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An intraocular lens carrier
· DISCUSSION While learning this technique, the surgeon may evert the iris with the sponge and this can be associated with loss of pigment from the posterior surface of the iris. In spite of this, the eyes are amazingly quiet postoperatively. With increased experience, the surgeon is able to keep the iris from everting, in most cases, and to minimize its overall trauma. Sodium hyaluronate (Healon ®), frequently used to aid lens insertion, does not facilitate this method. It is only a minor annoyance, however, necessitating a few more sponges to clean the capsule. Another situation that may confront the beginning ECCE surgeon is the patient who presents surgically with a very soft eye and a concave posterior capsule. To remove 12-0'clock cortex in this type of eye, it is necessary to press down on the posterior sclera to elevate the posterior capsule. Bruner, Stark, and Maumenee have used cellulose sponges to wipe away cortical material during triple procedures. 2 They use dry sponges in a sweeping movement and caution that gentleness must be exercised to avoid tearing the capsule in the process. Hyde (personal communication, April 1982) also employed a cortical wiping maneuver during two triple procedures but ruptured the capsule in both cases. One would suspect that he had a dry capsule with a very dry sponge. When removing cortex, a slightly moistened sponge is desirable and a gentle touch is mandatory. During ECCE, there is usually an abundance offluid in the equatorial area which rapidly moistens the sponge and prevents capsule tearing. SUMMARY Cortical wiping with the sponge technique can be a valuable adjunct to the ophthalmologist who wishes to place an intraocular lens implant in a clean bag under direct visualization. As the ECCE surgeon gains experience, there will be less and less cortex to remove at 12 o'clock. The cortical wiping technique can make the difference between success and failure in the difficult case. REFERENCES
1. Welsh RC: Dagger maneuver of cleaning 12:00, in The Gills
Techniques: Modern Manual Extra-capsular Cataract Microsurgery. Miami, The Miami Educational Press, Inc., 1982:29R-30L 2. Bruner WE, Stark WJ, Maumenee AE: Combined keratoplasty, cataract extraction, and intraocular lens implantation: Experience at the Wilmer Institute. Ophthalmic Surg 12:657-660, 1981
An intraocular lens carrier Osvaldo I. Lopez, M.D. Andrew Q. Lewicky, M. D. Manuel Stillerman, M.D. Gerald Horn, M. D. Michael Korey, M. D. Raymond Petkus, M.D. Norman Lewis, M.D. Chicago, Illinois
ABSTRACT An intraocular lens carrier for anterior and posterior chamber lenses has been developed. The device consists of a protective polypropylene envelope with an insertion leaf, which allows anterior chamber lenses to be inserted without iris or corneal touch and posterior chamber lenses to be guided into the ciliary sulcus or capsular bag with minimal or no haptic manipulation. Key Words: intraocular lens carrier, polypropylene, Sheets glide
Recent advances in anterior and posterior chamber lens design have minimized undesirable side effects of intraocular lenses and have improved better postoperative results. Lens insertion, however, remains an unpredictable and often difficult procedure. Traditional methods for inserting anterior chamber lenses may result in iris tuck, loss of vitreous and, occasion~lly, corneal endothelial' contact. Posterior lens insertion requires haptic manipulation for placement in either the ciliary sulcus or the capsular bag, and this is often difficult. Excessive manipulation may result in vitreous loss from rupture of the posterior capsule or its supporting zonules, pigment dispersion and/or iris distortion from iris trauma and, occasionally, corneal endothelial contact. These result in greater postoperative morbidity. In 1978, Sheets reported the use of a thin polypropylene guide to facilitate intraocular lens (IOL) placement. 1 Such glides can be used to protect the posterior capsule by inserting the lens along the superior surface, or to protect the cornea by inserting the lens along the inferior surface. In either case the IOL is delivered with open haptics that must be manipulated for proper lens placement. Reprint requests to Osvaldo I. Lopez, M. D. , Chicago Eye Institute, 4200 North Central Avenue, Chicago, Illinois 60634.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
477
Anis described a technique in which two Sheets glides, one slightly longer than the other, arc superimposed and inserted between two limbal sutures 8 mm apart. 2 This technique can be used with the Anis lens 2 or other IOLs to provide protection both superior and inferior to the IOL. Anis was also the first to propose a "sleeve" for the delivery of IOLs.3 Inserting posterior chamber lenses with closed haptics through any type of delivery tube requires a means of ensuring that the IOL haptics open posterior to the pupillary plane, and a means of guiding the IOL into either the ciliary sulcus or capsular bag. The lens carri~r we have developed differs from the glides and 'sleeves previously used in its control of these requirements.
