Quick & Safe Techniques for AcrySof Delivery Dr. Suven Bhattacharjee, MS, DO, DNB, FRF. Complete care Eye Clinic Kolkata, INDIA No Financial Interest

Quick & Safe Techniques for AcrySof Delivery

Dr. Suven Bhattacharjee, MS, DO, DNB, FRF.

Complete care Eye Clinic Kolkata, INDIA

No Financial Interest

[email protected]

‘Turn, Shoot & Unturn’ for the Multipiece

‘Shoot and Turn’ for the Single Piece

Purpose Estimate ‘Capsulo Zonular stress’ caused by AcrySof Multipiece IOL when injected without any rotation of the Injector (Shooter / Monarch / Royale).

Recommend a safe technique for Implantation for AcrySof Multipiece IOL.

Analyze the unfolding motions of the AcrySof Single piece IOL.

Recommend easy technique for delivery of AcrySof single piece IOL in bag.

Capsulo Zonular Stress - IndicatorsAvailable space in Ant Chamber

Mean Anterior Chamber Depth (2.93 mm)1 + Mean thickness of Crystalline lens(4.2 mm)2 = 7.13 mm

If the Space Required for Unrestricted Unfolding is > 6mmLeading haptic has to be bent against PC for safe unfolding in AC / Cap bag

CZ stress is directly proportional to:1. Space required for unrestricted unfolding and2. Force required to bend the leading haptic.

1. Tanja M. Rabsilber, MD, Ramin Khoramnia, Gerd U. Auffarth, MD: Anterior chamber measurements using Pentacam rotating Scheimpflug camera: J Cataract Refract Surg 2006; 32:456–459

2. Vargas LG, Peng Q, Escobar-Gomez M, Apple DJ. Overview of modern foldable intraocular lenses and clinically relevant anatomy and histology of the crystalline lens. Int Ophthalmol Clin. 2001;41(3):1-15.

Materials & Methods

AcrySof MA60AC(MP) Mutipiece & SN60WF (IQ) Single piece IOLs

Synchronized Surgical videos - Eye and Injector

AcrySof MP ‘Direct Shoot’ - 20 eyes‘Turn, Shoot & Unturn’ - 10 eyesAcrySof IQ ‘Direct Shoot’ - 18 eyes ‘Shoot & Turn’ - 12 eyes

Laboratory Video Set up

Top Cam

Front Cam

Microscope head

Slit Lamp head

• IOLs injected into transparent plastic chamber filled with OVD.

• Operating microscope used to capture top view. • Detached Slit lamp head used for front view.

Calibration & Measurements

Magnification Correction• Caliper jaws set to 1 mm & Immersed in OVD chamber• Still Image extracted & Scale with smallest marking corresponding to distance between caliper jaws Superimposed •Used this as a ‘mm’ scale for measurements.

Haptic bending force measurement – Set up

• IOL partially delivered till stage requiring maximum vertical space • Haptic pushed on the pan of a precision laboratory weighing scale to

bend on itself till 3 mm • Force required for every mm of bending noted.

Observation - AcrySof Multipiece MA60AC Vertical space required for unrestricted unfolding

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Leading haptic bending force - AcrySof Multipiece

Leading Haptic - Horizontal

1st mm: 399 + 11 mg

2nd mm: 855 + 19 mg

3rd mm: 1420 + 72 mg

Leading haptic - Vertical

•1st mm: 30 + 7 mg•2nd mm: 94 + 13 mg•3rd mm: 168 + 21 mg

Leading haptic points to the right within cartridge barrelTherefore,To ensure that the leading haptic points left and down – ‘Injector’ needs to be turned clockwise by 160° before beginning delivery of IOL

Leading haptic orientation – Prior to Unfolding

Observation -‘Arc of Sweep’ of Leading hapticAcrySof MA60AC - Multipiece

• Relevant only till the final stages of optic delivery• IOL injected without any rotation of delivery system• Superimposition of 1st frame over last frame during unfolding shows ‘arc of sweep’ of leading haptic

Angle between haptic position at onset and completion of unfolding = 170 ̊ clockwise Therefore, Angle by which Injector is to be rotated to maintain constant haptic position throughout Unfolding = 170 ̊ Anticlockwise

170°

Vertical Space required – Direct Shoot – AcrySof IQ

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IOL rotates clockwise 90̊ - trailing haptic delivers outside capsular bag

‘Shoot & Turn’ Technique - AcrySof IQ

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5 6

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Haptics colour tagged for better visualization Injector rotates anticlockwise 90̊ as IOL is delivered - Trailing haptic

unfolds at same plane as leading haptic - ‘Reduced space & In the bag’

New Techniques for Acrysof IOL Delivery

• Insert Barrel of cartridge into AC – bevel down - Haptic pointing right

• Rotate (Turn) Injector Clockwise by 160 ̊

• Advance rod by pushing (Shoot) or screwing to deliver IOL. - haptic emerges pointing left and down

• Rotate Injector anticlockwise (Unturn) by 170 ̊ as the IOL is delivered to maintain the

haptic horizontal throughout.

Multipiece - Turn, Shoot and Unturn

Watch Video!

• Insert Barrel of cartridge into AC – bevel down

• Advance rod by pushing (Shoot) or screwing to deliver IOL

• As IOL delivers into capsular bag - Rotate Injector anticlockwise (Turn) by 90 ̊

• Trailing haptic of IOL is also delivered into capsular bag.

Single piece - Shoot and Turn

Results: Surgical video analysisTime from emergence of leading haptic till IOL delivery

AcrySof MP (Direct shoot) – 8 sec ( Turn, shoot & Unturn) – 9 secAcrySof SP (Direct shoot) – 6 sec ( Shoot & Turn) – 4 sec

Leading haptic placement & IOL delivery• AcrySof MP (Direct Shoot) 20 eyes

– 8 eyes – leading haptic into bag directly

– 12 eyes – Leading haptic orientation corrected in AC

and then placed in the bag

1 eye - haptic stuck on Iris, endoth touch

– 6 eyes – OVD top up during delivery

– AcrySof MP (Turn, Shoot and Unturn) 10 eyes

– All 10 safely in the bag in controlled manner

Trailing haptic placement & IOL delivery• AcrySof IQ (Direct Shoot) 18 eyes

– All eyes

– Optic delivered obliquely

– Trailing haptic manipulated into bag

• AcrySof IQ (Shoot & Turn) 12 eyes

– All eyes - Optic delivered

Completely in the bag

– 11 Eyes -Trailing haptic into the bag

Conclusion

• The ‘Turn, Shoot & Unturn’ technique reduces CZ Stress of AcrySof MP IOL by keeping the leading haptic horizontal and reducing the vertical space required for unfolding.

• The ‘Shoot & Turn’ technique delivers the AcrySof SP IOL in the capsular bag in a single action by countering the rotation of the IOL as it unfolds.