Quick & Safe Techniques for AcrySof Delivery

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

2. Purpose • Estimate‘CapsuloZonular stress’ caused by AcrySofMultipiece IOLwhen injected without any rotation of the Injector (Shooter / Monarch / Royale). • Recommend a safe technique for Implantation for AcrySofMultipieceIOL. • Analyze the unfolding motions of the AcrySof Single piece IOL. • Recommend easy technique for delivery of AcrySof single piece IOL in bag. CapsuloZonular 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 • 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 > 6mm Leading haptic has to be bent against PC for safe unfolding in AC / Cap bag • CZ stress is directly proportional to: • Space required for unrestricted unfolding and • Force required to bend the leading haptic.

3. Materials & Methods AcrySof MA60AC(MP) Mutipiece & SN60WF (IQ) Single piece IOLs Synchronized Surgical videos - Eye and Injector AcrySof MP ‘Direct Shoot’ - 20 eyes ‘Turn, Shoot & Unturn’ - 10 eyes AcrySof IQ ‘Direct Shoot’ - 18 eyes ‘Shoot & Turn’ - 12 eyes

4. 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.

5. 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.

6. Observation - AcrySof Multipiece MA60AC Vertical space required for unrestricted unfolding 1 8 4 2 7 3 4 5 6

7. Leading haptic bending force - AcrySof Multipiece Leading haptic - Vertical Leading Haptic - Horizontal • 1st mm: 30 + 7 mg • 2nd mm: 94 + 13 mg • 3rd mm: 168 + 21 mg 1st mm: 399 + 11 mg 2nd mm: 855 + 19 mg 3rd mm: 1420 + 72 mg Leadinghaptic 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

8. Observation -‘Arc of Sweep’ of Leading hapticAcrySof MA60AC - Multipiece • Relevant only till the final stages of optic delivery • IOL injected without any rotation of delivery system • Superimposition of 1st 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 ̊ clockwiseTherefore, Angle by which Injector is to be rotated to maintain constant haptic position throughout Unfolding = 170 ̊ Anticlockwise

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

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

11. New Techniques for Acrysof IOL Delivery Multipiece - Turn, Shoot and Unturn • Insert Barrel of cartridge into AC – bevel down - Hapticpointing 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. Watch Video! Single piece - Shoot and Turn • 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.

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