Transcript Document

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
[email protected]
No Financial Interest
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
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 > 6mm
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
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
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 - AcrySof Multipiece MA60AC
Vertical space required for unrestricted unfolding
1
8
4
2
3
4
7
5
6
Leading haptic bending force - AcrySof Multipiece
Leading haptic - Vertical
Leading Haptic - Horizontal
1st mm: 399 + 11 mg
•1st mm: 30 + 7 mg
2nd mm: 855 + 19 mg
•2nd mm: 94 + 13 mg
3rd mm: 1420 + 72 mg
•3rd 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
AcrySof 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
Vertical Space required – Direct Shoot – AcrySof IQ
IOL rotates clockwise 90̊ - trailing haptic delivers
outside capsular bag
1
8
2
7
8
3
6
4
5
‘Shoot & Turn’ Technique - AcrySof IQ
Haptics colour 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
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
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
Trailing haptic placement & IOL delivery
•
•
AcrySof MP (Direct Shoot) 20 eyes
AcrySof IQ (Direct Shoot) 18 eyes
–
8 eyes – leading haptic into bag directly
–
All eyes
–
12 eyes – Leading haptic orientation corrected in AC
–
Optic delivered obliquely
–
Trailing haptic manipulated into bag
and then placed in the bag
1 eye - haptic stuck on Iris, endoth touch
–
–
•
AcrySof IQ (Shoot & Turn) 12 eyes
6 eyes – OVD top up during delivery
–
AcrySof 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 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.