Eyeworld

ring while I am injecting the Cionni CTR. This allows the CTR to be bent so that it doesn't engage a loose cap- sular bag and cause more zonular damage. Once more than half of the CTR is in the eye, the Sinskey hook can be removed to release the lead- ing loop into the bag. Then the plunger in the injector is completely extended to release the trailing loop into the bag. Sometimes it is easier to release the trailing loop first, fol- lowed by the leading loop. For a sur- geon who wants to inject with his right hand, Cionni type 1L (Morcher, Stuttgart, Germany) rings should be purchased. For a surgeon who wants to inject with his left hand, Cionni type 2C (Morcher) rings should be obtained. The 1L is injected counterclockwise in the capsular bag with the surgeon's right hand. The 2C is a one-loop Cionni that is injected clockwise with the surgeon's left hand. Always monitor the Cionni loop during insertion to make sure that it stays anterior to the anterior capsule and doesn't get placed in the bag. When suturing, it is very im- portant that the surgeon uses the 9- 0 prolene, not the 10-0, because the 9-0 will not degrade in the eye over time like a 10-0 will. Don't over tighten the 9-0 prolene suture to the sclera because this can decenter the entire capsular bag and IOL. Create a Hoffman scleral pocket in order to bury the 9-0 prolene knot. Richard S. Hoffman, M.D., clinical associate professor of oph- thalmology, Casey Eye Institute, Oregon Health & Science University, Portland, came up with the idea to create an incision on the cornea so the surgeon can tunnel back into the sclera to create a pocket so that the CTR can be sutured under the March 2011 sclera without dissecting the con- junctiva. It's a very good way to se- cure the Cionni CTR as well as the Ahmed capsular tension segment (CTS). I really like the Hoffman scle- ral pocket and I use that all the time. If a surgeon has already placed a standard CTR and the capsular bag is still decentered, an Ahmed CTS may be placed and suture fixated to the sclera to better center the capsular bag. Great devices that aren't used enough The devices mentioned are some of the wonderful tools that surgeons probably aren't using enough. The long-term effectiveness of CTRs has been excellent and that's why the FDA finally approved the basic model in 2003, 10 years after the CTR was originally designed. I recently had a patient who had a retinal detachment, which was dealt with using silicone oil, causing about 6 clock hours of zonular de- hiscence. However, I was able to take the cataract out, put a one-loop Cionni CTR in, and suture it to the sclera. Surgeons should bear in mind that this can't be done in a 15-20 minute case; the procedure does take extra time. I usually schedule these at the end of the day so I can spend all the time I want on them. The pa- tient mentioned now has the lens implant in a very appropriate posi- tion in the eye so it was worth the extra effort. EW Editors' note: Dr. Bakewell has no fi- nancial interests related to this article. Contact information Bakewell: 520-293-6740, EyemanAZ@aol.com EW CATARACT/IOL 53

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