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Hydroimplantation: Foldable intraocular lens implantation without an ophthalmic viscosurgical device

Tak, Harshul MS

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Journal of Cataract & Refractive Surgery: March 2010 - Volume 36 - Issue 3 - p 377-379
doi: 10.1016/j.jcrs.2009.10.042
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Abstract

Numerous reports demonstrate that an ophthalmic viscosurgical device (OVD) left in the eye after cataract surgery will probably induce a postoperative intraocular pressure (IOP) spike.1,2 Residual OVD within the capsular bag may also cause the capsular bag distension syndrome.3,4

After it is used for intraocular lens (IOL) implantation, an OVD must be thoroughly removed from the anterior chamber, particularly from behind the IOL optic. However, many surgeons prefer not to place the irrigation/aspiration (I/A) tip behind the optic for fear of inducing a posterior capsule rupture. Today, with small incision sizes of 1.6 to 1.8 mm in microincisional cataract surgery, it has become increasingly difficult to remove the OVD from behind the IOL completely. I describe a hydroimplantation technique for insertion of a foldable posterior chamber IOL (PC IOL) without use of an OVD.

SURGICAL TECHNIQUE

Irrigation/aspiration is completed, but no OVD is injected into the eye. To prepare the incision, the automated irrigation cannula is kept in the eye and, if required, the incision is enlarged to the desired size with a keratome (Figure 1) (Video).

Figure 1
Figure 1:
Preparing the incision: Irrigation cannula is kept in the eye and the incision is enlarged to the desired size.

To load the PC IOL, a small amount of balanced salt solution (BSS) is put in the cartridge and the tip, which is sufficient to lubricate the IOL. (Alternatively, a very small amount of OVD can be painted on the cartridge hub and tip or a little OVD can be put in the nozzle and balanced salt solution can be put into the cartridge hub). A 1-piece acrylic IOL is grasped with the forceps, put in the cartridge, and folded properly (Figure 2). The IOL is brought to the end of the cartridge tip.

Figure 2
Figure 2:
Loading the IOL: A 1-piece acrylic IOL is loaded with balanced salt solution in the cartridge and tip.

To implant the IOL, the irrigation cannula of the bimanual I/A phaco machine is kept on continuous irrigation mode and introduced through the left side port (right if the surgeon is left handed). The irrigation cannula should be loose enough in the side-port incision to allow the maneuverability required during IOL insertion. After it is placed in the eye, the irrigation cannula provides excellent stability and positioning to the eye and it also keeps the anterior chamber and capsular bag well distended for PC IOL insertion.

The tip of the cartridge is then inserted into the anterior chamber (Figure 3, A), and the leading haptic and optic of the PC IOL are slowly injected into the capsular bag (Figure 3, B). If air bubbles occur during insertion of the IOL, they will be washed away because of the continuous flow of the irrigation fluid. If required, the tip of the irrigation cannula can be used to unfold the leading haptic and guide it into the capsular bag. The tip of the irrigation cannula lying over the unfolding optic of the IOL also helps prevent tilting and inversion of the IOL. The trailing haptic, which remains in the anterior chamber, is dialed with the help of a Lester hook. The depth of the anterior chamber and capsular bag is well maintained by the irrigation fluid (Figure 3, C and D). The Lester hook sometimes gets trapped in the closed loop haptics of some IOL types. If this occurs, the optic of the IOL is pushed slightly downward with the tip of the irrigating cannula and, at the same time, the Lester hook is pulled upward. This maneuver helps release the Lester hook safely without damaging the posterior capsule. Irrigation/aspiration is not needed after the IOL is implanted because no OVD was used. Instead, the incisions are hydro stitched.

Figure 3
Figure 3:
Implanting the IOL. A: The irrigation cannula is inserted into the eye on continuous irrigation mode; the anterior chamber and capsular bag are well formed by BSS. The tip of the cartridge is inserted into the anterior chamber, and the IOL is gradually injected into the eye. B: The leading haptic and optic of the IOL are inserted into the capsular bag. C: The trailing haptic is dialed with the help of the Lester hook. D: The entire IOL is implanted in the capsular bag.
Figure 3
Figure 3:
(continued)
Figure 3
Figure 3:
(continued)
Figure 3
Figure 3:
(continued)

Clinical Experience

I have used the hydroimplantation technique for more than a year and implanted approximately 400 1-piece foldable acrylic PC IOLs with no posterior capsule rupture or other complication.

