1. Quick & Safe Techniques for AcrySof Delivery Dr. Suven Bhattacharjee, MS, DO, DNB, FRF. Complete care Eye Clinic Kolkata, INDIA No Financial Interest suvenb@gmail.com ‘Turn, Shoot & Unturn’ for the Multipiece ‘Shoot and Turn’ for the Single Piece

2. 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 If the Space Required for Unrestricted Unfolding is > 6mm Leading haptic has to be bent against PC for safe unfolding in AC / Cap bag CZ stress is directly proportional to: 1.Space required for unrestricted unfolding and 2.Force required to bend the leading haptic. 1.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 2.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.

3. 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

4. Laboratory Video Set up Top Cam Front Cam Microscope head Slit Lamp 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. 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.

5. 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.

6. Observation - AcrySof Multipiece MA60AC Vertical space required for unrestricted unfolding 1 2 356 7 8 4 4

7. Leading haptic bending force - AcrySof Multipiece Leading Haptic - Horizontal 1 st mm: 399 + 11 mg 2 nd mm: 855 + 19 mg 3 rd mm: 1420 + 72 mg Leading haptic - Vertical 1 st mm: 30 + 7 mg 2 nd mm: 94 + 13 mg 3 rd mm: 168 + 21 mg 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 Leading haptic orientation – Prior to Unfolding

8. 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 1 st frame over last frame during unfolding shows ‘arc of sweep’ of leading haptic 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 170°

9. Vertical Space required – Direct Shoot – AcrySof IQ 1 2 3 5 6 7 8 4 8 IOL rotates clockwise 90 ̊ - trailing haptic delivers outside capsular bag

10. ‘Shoot & Turn’ Technique - AcrySof IQ 1 2 3 5 6 7 8 4 9 8 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’

11. New Techniques for Acrysof IOL Delivery 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. Multipiece - Turn, Shoot and Unturn 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. Single piece - Shoot and Turn

12. 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.