IOL injector technology aims to keep pace with microincisional phaco platforms

Surgeons tout better injectors, as well as preloaded injectors, for their role in making cataract surgery safer, faster and more sterile.

The advent of foldable IOLs propelled phacoemulsification into the mainstream of cataract surgery, allowing small incisions and minimizing complications. However, since the first injection device for a foldable IOL emerged in the mid-1980s, injection technology has lagged as incisions have shrunk.

Ultrasound, vacuum and fluidics provide fast, safe and efficient lens extraction, and increasingly small incisions have become the norm for both crystalline lens removal and IOL insertion.

Current IOL injection systems include the Unfolder Series (Advanced Medical Optics), Monarch III IOL delivery system (Alcon), SofPort Advanced Optics Lens Insertion System with Easy-Load inserter (Bausch & Lomb), MicroSTAAR and Canon-STAAR (STAAR Surgical), and others.

Some of the injectors may be used with incisions smaller than 2 mm. Most injectors must be loaded, but the paradigm is gradually shifting toward preloaded cartridges.

In telephone interviews with Ocular Surgery News, OSN Cataract Surgery Section Member Louis D. “Skip” Nichamin, MD, surgeon Mark Packer, MD, and OSN Refractive Surgery Section Member Kerry D. Solomon, MD, discussed their preferred IOL injection systems and techniques.

Bausch & Lomb’s SofPort injector.

Image: Nichamin LD

Insertion of the ReZoom lens with the AMO Unfolder.

Image: Packer M

Alcon’s Monarch D cartridge as the IOL is loaded.

Image: Solomon KD

“I’m really looking for something that will allow me to place a lens through as small an incision as possible,” Dr. Solomon said. “Preloaded is always a plus, if possible, but if not, then it needs to be easy to load and easy to use. The biggest preference for me is ease of use and size of the incision.”

Currently, the smallest incision that can offer optimal outcomes is about 2 mm, Dr. Solomon said.

“At the end of the day, quality of vision is going to rule,” he said. “That’s one area that we can’t compromise.”

Small incisions minimize endophthalmitis, a common complication of cataract surgery, Dr. Solomon said.

“The smaller our incision and the more square our incision, the better the integrity of the incision and the less the likelihood that it will leak short term or long term,” Dr. Solomon said.

Dr. Packer emphasized the need to avoid stretching a small incision to inject an IOL.

“The thing is that you don’t really want to stretch these incisions so much,” he said. “You want to make an incision that’s an adequate size so you can easily put it in without tearing the edge of the incision, which is going to deform the incision and make the sealing of the incision a little more difficult.”

Dr. Nichamin stressed the importance of safe and consistent IOL injection.

“Historically, the early delivery systems were a bit willy-nilly,” Dr. Nichamin said. “A lens could deliver in a multitude of various fashions, some of which, unfortunately, would involve damage to the intraocular lens, to the haptic or the optic. Our first priority, of course, is to get the implant into the eye in one piece, undamaged.”

Incision size and surgical technique

Microcoaxial phaco has spurred the development of injection technology that is amenable to smaller incisions, Dr. Nichamin said.

“History is repeating itself, wherein the intraocular lenses have to catch up with the phaco technology,” he said.

Dr. Nichamin said he uses the Bausch & Lomb Stellaris Vision Enhancement System to perform microcoaxial phaco through a 1.8-mm incision.

The syringe-like SofPort injector offers some advantages, Dr. Nichamin said. For example, the surgeon can inject the three-piece silicone lens in a planar fashion, simplifying the surgical technique and minimizing manipulation of the lens, he said.

“The lens doesn’t need to be turned over within the eye, which I also find to be advantageous,” Dr. Nichamin said. “I think it’s extremely reliable and easy to use, particularly in regard to the planar delivery of the entire lens.”

A technician can load the lens case into the Easy-Load inserter without touching it, according to Bausch & Lomb. The SofPort injector is derived from the Mport injector, Dr. Nichamin said.

The Alcon Monarch III injector and new D cartridge configuration allow the delivery of most AcrySof lenses through a 2.2-mm or smaller incision, Dr. Solomon said.

