September 2008




Snowman technique to weather all seasons

by Maxine Lipner Senior EyeWorld Contributing Editor



A cool new method helps to make toric lens implantation child’s play

When implanting an AcrySof toric IOL (Alcon, Fort Worth, Texas) having a meticulous technique is particularly important with patients paying extra for the premium lens. Recently David V. Leaming, M.D., Palm Springs, Calif., devised a new method to help insure easy implantation of the lens. The technique which he dubbed the “snowman” method helps to prevent spinning of this toric IOL and allows for faster unfolding.

With the technique, Dr. Leaming essentially builds a three tier snowman in the eye out of viscoelastic and balanced salt solution. “I inject DisCoVisc (Alcon) until I get a little ball of it, [and go on] to where it creates an enlarging ball of viscoelastic in the anterior chamber,” Dr. Leaming said. “Then the next step if I’m using viscoelastic in the bag is to place the cannula in the bag and start the second ball of viscoelastic in there.” On top of these two balls of viscoelastic, Dr. Leaming will many times top this off with a much smaller ball. “This is probably ¼ to 1/5 the size of the other two balls of viscoelastic,” he said. “It is [placed] just at the entrance wound.” The idea of this third ball is to give practitioners space where the lens is inserted.

Making the connection

The method evolved from one developed by Steven Arshinoff, M.D., University of Toronto, known as the “Ultimate Soft Shell technique.” “I was looking to use Dr. Arshinoff’s ultimate soft shell technique where you essentially seal off the interior capsulorrhexis with viscoelastic and then you fill the capsular bag with balanced salt solution,” Dr. Leaming said. In working with this method it occurred to Dr. Leaming that the use of a ball of balanced salt solution here could be advantageous. “A round ball that is getting bigger and bigger is a nice form because as it forms it makes a plug over the capsulorrhexis,” Dr. Leaming said. With this in mind, he began to substitute balanced salt solution. at the base of the “snowman” for viscoelastic when using toric lenses. Dr. Leaming finds that there are several advantages to using balanced salt solution in conjunction with the Snowman technique here. “When I insert the AcrySof toric IOL in it opens up quicker because it’s not opening against the viscoelastic—it is opening against balanced salt solution,” he said. “Also, when I remove the viscoelastic at the end of the case instead of the lens sometimes spinning and turning in the bag, if you’re removing balanced salt solution, it tends to more or less stay put.” As a result, he finds that he doesn’t have to worry as much about turning or repositioning the toric lens at the end of the case.

While the technique is relatively straightforward, there is one key here. Dr. Leaming recommends zigzagging the cannula during the removal process. “Once you fill the bag with balanced salt solution if you withdraw the cannula directly from the wound, sometimes the balanced salt solution will follow,” Dr. Leaming said. “If you zigzag it as you’re removing the cannula from the bag it tends to seal and you don’t get any loss of balanced salt solution from the bag.”

Putting another spin

Richard R. Burns, M.D., San Diego, recently tried the new method and found it to be an extremely helpful one. He has, however, made a small change. “I tend to use a little less viscoelastic than Dr. Leaming does,” he said. “But I did find that it did do what we wanted it to do which was to stop the properllering [motion] of the implant once it is seated.”

Dr. Burns reduced the amount of DisCoVisc due to concerns about the viscoelastic. “I didn’t fill the chamber with DisCoVisc, because in my past history with the DisCoVisc I would get some pressure elevations and I didn’t like that,” he said. Instead he opted to just coat the endothelial side of the cornea with the DisCoVisc and proceeded from there. “I then put a big bolus of the DisCoVisc right at the entrance wound and then put the balanced salt solution solution in to deepen the chamber,” he said. In addition to keeping the lens from spinning, Dr. Burns found that Dr. Leaming’s technique also made it easier to ensure that all of the viscoelastic was out of the eye following the procedure. “What you’re doing is you’re able to get the implant in the bag and not have any viscoelastic behind it that you have to remove,” Dr. Burns said. This coupled with the fact that the lens stayed put made this a technique that Dr. Burns plans to use for all his toric cases in the future. “I would say that anytime you put something where you want it to go and it stays there, you’ve eliminated of the unknowns,” Dr. Burns said. “In the case of the toric lens, that’s a critical step.”

Editors’ note: Dr. Leaming conducts the annual ASCRS and ESCRS surveys sponsored by Advanced Medical Optics (Santa Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.). Dr. Burns has no financial interests related to his comments.


Burns: 951-296-9300,

Leaming: 760-320-7051,

Snowman technique to weather all seasons Snowman technique to weather all seasons
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