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At Issue: What is your preferred insertion device?
Q: At Issue posed the following question to a panel of experts: “What is your preferred insertion device?”
A: Depends on many factors
---Steve A. Arshinoff, MD, FRCSC, can be reached at York Finch Eye Associates, 2115 Finch Ave. W, Ste. 316, Toronto, Ontario M3N 2V6 Canada; (416) 745-6969; fax: (416) 745-6724. Dr. Arshinoff has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Pharmacia & Upjohn and Alcon. Steve A. Arshinoff, MD, FRCSC: Discussion of the preferred insertion devices for IOLs on the surface would seem to be a simple issue. However, the choice of insertion device depends upon incision technique, goal for astigmatic alteration, if any, IOL choice, viscoelastic chosen, etc. I will therefore describe my choice of IOL insertion device in this context.
I use clear corneal incisions on the steep axis for my cataract procedures. If there is no significant astigmatism, I place the incision at 180° in near-clear cornea. I think it is important for the surgeon to make his procedures consistent from case to case, so that the nurses can easily prepare for subsequent steps. I, therefore, like to use instruments that can have broad applications and are not specific to one lens. I prefer to have a stable anterior chamber and capsular bag prior to IOL implantation and, consequently, use either the soft shell technique, Healon GV (sodium hyaluronate; Pharmacia & Upjohn) or Healon5 (sodium hyaluronate 2.3%; Pharmacia & Upjohn) to maintain a deep, stable anterior chamber and an open bag.
I have been disappointed with most IOL injectors and their often unreliable behavior in the event that loading was imprecise. I have been impressed with Alcon’s (Fort Worth, Texas) new Monarch injector (but must confess only brief experience with it), into which the IOL is easily loaded and the injector then rolls the IOL upon injection to achieve the injectable conformation.
Nevertheless, my preference is still to pick up the IOL with Lieberman (Alcon “paddle” forceps, Micra UK F310 ND0084) and then to grasp the folded IOL with Buratto forceps (Janach J2186.2 Inax 07775 Italy). This combination works for round silicone and AcrySof (Alcon) IOLs. I prefer it because it allows me to grasp the IOL on an oblique angle, with the paddles being rotated into the gussets of the haptics, thus permitting one-step IOL insertion and dropping into the bag, without the need for maneuvering of the trailing haptic or rotation of the implanted IOL, except slightly with the irrigation and aspiration, as “rock ‘n’ roll” is performed to remove the viscoelastic.
I find this combination to be the most generally applicable, and it allows me considerable latitude in choice of incision size, placement and IOL choice. I vary from this choice primarily when I implant the MemoryLens (CIBA Vision; Duluth, Ga.), at which time I use McPherson forceps and dial the IOL into position using an Arshinoff dialer (Xomed; Jacksonville, Fla.).
A: Injection systems
---I. Howard Fine, MD, is an associate clinical professor of ophthalmology at the Oregon Health Sciences University. He can be reached at 1550 Oak St., Ste. 5, Eugene, OR 97401-7701; (541) 687-2110; fax: (541) 484-3883. Dr. Fine has no direct financial interest in any of the products mentioned in this article. He is a paid Array IOL consultant for Allergan. I. Howard Fine, MD: I prefer injection systems over forceps insertion devices because of the ability to maintain better sterility. The lens comes out of the sterile package, is folded into the sterile injection system and is placed in the capsular bag directly without ever contacting the surface of the eyeball. In general, injection devices also go through smaller incisions than do implantation forceps.
The two devices that I like best are the AMO Unfolder (Allergan; Irvine, Calif.) for their SI40NB and SA40N silicone lenses, and the STAAR (Monrovia, Calif.) Shooter for the AA4207VF and the AA4203TF silicone plate haptic lenses and the CC4203VF collamer plate haptic lens, as well as the STAAR AQ2010 three-piece silicone IOL.
A: Folding forceps or MPORT inserter
---William F. Maloney, MD, can be reached at Eye Surgery Associates, 2023 W. Vista Way, Ste. A, Vista, CA 92083; (760) 941-1400; fax: (760) 941-9643; e-mail: 74044.2361@compuserve.com. Dr. Maloney has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Bausch & Lomb. William F. Maloney, MD: I use a three-piece silicone foldable lens in most cases (the Bausch & Lomb Surgical L161U; Claremont, Calif.) and insert the lens using either a folding forceps or, more recently, the MPORT inserter (Bausch & Lomb Surgical).
I find each of these insertion techniques equally easy, but I feel that the “closed system” approach of the MPORT is preferable because I believe that, in the long run, it will reduce the incidence of postop infections.
A: Depends on IOL being used
---Louis D. “Skip” Nichamin, MD, can be reached at Laurel Eye Clinic, 50 Waterford Pike, Brookville, PA 15825; (814) 849-8344; fax: (814) 849-7130; e-mail: nichamin@laureleye.com. Dr. Nichamin has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned. Louis D. “Skip” Nichamin, MD: My choice of insertion device is determined by the particular IOL that is being employed. My current implant breakdown is as follows: 60% Bausch & Lomb model L161U (“normal” eyes with no predisposition toward inflammation or vitreoretinal disease), 25% hydrogel-acrylic (patients inclined toward in creased inflammation such as diabetics), and 15% Allergan Array multifocal (carefully selected candidates).
