Eyeworld Supplements

2 End velocity settings may be set in linear or fixed modes. I prefer a linear end velocity, but by no means is my preference absolutely stan- dard. Each surgeon will find his/her own preferential settings as he/she gains personal experience with the instrument. The directions for use detail that the AutoSert IOL Injector has been validated using the driving console default setting (1.7 mm/sec, 3 seconds, and 1.7 mm/sec for initial velocity, pause, and final velocity, respectively) at 18 degrees C. Using a higher velocity and shorter pause, especially with high diopter lenses, could induce damage to the IOL and/or the IOL cartridge, affecting successful IOL implantation. While there are many insertion devices available today based on in- cision size and surgeon preference, I believe the AutoSert IOL Injector reduces risk variables because of its controlled and programmable veloc- ity profile, and it frees my second hand. This is a natural step in the evolution of IOL insertion. Now surgeons can have an automated delivery and have their second hand where they want it. ULTRACHOPPER tip The second addition to my surgical portfolio is the ULTRACHOPPER tip (Alcon). I use this new ultrasound tip to prepare the nucleus for pre-chop and/or ultrasound division of the nu- cleus. I ask for the ULTRACHOPPER tip if the patient has a dense nucleus or pseudoexfoliation. After the capsulorhexis and hydrodissection, I use the ULTRACHOPPER tip with torsional ultrasound with 60% power as the maximum. I score the nucleus into four to six segments. Next I use my normal ultrasound tip to sculpt into the scored areas. Some surgeons may use a pre-chopper at this point to help separate the segments. My ULTRACHOPPER tip approach allows me to penetrate a dense nucleus with less ultrasound power and less stress on the zonules. From this point on, I divide the nucleus and remove each fragment in my normal manner. After removal of the nucleus and cortex, I polish the capsule and then use the AutoSert IOL Injector to insert the IOL into the proper position. On a dense cataract case, my order of the procedure is: CCC, hydrodissection, ULTRACHOPPER tip, ultrasound, I/A, AutoSert IOL Injector, and then OVD removal. Both the ULTRACHOPPER tip and AutoSert IOL Injector have been key additions to my surgical armamen- tarium, and they continue to help make cataract surgery a state-of-the- art procedure. Dr. Serafano is in private practice, Complete Eye Care Associates, Los Alamitos, Calif., and is associate clinical professor of ophthal- mology, University of Southern California. Contact information Serafano: serafano@gte.net EW Chicago 2012 Monday, April 23, 2012 2 Redefining control in single-hand IOL injection Serafano continued from page 1 Insertion moves from one-handed devices— and even nurse-assisted methods—to foot pedals, and for good reason I n today's age of refractive cataract surgery, as incision size has been reduced, inserting the IOL into the eye has become increasingly challenging. I think that as incisions get smaller, we have a number of chal- lenges that have not been solved. Placing the injector into the eye, for instance, could cause stretching or tearing of a small, tight incision. Yet a wider incision that facilitates the entry of the hardware of the injector cartridge into the eye seems contrary to our goal of achieving the smallest possible incision. Surgeons have tried to use the incision tunnel as an extension of the cartridge. The problem is when we do that, several things can hap- pen. The common issue is that the lens pushes the eye away. Countertraction is necessary to stabilize the eye and is highly bene- ficial in small incision implantation. Surgeons require one hand to turn the screw on a screw-type injector. The other hand stabilizes the device. Yet there is no countertraction. In some cases, nurses also have helped turn the screw to inject the lens, but three hands are required to achieve countertraction. It seems that we do not have a way of consistently inserting the lens through the smallest possible incision perfectly time after time. European surgeons tried to develop a patient-assisted method, where patients look toward the cartridge, which provides some de- gree of resistance rather than coun- tertraction. My observation is that this is not a very reliable method. Some surgeons have designed a one-handed injector, myself in- cluded. This permits countertraction with an instrument held in the left hand through the side port while the right hand is used to inject. This is very effective. But there is the issue of poten- tial energy. As surgeons start to in- ject a lens using a smaller cartridge, the lens can occasionally demon- strate sudden behavior as it leaves the cartridge. That uncontrolled movement can cause some signifi- cant repercussions. To avoid that, some surgeons prefer a C cartridge, rather than a D cartridge, which has a greater internal surface area to reduce potential energy. However, if we are trying to go through smaller incisions, we want to use the smallest cartridge. To achieve maximum control with the smallest cartridge, a screw-type injector rather than a one-handed injector would be preferable, as long as enough hands are available to reap the benefit of countertraction. Several years ago, I modified the one-handed injection technique to insert the lens with less resistance. I found that it was an advantage to flare the internal incision. My exter- nal incision is slightly smaller than the internal opening. That's my way of inserting the lens with a one- handed injector. Still, I knew that there was room for improvement. Then Alcon (Fort Worth, Texas) developed the footswitch-driven AutoSert IOL Injector handpiece. The INTREPID AutoSert IOL Injector handpiece frees up the surgeon's left hand for countertraction. by Robert H. Osher, M.D. " The AutoSert IOL Injector handpiece gives a reproducible, consistent way of injecting the lens " Robert H. Osher, M.D. Please refer to pages 10-12 for important safety information about the Alcon surgical products described in this supplement.

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