Quick Safe Techniques for Acry Sof Delivery Turn

Quick & Safe Techniques for Acry. Sof Delivery ‘Turn, Shoot & Unturn’ for the Multipiece ‘Shoot and Turn’ for the Single Piece Dr. Suven Bhattacharjee, MS, DO, DNB, FRF. Complete care Eye Clinic Kolkata, INDIA suvenb@gmail. com No Financial Interest

Purpose Estimate ‘Capsulo Zonular stress’ caused by Acry. Sof Multipiece IOL when injected without any rotation of the Injector (Shooter / Monarch / Royale). Recommend a safe technique for Implantation for Acry. Sof Multipiece IOL. Analyze the unfolding motions of the Acry. Sof Single piece IOL. Recommend easy technique for delivery of Acry. Sof single piece IOL in bag. Capsulo Zonular Stress - Indicators Available space in Ant Chamber Mean Anterior Chamber Depth (2. 93 mm)1 + Mean thickness of Crystalline lens(4. 2 mm)2 = 7. 13 mm 1. 2. Tanja M. Rabsilber, MD, Ramin Khoramnia, Gerd U. Auffarth, MD: Anterior chamber measurements using Pentacam rotating Scheimpflug camera: J Cataract Refract Surg 2006; 32: 456– 459 Vargas LG, Peng Q, Escobar-Gomez M, Apple DJ. Overview of modern foldable intraocular lenses and clinically relevant anatomy and histology of the crystalline lens. Int Ophthalmol Clin. 2001; 41(3): 1 -15. If the Space Required for Unrestricted Unfolding is > 6 mm Leading haptic has to be bent against PC for safe unfolding in AC / Cap bag 1. 2. CZ stress is directly proportional to: Space required for unrestricted unfolding and Force required to bend the leading haptic.

Materials & Methods Acry. Sof MA 60 AC(MP) Mutipiece & SN 60 WF (IQ) Single piece IOLs Synchronized Surgical videos - Eye and Injector Acry. Sof MP ‘Direct Shoot’ - 20 eyes ‘Turn, Shoot & Unturn’ - 10 eyes Acry. Sof IQ ‘Direct Shoot’ - 18 eyes ‘Shoot & Turn’ - 12 eyes

Laboratory Video Set up Top Cam Microscope head • IOLs injected into transparent plastic chamber filled with OVD. • Operating microscope used to capture top view. • Detached Slit lamp head used for front view. Front Cam Slit Lamp head Calibration & Measurements Magnification Correction • Caliper jaws set to 1 mm & Immersed in OVD chamber • Still Image extracted & Scale with smallest marking corresponding to distance between caliper jaws Superimposed • Used this as a ‘mm’ scale for measurements.

Haptic bending force measurement – Set up • IOL partially delivered till stage requiring maximum vertical space • Haptic pushed on the pan of a precision laboratory weighing scale to bend on itself till 3 mm • Force required for every mm of bending noted.

Observation - Acry. Sof Multipiece MA 60 AC Vertical space required for unrestricted unfolding 1 8 4 2 3 4 7 5 6

Leading haptic bending force - Acry. Sof Multipiece Leading haptic - Vertical Leading Haptic - Horizontal 1 st mm: 399 + 11 mg • 1 st mm: 30 + 7 mg 2 nd mm: 855 + 19 mg • 2 nd mm: 94 + 13 mg 3 rd mm: 1420 + 72 mg • 3 rd mm: 168 + 21 mg Leading haptic orientation – Prior to Unfolding Leading haptic points to the right within cartridge barrel Therefore, To ensure that the leading haptic points left and down – ‘Injector’ needs to be turned clockwise by 160° before beginning delivery of IOL

Observation -‘Arc of Sweep’ of Leading haptic Acry. Sof MA 60 AC - Multipiece • Relevant only till the final stages of optic delivery • IOL injected without any rotation of delivery system • Superimposition of 1 st frame over last frame during unfolding shows ‘arc of sweep’ of leading haptic 170° Angle between haptic position at onset and completion of unfolding = 170 clockwise Therefore, Angle by which Injector is to be rotated to maintain constant haptic position throughout Unfolding = 170 Anticlockwise

Vertical Space required – Direct Shoot – Acry. Sof IQ IOL rotates clockwise 90 - trailing haptic delivers outside capsular bag 1 8 2 7 8 3 6 4 5

‘Shoot & Turn’ Technique - Acry. Sof IQ Haptics colour tagged for better visualization Injector rotates anticlockwise 90 as IOL is delivered - Trailing haptic unfolds at same plane as leading haptic - ‘Reduced space & In the bag’ 1 9 2 8 8 7 3 4 5 6

New Techniques for Acrysof IOL Delivery Multipiece - Turn, Shoot and Unturn • Insert Barrel of cartridge into AC – bevel down - Haptic pointing right • Rotate (Turn) Injector Clockwise by 160 • Advance rod by pushing (Shoot) or screwing to deliver IOL. - haptic emerges pointing left and down • Rotate Injector anticlockwise (Unturn) by 170 as the IOL is delivered to maintain the haptic horizontal throughout. Single piece - Shoot and Turn Watch Video! • Insert Barrel of cartridge into AC – bevel down • Advance rod by pushing (Shoot) or screwing to deliver IOL • As IOL delivers into capsular bag - Rotate Injector anticlockwise (Turn) by 90 • Trailing haptic of IOL is also delivered into capsular bag.

Results: Surgical video analysis Time from emergence of leading haptic till IOL delivery Acry. Sof MP (Direct shoot) – 8 sec ( Turn, shoot & Unturn) – 9 sec Acry. Sof SP (Direct shoot) – 6 sec ( Shoot & Turn) – 4 sec Leading haptic placement & IOL delivery Trailing haptic placement & IOL delivery • • Acry. Sof MP (Direct Shoot) 20 eyes Acry. Sof IQ (Direct Shoot) 18 eyes – leading haptic into bag directly – All eyes – 12 eyes – Leading haptic orientation corrected in AC – Optic delivered obliquely and then placed in the bag 1 eye - haptic stuck on Iris, endoth touch – Trailing haptic manipulated into bag • Acry. Sof IQ (Shoot & Turn) 12 eyes – 6 eyes – OVD top up during delivery – Acry. Sof MP (Turn, Shoot and Unturn) 10 eyes – All 10 safely in the bag in controlled manner – All eyes - Optic delivered Completely in the bag – 11 Eyes -Trailing haptic into the bag Conclusion • The ‘Turn, Shoot & Unturn’ technique reduces CZ Stress of Acry. Sof MP IOL by keeping the leading haptic horizontal and reducing the vertical space required for unfolding. • The ‘Shoot & Turn’ technique delivers the Acry. Sof SP IOL in the capsular bag in a single action by countering the rotation of the IOL as it unfolds.