EyeWorld Asia-Pacific December 2020 Issue

EWAP DECEMBER 2020 45 SKILLS posterior continuous curvilinear capsulorhexis to turn the tear into a stable round hole, which is unlikely to tear out,” Dr. Kim said. Dr. Davidson said he prefers to align haptics 90 degrees away from anterior capsule tear because putting the haptic at the tear may cause undue stress at the equator that could cause the tear to run to the posterior capsule. If there’s a posterior capsular tear that’s somewhat linear, you can still get a one- piece lens in the bag most of the time, as long as the haptics are 90 degrees to the tear, Dr. Davidson said. If there is an anterior capsule tear, Dr. Vann uses a single-piece IOL, injecting into the anterior chamber and trying to depress the optic underneath the capsular bag, tucking the haptic with the second instrument. Strategy for removing OVD from behind the IOL? Dr. Davidson usually manipulates and rotates the IOL with the I/A handpiece. He continues to deliver the posterior trailing haptics with the I/A handpiece and does not use a second instrument through the sideport. “I’m already evacuating the viscoelastic before the lens is fully unfolded,” he said. “I don’t have to intentionally lift the edge of the IOL to evacuate the OVD from behind it because the OVD is gone before the lens is unfolded.” Dr. Kim said he does not advise relying on indirect means to remove OVD from behind the IOL. You don’t want to leave OVD inside the bag because it can cause capsular bag distention syndrome and a myopic refractive surprise from the anteriorly displaced IOL. The best way to remove OVD is to get it directly by going behind the IOL and removing it from within the bag. This way you have no doubt that all the OVD is out of the bag. Single-piece To liberate a stuck haptic, apply centrifugal pressure to the X-Y plane of the optic to the back of the haptic tip with the I/A needle tip. Source: John Davidson, MD Ronald Yeoh, FRCS, FRCOphth, DO, FAMS Consultant Eye Surgeon & Medical Director, Consultant & Founder Eye & Retina Surgeons Cl. Associate Professor Duke-NUS Graduate Medical School, Singapore National Eye Centre ASIA-PACIFIC PERSPECTIVES T his article highlights an often neglected area of IOL implantation: that of the actual injection maneuver itself. Many problems can arise from improper injection. Stabilization is best done by using a pair of McPherson forceps or a Sinskey hook in the side port. As far as injectors are concerned, the three main contenders are 1) single-handed plunger 2) double- handed screw, and 3) automated injectors. Single-handed injectors work well, but the surgeon has to be wary of “ballistic” injection of an IOL as it enters the eye and can lead to posterior capsule rupture or iris damage. Double-handed injectors work well in incisions of 2.75 mm or larger as countertraction is not really needed. The challenge arises when the incision is 2.2 mm or smaller as countertraction is needed by the nondominant hand while the dominant hand presses the injector cartridge to the wound. The surgeon then needs a third hand to screw the IOL in! This is where automated injectors such as Autosert or Autonome come in since they remove the need for the third hand. I use automated injectors for all my single-piece acrylic IOLs injected through a 2.2-mm incision. A trapped trailing haptic is a tricky complication. If it is not handled appropriately and the injector is just pulled away from the eye in an attempt to free it, the knob on the tip of the trailing haptic is likely to be amputated and the lens has to be replaced. An IOL with an amputated haptic should not be implanted as it may decenter. The correct maneuver is to maintain the injector cartridge at the incision and carefully cut the cartridge over the stuck haptic. This frees the haptic and allows injection to proceed. An important point in preventing this complication of a trapped trailing haptic is that when the IOL is being advanced in the cartridge prior to injection, the tip of the trailing haptic should still be forward in the IOL taco. If the trailing haptic is seen to be extending straight backwards over the plunger, the lens needs to be reloaded properly. Editors’ note: Dr. Yeoh is a consultant for Alcon, Johnson & Johnson, and Zeiss. continued on page 48