Quick

1
Quick Safe Techniques for AcrySof 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_at_gmail.com
No Financial Interest
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Purpose

• Estimate Capsulo Zonular stress caused by
  AcrySof Multipiece IOL when injected without any
  rotation of the Injector (Shooter / Monarch /
  Royale).
• Recommend a safe technique for Implantation for
  AcrySof Multipiece IOL.
• Analyze the unfolding motions of the AcrySof
  Single piece IOL.
• Recommend easy technique for delivery of AcrySof
  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

• Tanja M. Rabsilber, MD, Ramin Khoramnia, Gerd U.
  Auffarth, MD Anterior chamber measurements using
  Pentacam rotating Scheimpflug camera J Cataract
  Refract Surg 2006 32456459
• 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.
  200141(3)1-15.

If the Space Required for Unrestricted Unfolding
is gt 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.

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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
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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.

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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.

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Observation - AcrySof Multipiece MA60AC Vertical
space required for unrestricted unfolding
1
8
4
2
7
3
5
6
4
7
Leading haptic bending force - AcrySof Multipiece
Leading Haptic - Horizontal
Leading haptic - Vertical

• 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
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
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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 clockwise
Therefore, Angle by which Injector
is to be rotated to maintain constant haptic
position throughout Unfolding 170
Anticlockwise
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Vertical Space required Direct Shoot AcrySof
IQ
IOL rotates clockwise 90 - trailing haptic
delivers outside capsular bag
1
8
2
7
8
3
6
5
4
10
Shoot Turn Technique - AcrySof 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
8
2
8
7
3
6
5
4
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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.

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.

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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

• 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

• Trailing haptic placement IOL delivery
• AcrySof IQ (Direct Shoot) 18 eyes
• All eyes
• Optic delivered obliquely
• Trailing haptic manipulated into bag
• AcrySof IQ (Shoot Turn) 12 eyes
• 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 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.