For anterior chamber lens insertion the carrier is positioned with the insertion leaf posterior to the envelope on the surface of the iris. Figures 1 and 2 demonstrate its position and the insertion technique. Iris tuck is unlikely because the IOL is glided through the prepositioned carrier without direct iris contact. The cornea is protected by the surrounding polypropylene envelope. The carrier also tamponades the pupil, minimizing the possibility of vitreous loss .
SURGICAL TECHNIQUE The cartier (Figure l),'made of polypropylene, resembles a flattened tube 4 mm longer at the tapered end of one surface, the insertion leaf. The carrier's central diameter is 7.40 mm; its two surfaces are less than 0.002 inches thick. (A Sheets glide is 0.003 inches.) This thin cross-section gives the carrier a flexibility similar to that of a Sheets glide. When an implant is positioned within the glide, it is surrounded by the carrier envelope.
Fig. 2.
Fig. 1.
478
(Lopez) Carrier placed in anterior chamber angle with insertion leaf posterior to envelope.
(Lopez) Anterior chamber lens slides through carrier into position.
Posterior chamber lenses are implanted with the carrier's insertion leaf anterior to the carrier envelope and placed in the ciliary sulcus or in the inferior capsular bag (Figure 3). Prior to insertion, the posterior chamber lens is rotated within the carrier envelope so the haptics are closed (Figure 4). The implant is then glided through the carrier, the hap tics opening under the insertion leaf beyond the carrier envelope (Figure 5). This guides the lens into the ciliary sulcus or capsular bag as desired. Leaving large capsular flaps nasally and medially and positioning the IOL haptics to open horizontally rather than vertically facilitates capsular bag fixation. The tapered insertion leaf may also be utilized to dilate a miotic pupil with essentially no trauma to the iris. Although the carrier has the same flexibility as a Sheets glide, it should be held firmly while delivering the implant to avoid distal rupture of the capsule or zonules.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
Fig. 3.
(Lopez) Insertion leaf placed in capsular bag or ciliary sulcus as desired. Posterior chamber lens engaged in carrier, with haptics closing after one-quarter rotation.
Fig. 5.
(Lopez) Raptics open under insertion leaf in capsular bag or ciliary sulcus.
SUMMARY A lens carrier for inserting anterior and posterior chamber lenses has been developed. Gliding the lens through the carrier's polypropylene envelope with its enclosed sides and open distal leaf simplifies lens insertion and reduces lens manipulation . When used for posterior chamber lenses, the carrier protects the endothelium and posterior capsule while minimizing pigment dispersion; when the carrier is reversed for anterior chamber lenses, it protects the endothelium while tamponading the pupil. REFERENCES
1. Sheets JR , Maida JW: Lens glide in implant surgery. Arch
Ophthalmol 96:145-146, 1978 2. Anis AY: The Anis posterior chamber capsular lens. Cant Intraacul Lens Med J 6:286-290, 1980 3. Anis AY: United States Patent 4,251,887, February 24, 1981
Fig. 4.
(Lopez) Lens is glided through carrier using simple blunt "pusher." AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
479
1. Welsh RC: Dagger maneuver of cleaning 12:00, in The Gills
Techniques: Modern Manual Extra-capsular Cataract Microsurgery. Miami, The Miami Educational Press, Inc., 1982:29R-30L 2. Bruner WE, Stark WJ, Maumenee AE: Combined keratoplasty, cataract extraction, and intraocular lens implantation: Experience at the Wilmer Institute. Ophthalmic Surg 12:657-660, 1981
An intraocular lens carrier Osvaldo I. Lopez, M.D. Andrew Q. Lewicky, M. D. Manuel Stillerman, M.D. Gerald Horn, M. D. Michael Korey, M. D. Raymond Petkus, M.D. Norman Lewis, M.D. Chicago, Illinois
ABSTRACT An intraocular lens carrier for anterior and posterior chamber lenses has been developed. The device consists of a protective polypropylene envelope with an insertion leaf, which allows anterior chamber lenses to be inserted without iris or corneal touch and posterior chamber lenses to be guided into the ciliary sulcus or capsular bag with minimal or no haptic manipulation. Key Words: intraocular lens carrier, polypropylene, Sheets glide
