EyeWorld India December 2020 Issue

SKILLS EWAP DECEMBER 2020 43 by Ellen Stodola Editorial Co-Director Contact information Davidson: doctorjohn@johndavidsonmd.com Kim: kim@professionaleye.com Vann: Robin.Vann@duke.edu This article originally appeared in the September 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Pearls for injecting single-piece IOLs W hen preparing to inject a single-piece IOL, there are several potential issues that may arise during the process. Experts discussed some of these and how they routinely handle them. What’s the best way to stabilize the eye during injection? Do you prefer twist injectors or push injectors? According to D. Brian Kim, MD, the best way to stabilize the eye is to use a second instrument inside the sideport incision to provide countertraction to inject the IOL. The sideport is ideal because it is about 90 degrees away from the main incision and allows him to move the eye to assist with IOL injection. “I don’t recommend grasping the limbal tissue with 0.12 forceps since this could cause trauma,” Dr. Kim said. Dr. Kim thinks surgeons make decisions based on which IOL they prefer, not which injector they prefer. In addition, some surgeons may not have a choice if the ASC or hospital only offers certain IOLs. John Davidson, MD, noted that he has preferred the single- handed injector to the two- handed screw-type twist injector for nearly 20 years because the single-handed injector allows him to stabilize the eye with the non-dominant hand with a second instrument in the secondary incision. This keeps the eye in the primary position while you’re injecting the lens, he said, and gives control over the eye. You can watch the lens glide under the nasal leaflet of the anterior capsule, ensuring placement in the bag. With the two-handed injector, Dr. Davidson said, you can’t stabilize the eye and end up having to push the globe nasally and often cannot visualize delivery of the lens in the bag, which is especially important in small pupil cases. Robin Vann, MD, said stabilizing the eye depends on the kind of IOL injector being used. He has experience with the Alcon UltraSert. The plunger is advanced best with the thumb, he said, but this can also induce torque. “I’ve found using a second instrument in my sideport incision helps stabilize the eye from the torque motion when I use my thumb to advance the plunger for injecting it into the eye,” he said. Discussing different injector types, Dr. Vann said the push injector is nice, but if thumb- driven, he doesn’t like the torque. “From a stabilization standpoint and ability to get the lens into the eye as easily as possible, I prefer a twist injector,” Dr. Vann said. He noted that the twist injector plunger advancement doesn’t come preloaded in the monofocal lens that he prefers, so that’s why he often uses the push injector. Alcon has a preloaded injector, AutonoMe, that advances the IOL plunger by pressing a knob on the injector, giving it the same insertion feel of a twist type injector without the torque of manual thumb advancement, Dr. Vann said. This injector is not available in the U.S. though. What if the trailing haptic becomes trapped between the plunger and the cartridge? If the haptic becomes stuck to the optic? Dr. Davidson uses his non- dominant hand to stabilize the injector where the cartridge is mounted and takes his dominant hand and twists with a wiggle motion on the plunger as he’s withdrawing the plunger, hoping to loosen the plunger from the optic. He doesn’t come out of the eye with the injector. Dr. Davidson discussed what to do if the haptic is stuck to the optic. “A lot of surgeons will pinch the haptic with forceps, Using a single-handed injector while fix- ating the globe with a second instrument provides excellent visualization of the an- terior capsule leaflet, ensuring placement of the IOL in the bag during injection. Source: John Davidson, MD