR with an inserter, including a Sinskey-guided insertion or a suture-guided insertion. These techniques help guide the leading tip of the CTR around the equator of the capsular bag." Alternatively, the CTR can be inserted man- ually with the assistance of a Sinskey hook in the distal eyelet and a Kuglen hook guiding the CTR into the bag, Dr. Hart said, adding that he most often uses a disposable inserter. Several methods for placement of the CTR have been described in the literature, Dr. McKee said. "I currently use the preloaded CTRs from Bausch + Lomb, as they are high quality, easy to insert, and come preloaded in a sterile disposable injector," he said. "These come in right- and left-handed orientation, but by sim- ply inverting the injector, the orientation can be reversed. With the preloaded CTR, I insert the tip of the injector into the capsular opening and slowly inject the CTR." The terminal trailing eyelet will be engaged by a small rod/hook in the injector advancing the CTR. Once this hook is fully advanced, the CTR can be disengaged from the injector with a second instrument or often by simply elevating the hook and having the CTR fall into the capsule. Dr. McKee noted that it is important that the capsule is intact for proper placement of a CTR. "A CTR should not be placed in the ciliary sulcus," he said. "The capsule should be intact continued from page 27 Traumatic zonular dialysis Weakened and stretched zonules Source (all): John Hart Jr., MD

• Blank Page