“The advantage of the D cartridge, believe it or not, even though it’s smaller, for the lenses to go in, it has more space to load the lens,” he said.

Dr. Packer discussed the wound- assisted surgical technique used with the Monarch III D cartridge.

“With the Monarch D cartridge, you can introduce the AcrySof through a 2.2-mm incision using this wound- assisted technique where you don’t really push the injector tip all the way into the eye,” Dr. Packer said. “You just kind of open up the outside of the incision and then use the incision as kind of a guide to push the lens through.”

The AMO Unfolder injectors complement the Tecnis one-piece aspheric IOL, although the Tecnis injector might require a slightly larger incision to accommodate it, Dr. Packer said.

The original Unfolder was compatible with the three-piece silicone IOL, and the Unfolder Emerald injector works well with the 6-mm hydrophobic acrylic Sensar IOL, he said.

“The Unfolder [Series], I have lots of good things to say about that,” Dr. Packer said. “Of course, that’s been the standby for all silicone lenses.”

Emerging innovations

“As far as injector technology, I think we’re pretty far along,” Dr. Solomon said. “As we look toward furthering developments, someday we’d all like to see an accommodative lens that is able to be delivered through a very small incision that provides a wonderful range of vision with good quality, reliability and predictability.”

Preloaded injectors are moving to the forefront, with various benefits, Dr. Nichamin said.

“Not only is it just a matter of convenience, but also one of sterility and safety,” he said. “It’s potentially advantageous not to have to touch and manipulate the lens. Rather, if it comes in a sterile, prepackaged form and we simply dunk it into the eye, that’s a good thing.”

Dr. Nichamin said the Easy-Load inserter is an incremental step toward preloaded technology.

“The Easy-Load device right now is about as close as we currently have come to having a preloaded system,” he said.

The Visiogen Synchrony dual- optic accommodating IOL and preloaded injector are notable innovations, Dr. Packer said.

“They developed an injector that is an amazing feat of technology given the fact that you’ve got two lenses connected by these flexible hinges,” he said. “It comes preloaded. It’s remarkably easy to use once you get the hang of it.”

Dr. Packer noted the Canon- STAAR preloaded injector is available in Japan and other countries but not in the United States.

“Loading the lens is just potential for mistakes being made. You can remove a lot of uncertainty by having it as a preloaded system,” he said.

A preloaded version of the Monarch D may be on the horizon, Dr. Solomon noted.

For more information:

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 is a medical monitor for Bausch & Lomb. He has no financial interest in the products mentioned in this article.

Mark Packer, MD, can be reached at Drs. Fine, Hoffman and Packer, LLC, 1550 Oak St., Suite 5, Eugene, OR 97401; 541-687-2110; fax: 541-484-3883; e-mail: mpacker@finemd.com. Dr. Packer is a consultant to Advanced Medical Optics, Bausch & Lomb and Visiogen.

Kerry D. Solomon, MD, can be reached at Medical University of South Carolina, Storm Eye Institute, 167 Ashley Ave., Room 221, P.O. Box 250676, Charleston, SC 29425; 843-792-8854; fax: 843-792-6347; e-mail: solomonk@musc.edu. Dr. Solomon is a consultant to Advanced Medical Optics, Alcon and Bausch & Lomb.

Advanced Medical Optics, maker of the Unfolder system, can be reached at 1700 E. St. Andrew Place, Santa Ana, CA 92705; 714-247-8200; Web site: www.amo-inc.com.

Alcon, maker of the Monarch III IOL delivery system, can be reached at 6201 South Freeway, Fort Worth, TX 76134; 817-293-0450; Web site: www.alconlabs.com.

Bausch & Lomb, maker of the Mport and SofPort, can be reached at 180 Via Verde, San Dimas, CA 91773; 800-338-2020; Web site: www.bausch.com.

STAAR Surgical, maker of the Canon-STAAR, can be reached at 1911 Walker Ave., Monrovia, CA 91016; 626-303-7902; Web site: www.staar.com.

Visiogen, maker of the Synchrony dual optic accommodating IOL and preloaded injector, can be reached at 2 Goodyear, Suite B, Irvine, CA 92618; 949-341-0700; Web site: www.visiogen.com.

Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.