DISCUSSION

The importance of preventing corneal endothelium contact with IOLs and other surgical instruments was recognized early in implantation surgery. Materials used to avert contact included air, balanced salt solution, and OVDs. These materials are optically clear and sterile and maintain the anterior chamber space during intraocular surgical manipulations.

The advent of self-sealing small-incision cataract surgery by phacoemulsification with foldable IOL implantation may negate the need for the unique properties of OVDs during IOL implantation.

The use of an OVD for implantation of a foldable IOL is currently the standard technique in cataract surgery.5 Various techniques have been described to implant IOLs without or with minimal use of an OVD, such as the use of the anterior chamber maintainer,6,7 the KS-VF injector,8 the empty-bag technique,9 and the ultimate soft-shell technique.10 All these techniques aim to reduce the use of OVD for IOL implantation; however, to date, no technique is being used universally because of the limitations. The hydroimplantation technique can be easily adopted by every surgeon and for any single-piece acrylic foldable IOL. Since more IOLs used today are of this design, the technique is very useful.

The technique has limitations in cases with compromised capsulorhexes and those with posterior capsule tears. I have also used this technique for implantation of a nonfoldable 5.0 mm, 5.25 mm, and 6.0 mm poly(methyl methacrylate) PC IOL but have had no experience with a 3-piece foldable PC IOL. I do not recommend using the technique for IOLs that open abruptly, such as foldable silicone IOLs.

The hydroimplantation technique has the advantage of increased efficiency, reduced surgical time and cost, no need for OVD removal from behind the IOL, no need for additional instrumentation, no OVD-induced elevated IOP postoperatively, and no risk of early capsular bag distension syndrome.

REFERENCES

1. Rainer G, Menapace R, Findl O, Georgopoulos M, Kiss B, Petternel V. Intraocular pressure after small incision cataract surgery with Healon5 and Viscoat. J Cataract Refract Surg. 2000;26:271-276.
2. Holzer MP, Tetz MR, Auffarth GU, Welt R, Völcker H-E. Effects of Healon 5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. J Cataract Refract Surg. 2001;27:213-218.
3. Davison JA. Capsular bag distension after endophacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg. 1990;16:99-108.
4. Holtz SJ. Postoperative capsular bag distension. J Cataract Refract Surg. 1992;18:310-317.
5. Leaming DV. Practice styles and preferences of ASCRS members—2003 survey. J Cataract Refract Surg. 2004;30:892-900.
6. Shingleton BJ, Mitrev PV. Anterior chamber maintainer versus viscoelastic material for intraocular lens implantation: case-control study. J Cataract Refract Surg. 2001;27:711-714.
7. Blumenthal M, Assia E, Chen V, Avni I. Using an anterior chamber maintainer to control intraocular pressure during phacoemulsification. J Cataract Refract Surg. 1994;20:93-96.
8. Shimizu K, Kobayashi K, Takayama S, Zhaobin G. Preloaded injector for intraocular lens implantation without the use of ophthalmic viscosurgical devices. J Cataract Refract Surg. 2008;34:1157-1160.
9. Cionni RJ, Temel M, Marques DMV, Marques FF. Empty-bag technique for acrylic intraocular lens implantation using Healon5. J Cataract Refract Surg. 2004;30:453-456.
10. Arshinoff SA. Using BSS with viscoadaptives in the ultimate soft-shell technique. J Cataract Refract Surg. 2002;28:1509-1514.

SUPPLEMENTARY DATA

Figure
Figure:
Video. This video describes a technique for implantation of single-piece acrylic foldable IOL with the help of the irrigation cannula of the phacoemulsification machine without using OVDs in the eye. The irrigating cannula introduced through a side port gives excellent stability and positioning to the eye; if required, the cannula tip can be used to guide the leading haptic of the IOL into the bag. The fluid coming from the side port via the bimanual irrigation cannula keeps the capsular bag and anterior chamber adequately formed while the foldable IOL is inserted. The hydroimplantation technique has the advantage of increased efficiency, reduced surgical time and cost, no need for OVD removal from behind the IOL, no need for additional instrumentation, no OVD-induced IOP elevation postoperatively, and no risk for early capsular bag distension syndrome.
Figure
Figure:
No Caption available.
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