Recent advances in anterior and posterior chamber lens design have minimized undesirable side effects of intraocular lenses and have improved better postoperative results. Lens insertion, however, remains an unpredictable and often difficult procedure. Traditional methods for inserting anterior chamber lenses may result in iris tuck, loss of vitreous and, occasion~lly, corneal endothelial' contact. Posterior lens insertion requires haptic manipulation for placement in either the ciliary sulcus or the capsular bag, and this is often difficult. Excessive manipulation may result in vitreous loss from rupture of the posterior capsule or its supporting zonules, pigment dispersion and/or iris distortion from iris trauma and, occasionally, corneal endothelial contact. These result in greater postoperative morbidity. In 1978, Sheets reported the use of a thin polypropylene guide to facilitate intraocular lens (IOL) placement. 1 Such glides can be used to protect the posterior capsule by inserting the lens along the superior surface, or to protect the cornea by inserting the lens along the inferior surface. In either case the IOL is delivered with open haptics that must be manipulated for proper lens placement. Reprint requests to Osvaldo I. Lopez, M. D. , Chicago Eye Institute, 4200 North Central Avenue, Chicago, Illinois 60634.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
477
Anis described a technique in which two Sheets glides, one slightly longer than the other, arc superimposed and inserted between two limbal sutures 8 mm apart. 2 This technique can be used with the Anis lens 2 or other IOLs to provide protection both superior and inferior to the IOL. Anis was also the first to propose a "sleeve" for the delivery of IOLs.3 Inserting posterior chamber lenses with closed haptics through any type of delivery tube requires a means of ensuring that the IOL haptics open posterior to the pupillary plane, and a means of guiding the IOL into either the ciliary sulcus or capsular bag. The lens carri~r we have developed differs from the glides and 'sleeves previously used in its control of these requirements.
For anterior chamber lens insertion the carrier is positioned with the insertion leaf posterior to the envelope on the surface of the iris. Figures 1 and 2 demonstrate its position and the insertion technique. Iris tuck is unlikely because the IOL is glided through the prepositioned carrier without direct iris contact. The cornea is protected by the surrounding polypropylene envelope. The carrier also tamponades the pupil, minimizing the possibility of vitreous loss .
SURGICAL TECHNIQUE The cartier (Figure l),'made of polypropylene, resembles a flattened tube 4 mm longer at the tapered end of one surface, the insertion leaf. The carrier's central diameter is 7.40 mm; its two surfaces are less than 0.002 inches thick. (A Sheets glide is 0.003 inches.) This thin cross-section gives the carrier a flexibility similar to that of a Sheets glide. When an implant is positioned within the glide, it is surrounded by the carrier envelope.
Fig. 2.
Fig. 1.
478
(Lopez) Carrier placed in anterior chamber angle with insertion leaf posterior to envelope.
(Lopez) Anterior chamber lens slides through carrier into position.
Posterior chamber lenses are implanted with the carrier's insertion leaf anterior to the carrier envelope and placed in the ciliary sulcus or in the inferior capsular bag (Figure 3). Prior to insertion, the posterior chamber lens is rotated within the carrier envelope so the haptics are closed (Figure 4). The implant is then glided through the carrier, the hap tics opening under the insertion leaf beyond the carrier envelope (Figure 5). This guides the lens into the ciliary sulcus or capsular bag as desired. Leaving large capsular flaps nasally and medially and positioning the IOL haptics to open horizontally rather than vertically facilitates capsular bag fixation. The tapered insertion leaf may also be utilized to dilate a miotic pupil with essentially no trauma to the iris. Although the carrier has the same flexibility as a Sheets glide, it should be held firmly while delivering the implant to avoid distal rupture of the capsule or zonules.
AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
Fig. 3.
(Lopez) Insertion leaf placed in capsular bag or ciliary sulcus as desired. Posterior chamber lens engaged in carrier, with haptics closing after one-quarter rotation.
Fig. 5.
(Lopez) Raptics open under insertion leaf in capsular bag or ciliary sulcus.
SUMMARY A lens carrier for inserting anterior and posterior chamber lenses has been developed. Gliding the lens through the carrier's polypropylene envelope with its enclosed sides and open distal leaf simplifies lens insertion and reduces lens manipulation . When used for posterior chamber lenses, the carrier protects the endothelium and posterior capsule while minimizing pigment dispersion; when the carrier is reversed for anterior chamber lenses, it protects the endothelium while tamponading the pupil. REFERENCES
1. Sheets JR , Maida JW: Lens glide in implant surgery. Arch
Ophthalmol 96:145-146, 1978 2. Anis AY: The Anis posterior chamber capsular lens. Cant Intraacul Lens Med J 6:286-290, 1980 3. Anis AY: United States Patent 4,251,887, February 24, 1981
Fig. 4.
(Lopez) Lens is glided through carrier using simple blunt "pusher." AM INTRA-OCULAR IMPLANT SOC J-VOL. 9, FALL 1983
479