With the Bausch & Lomb L161U, I have come to embrace their new MPORT injector delivery device. This is a somewhat unique device in that the lens optic is compressed into an M-shape, as opposed to conventional folding or rolling of the optic. It may be used with one hand by simply depressing the plunger and requires no rotational movements. As with all injector delivery devices, care must be taken when loading the implant, and if resistance is experienced during insertion, one should stop and inspect the implant and inserter and most likely reload the device.
The MPORT, along with other new injector delivery devices such as the AMO Unfolder and the Alcon Monarch, represent a new generation of insertion instrumentation. Until recently, injectors designed for the delivery of three-piece IOLs were often fraught with problems leading to inconsistent and, on occasion, traumatized delivery of IOLs. Fortunately, these newer devices now in large part obviate the need for the manual loading and inserting of IOLs.
If an injector, however, is not available or appropriate for a given case, my preferred manual instrumentation will again depend upon the type of IOL. Instruments that I have designed with Rhein Medical (Tampa, Fla.) are helpful with certain silicone implants, particularly those with greater central optic thickness and 5.5 mm optic dimensions. For thinner optics or other biomaterials, I find the choice of instrumentation to be less critical.
A: Unfolder insertion device
---Randall J. Olson, MD, can be reached at the John A. Moran Eye Center, Department of Ophthalmology, 50 N. Medical Drive, Salt Lake City, UT 84132; (801) 585-6622; fax: (801) 581-3357; e-mail: Randall.Olson@hsc.utah.edu. Dr. Olson has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Allergan. Randall J. Olson, MD: I have been extremely pleased with the Unfolder (Allergan) insertion device and use it almost 100% of the time. The only exception is where a different IOL material is in the first eye in that I usually do not mix materials. My reasons for using the Unfolder device are:
- It allows me to easily implant an IOL without the need for counter-traction to have the device make its way through the wound, for any wound that is 2.8 mm or larger, and still have a full 6 mm optic. The SI55 with the Unfolder can be used in wounds as small as 2.5 mm.
- The entire lens can easily be inserted, including the trailing loops, so that none of the lens is exposed to the extraocular environment, which I feel is a potential source of bacterial contamination.
- When used according to the manufacturer’s parameters, the device has an exceedingly low failure rate, such that I have not had difficulty or failure of lens insertion in regards to either damage to the cartridge or IOL or inability to insert the IOL in the past 2 years.
- The device allows insertion of a three-piece IOL through this small incision that has been shown to have significant posterior capsule opacification prevention capability consistent with any other lens on the market.
- I feel that enlargement of a wound for any reason is an additional step that may cause difficulty either in regards to an inadvertent move by a patient under topical anesthesia (basically 100% of my cases) or problems with wound self-sealing.
- The little side port has been engineered such that I can, by usual examination, be certain that the lens is in position and that the leading haptic will not be damaged.
- Once the technicians understand how to use this, it is very easy to have it immediately ready, such that the insertion step takes a matter of seconds once the anterior chamber is filled with viscoelastic.
- The soft tip allows complete control of the IOL with slow or rapid insertion as the clinical situation may dictate.
Like all devices, there is a small learning curve in using the Unfolder. However, I have found that it is very easy to teach the few steps necessary for successful use of this instrumentation. I have been very pleased with the use of the Unfolder in my clinical practice.
  ---Dr. Olson uses the Unfolder system Reference: |
A: No ideal lens insertion system
---Priscilla E. Perry, MD, can be reached at 1310 N. 19th St., Monroe, LA 71201; (318) 388-2020; fax: (318) 361-0914; e-mail: PPerry20@aol.com. Dr. Perry has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned. Priscilla E. Perry, MD: The ideal lens insertion system would have the following characteristics:
- Delivery from the manufacturer in an insertion device so that no other steps are needed and the lens itself is never externally touched.
- Insertion through an unenlarged phaco incision (2.8 mm in my own cases).
- Completely reproducible and controlled insertion of the implant in every case.
No currently available system meets all of these requirements.
I primarily implant either the Alcon AcrySof MA30BA or the Allergan silicone SI40NB. The Allergan Unfolder insertion system is, in my opinion, the most predictable and straightforward of the available injection devices. It is easily loaded by the scrub nurse. The lens is delivered in a controlled fashion, and the trailing haptic also can be manipulated by the plunger. It is possible, however, for the plunger to override the optic. A definite advantage is that the lens can easily be inserted through an unenlarged incision of 2.8 mm.
Alcon has introduced an injector system, the Monarch, within this past year. My preference after using this instrument is to continue using a forceps insertion (Capital 1639-03). These particular forceps allow the scrub nurse to securely load and pass the lens to me, making a break in the surgical process unnecessary. The acrylic lens haptics and optics are certainly more likely than silicone to be damaged with either folding or injection, and both methods require enlargement of the phaco incision for non- traumatic entry.
The perfect system is yet to be a reality, but we can enjoy the benefits of great improvements in insertion technology from several companies over the past few years that will continue to be refined. We also have learned the surgical lesson that an enlarged, atraumatic insertion is more preferable than forced insertion simply for the sake of eliminating one step.