EyeWorld Asia-Pacific December 2020 Issue

SKILLS 44 EWAP DECEMBER 2020 A second instrument is placed through the sideport incision 90 degrees away from the main incision to stabilize the eye as the IOL injector is inserted. Under continuous irrigation, the I/A tip is positioned slightly under the optic-haptic junction in order to lift and push the stuck haptic off the optic. The I/A tip is slid under the optic, which is tilted and rotated 90 degrees within the capsular bag. This maneuver enables direct evacuation of all the OVD from within the capsular bag and ensures both haptics are within the capsular bag. Source (all): D. Brian Kim, MD stuck to the plunger. If it gets stuck on the optic, he said the I/A handpiece can apply suction to the area of the haptic that’s stuck to the optic. “That will often free it up to get it to expand and reshape itself to normal configuration,” he said. If the haptic becomes trapped between the plunger and cartridge, Dr. Kim has used an internal approach with a second instrument through the sideport incision to bluntly tease the haptic off the plunger. If this doesn’t work, he’ll partially withdraw the injector to expose the stuck portion of the haptic, using forceps to free it. If the IOL is completely in the eye and the haptic is stuck to the optic, Dr. Kim’s favorite technique is to use the I/A handpiece to gently push or lift the haptic off the optic. “I do this with the irrigation fluid turned on since it’s easier to manipulate a firm globe,” he said. If this doesn’t work, a second instrument with the I/A tip can apply opposing forces. With the I/A tip, he lifts up from under the haptic and pushes down on the optic with the cannula. How do you avoid IOL trauma? To avoid trauma to the IOL, for preloaded injectors, Dr. Vann said to make sure to use a lot of viscoelastic in the cartridge before advancing. Before the plunger meets the haptic, look closely to make sure it’s advancing in the proper plane so you’re not kinking or traumatizing the implant with the plunger advancing over top or down below the optic, he added. Inside the eye, once you’ve injected it, Dr. Vann tries to have his second instrument away from the optic. Dr. Davidson said he routinely checks the folding forceps under the microscope to make sure they don’t have any metal burrs on them that could scratch the lens. He instructs technicians to never handle the optic. It’s necessary to touch the optic when folding it in the cartridge, but when pulling it out of the case and handling it any other time, grab by the haptics, he said. How do you insert a single-piece acrylic IOL with an anterior capsular tear? Would you put in a single-piece with a posterior capsule tear? It is safe to place a single-piece acrylic IOL in a bag with an isolated anterior capsule tear, Dr. Kim said. The key is to rotate the haptics within the bag so they are perpendicular to the tear, ensuring the IOL remains well centered. In-the-bag single-piece acrylic IOLs should be avoided in the setting of posterior capsule tears for any defects bigger than the IOL optic. They should also be avoided in bags with any sized peripheral posterior capsule defect since the haptic can slip through the defect and lead to IOL dislocation. Small, fairly central posterior capsule tears can safely hold a single-piece acrylic IOL. “An even better strategy would be to perform a but this risks immediate flat chamber or use of additional OVD,” he said. Dr. Davidson said he prefers to take the tip of the I/A needle and nudge the haptic in the plane of the optic peripherally, which usually breaks the adhesion. Dr. Vann hasn’t often had a problem with a trailing haptic