1. Assessment of Incisional Wounds Before and After Intraocular Lens Insertion In Microincision Cataract Surgery
Akimi Kizawa1), Shuichiro Hayashi2),
Daijiro Kurosaka1)
1) Department of Ophthalmology, Iwate Medical University
School of Medicine
2) The Center for Electron Microscopy and Bio-Imaging
Reserch, Iwate Medical University

2. Introduction
Currently, cataract removal is performed through an incision about 1.2 mm in width for bimanual PEA and about 1.8 mm in width for coaxial PEA.
Intraocular lens (IOL) can be inserted using various techniques through an ultra-small incision. However, it is unclear whether the insertion of IOL damages ocular tissue around the wound site.
To examine tissue damage around the wound site after IOL insertion, we evaluated the difference between the wound width before and after IOL insertion and observed the wound site with scanning electron microscope (SEM).

3. Materials Slit knives 1.9mm～3.0mm (Kai Industries co.)① ①
Slit knives
1.9mm～3.0mm
(Kai Industries co.)
Cartridges and IOLs ②
Photo
cartridge
IOL ①
F18
Y60H ② C1
VA60BB ③ E1
YA60BBR ④
MonarchⅡC
SA60AT ⑤
MonarchⅢD
SN60WF ③ ④ ⑤
①,②,③:HOYA (in Japan)
④,⑤:Alcon

4. Methods
After the corneal incision was made with 1.9 to 3.0 mm keratome in five porcine eyes, varieties of IOLs were inserted. Incision widths before and after IOL insertion were measured using an inner gauge.　　　 　　 　　　
The porcine tissue around the corneal incisions were observed by SEM after inserting IOLs (Y60H with various widths and SN60AT at a 2.0mm).

5. Results
The incision sizes before IOL insertion were smaller than the sizes of the slit knives although the incision sizes were proportional to the size of the slit knives. (Fig.1).
After each IOL insertion, most of the incisions were enlarged. Although, the resistance ability of the human corneal tissue is different from that of a porcine, this should not decrease the value of this data(Fig.2). In addition, the smaller the sizes of the slit knives used, the smaller the difference between the incision sizes before and after IOL insertion (Fig.3).
In SEM, tissue damage was not observed at the wound made with slit knives more than 2.5 mm and before the Y60H insertion (Fig.4).
However, tissue damage such as elongation and rupture of collagen fiber was observed at wound after the Y60H insertion through incisions made with 1.9 to 2.4mm slit knives (Fig.5).
The results are summarized as follows:
The final incision width for Y60H was 2.5 mm, and among the various IOLS, the level of stress to the tissue was the lowest.
Furthermore, when incisions increased in size after IOL insertion, scanning electron microscopy showed damaged and stretched corneal collagen fibers.

6. Incision widths before
1.00
1.50
2.00
2.50
3.00
1.9
2.0
2.2
2.3
2.4
2.5
2.65
2.75
2.85
3.0
Slit knife（ｍｍ）
Incision widths before
IOL insertion（ｍｍ）
Y60H
YA60BBR
VA60BB
SA60AT
SN60WF
Figure 1.Slit knife and incision widths before IOL insertion
Incision widths before IOL insertion were measured using an inner gauge, and resulted in a smaller incision than the actual slit knife widths.

7. Figure 2. Slit knife and incision widths after IOL insertion
1.50
2.00
2.50
3.00
3.50
1.9
2.0
2.2
2.3
2.4
2.5
2.65
2.75
2.85
3.0
Slit knife（ｍｍ）
Incision widths after
IOL insertion（ｍｍ）
Y60H
YA60BBR
VA60BB
SA60AT
SN60WF
Figure 2. Slit knife and incision widths after IOL insertion
With each IOL, the smaller the slit knife width, the greater the incision width after IOL insertion.

8. 0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.9
2.0
2.2
2.3
2.4
2.5
2.65
2.75
2.85
3.0
Slit knife（ｍｍ）
Differences in incision widths
before and after IOL insertion（ｍｍ）
Y60H
YA60BBR
VA60BB
SA60AT
SN60WF
Figure 3. Slit knife and differences in incision widths before and after IOL insertion
The smaller the sizes of the slit knives used, the smaller the difference between the incision sizes before and after IOL insertion.
There is no difference between the incision width before and after SA60AT, SN60WF, and Y60H insertion with an incision made with a 3.0 mm, a 2.75 mm, and a 2.75 mm slit knife, respectively.

9. Normal tissue
A cross section made by
a slit knife
Figure 4. Scanning electron microscopic image of the corneal incision made with a 2.0 mm slit knife before IOL insertion
The collagen fiber of the incision margin is the same as normal tissue.

10. Y60H
SA60AT
×10,000
Figure 5. The collagen fiber of the corneal incision margin made with a 2.0 mm slit knife after IOLs (Y60H and SA60AT) insertion
Collagen fiber around the incision after each IOL insertion were elongated (orange circle) and ruptured (green circle).

11. Discussion
The present study shows that an incision, made with less than a 2.5 mm slit knife, enlarged and damaged the corneal tissue. Although, the resistance ability of the human corneal tissue is different from that of a porcine, this should not decrease the value of this data. The difference between the incision size of human eyes before and after IOL insertion might be smaller than that of porcine eyes. Further studies are required to determine the adequate incision size for human eyes.
However, this study suggests that the forcible insertion of the IOLs may damage tissue, leading to the deterioration of self-sealing and increasing the risk of induced astigmatism.
With the previous SA60AT, IOL insertion is based on the wound assist method, and IOLs are directly involved with tissue damage. However, when a cartridge is inserted, the cartridge increase the size of incisions. Although an incision as small as 1.6 mm is recommended for Y60H, the results suggest that the smaller the incision, the greater the tissue damage.

12. Conclusions
When IOL inserted through ultra-small incision, the tissue damage, such as an elongation of collagen fiber, may occur. So insertion of the IOL through too small incision should be avoided.