Two new innovations expand options in cataract surgery: AutoSert IOL Injector and ULTRACHOPPER tip

AutoSert IOL Injector

IOL insertion isn’t a simple “push” and it’s in. That’s a good thing, because investing a little time to understand IOL insertion—especially what is currently at the cusp of innovation —should help deliver superior outcomes for cataract patients.

The newest addition to my surgical portfolio on the INFINITI Vision System (Alcon, Fort Worth, Texas) is the INTREPID AutoSert IOL Injector (Alcon). AutoSert is an automated IOL injector handpiece that enables me to control advancement of the IOL with the INFINITI system foot pedal. This frees my other hand to stabilize the eye with a second instrument, which can also be used to adjust the position of the IOL as it is entering the capsular bag.

When I use MONARCH delivery systems (Alcon), I don’t have this same ability. I need both hands on the MONARCH insertion device to hold the injector and advance the plunger. Therefore I don’t have a convenient way to stabilize the eye. In that scenario, if the patient starts to move, I must press the cartridge against the incision to keep the IOL from being delivered outside the eye.

Other surgeons have used a onehanded injector or a three-handed technique (so to speak). In the threehanded technique, one hand is on the MONARCH injector, one hand is on the second instrument in the side port, and a surgical technician’s hand advances the MONARCH plunger and IOL. However, not everyone is willing to execute a three-handed delivery. Perhaps a more controlled velocity is going to make a difference in the integrity of the incision.

In my experience, the INTREPID AutoSert IOL Injector allows for a higher level of control in IOL delivery. In addition to the foot pedal control of the IOL advance, the INFINITI system software has three parameter settings the surgeon can control to meet his/her unique requirements. These parameters are: initial velocity, pause time, and final velocity. Based on my experience with hundreds of procedures with the AutoSert IOL Injector—from initial tests on cadaver eyes to clinical procedures on human eyes—these parameter settings offer advantages over using a manual injector.

With the AutoSert IOL Injector, the software will advance the IOL, using the initial velocity down the cartridge to the ready-to-insert position. Then when the surgeon presses the foot pedal, the AutoSert IOL Injector will advance the IOL to the end of the cartridge, where the software will pause the plunger advancement for a period of time. This pause time, set by the surgeon on the INFINITI system console, allows the IOL time to form in the tip of the cartridge and, in my experience, allows me time to prepare for insertion.

After the pause time elapses, and with my foot still depressed on the foot pedal, the AutoSert IOL Injector will begin to move the IOL out of the cartridge at the final velocity. The surgeon can set this final velocity to be fixed or linear. Linear velocity is like an accelerator you use when driving a car. As I push down on the foot pedal, it increases the velocity of insertion. If I want to slow down, I come off the foot pedal a bit.

End velocity settings may be set in linear or fixed modes. I prefer a linear end velocity, but by no means is my preference absolutely standard. Each surgeon will find his/her own preferential settings as he/she gains personal experience with the instrument.

The directions for use detail that the AutoSert IOL Injector has been validated using the driving console default setting (1.7 mm/sec, 3 seconds, and 1.7 mm/sec for initial velocity, pause, and final velocity, respectively) at 18 degrees C. Using a higher velocity and shorter pause, especially with high diopter lenses, could induce damage to the IOL and/or the IOL cartridge, affecting successful IOL implantation.

While there are many insertion devices available today based on incision size and surgeon preference, I believe the AutoSert IOL Injector reduces risk variables because of its controlled and programmable velocity profile, and it frees my second hand.

This is a natural step in the evolution of IOL insertion. Now surgeons can have an automated delivery and have their second hand where they want it.

ULTRACHOPPER tip

The second addition to my surgical portfolio is the ULTRACHOPPER tip (Alcon). I use this new ultrasound tip to prepare the nucleus for pre-chop and/or ultrasound division of the nucleus. I ask for the ULTRACHOPPER tip if the patient has a dense nucleus or pseudoexfoliation.

After the capsulorhexis and hydrodissection, I use the ULTRACHOPPER tip with torsional ultrasound with 60% power as the maximum. I score the nucleus into four to six segments. Next I use my normal ultrasound tip to sculpt into the scored areas. Some surgeons may use a pre-chopper at this point to help separate the segments. My ULTRACHOPPER tip approach allows me to penetrate a dense nucleus with less ultrasound power and less stress on the zonules. From this point on, I divide the nucleus and remove each fragment in my normal manner.

After removal of the nucleus and cortex, I polish the capsule and then use the AutoSert IOL Injector to insert the IOL into the proper position.

On a dense cataract case, my order of the procedure is: CCC, hydrodissection, ULTRACHOPPER tip, ultrasound, I/A, AutoSert IOL Injector, and then OVD removal. Both the ULTRACHOPPER tip and AutoSert IOL Injector have been key additions to my surgical armamentarium, and they continue to help make cataract surgery a state-of-theart procedure.

Dr. Serafano is in private practice, Complete Eye Care Associates, Los Alamitos, Calif., and is associate clinical professor of ophthalmology, University of Southern California. Contact information Serafano: serafano@gte.net