1) The document discusses the evolution of cataract surgery techniques and intraocular lens (IOL) insertion methods over time, from manual insertion to preloaded injector systems. 2) Preloaded injector systems have advantages over manual insertion methods like reducing risks of contamination, errors, and surgical time while improving reproducibility and safety. 3) The document describes various popular preloaded IOL injector systems from manufacturers like Alcon, Bausch + Lomb, Zeiss, and Johnson & Johnson and the types of IOLs they are designed for. 4) While preloaded injector systems have benefits, complications can still occur from issues like improper IOL loading or friction

1. NETHRADHAM
Super Speciality Eye Hospital
NETHRADHAMA
Super Speciality Eye Hospital
Dr.SMITH SNEHAL SUTE
Fellow- Phaco & Refractive Surgery

2. INTRODUCTION
• Multiple needles, tips, instruments, and devices enter and leave the anterior
chamber during cataract surgery.
• Introduction of the IOL into the capsular bag- an important step
• Each step of cataract surgery has evolved over the decades.
• The place of lens holding and folding forceps is being taken by myriad IOL
insertion systems.

3. • Sir Harold Ridley introduced the first IOL in 1949.
• Charles D. Kelman MD introduced phacoemulsification,
- led to the era of small-incision cataract surgery.
• Thomas R. Mazzocco MD, developed the first foldable IOL in
1980.
- allowed lens insertion without enlargement of the 3-mm
phaco wound
INTRODUCTION

4. IOL
DEPLOYMENT
Preloaded
injectors
Manual loading in
cartridge
Microbial safety
Mechanical loading
Surgical time
Reproducibilty
Plunger
mechanism
Screw
mechanism
1 handed
delivery
Less controlled
2 handed
delivery
Controlled

5. • Additional steps to load and prime
the IOL
• More number of errors
• Longer training for the operating
room staff
• Increased time of surgery.
PROBLEMS with Manual Injection Systems
• Contamination
Wang L, Wolfe AP, Paliwal CS. IOL delivery performance of
three IOL preloaded delivery systems XXXIII Congress of the
ESCRS 2015, ESCRS Official Website.
• Foreign-body
introduction
• Inadequate
cleaning
• Postoperative endophthalmitis

6. • Deposits on IOL surface:-
• shape of the cartridge or nozzle
• linear deposits
• hexagonal-shaped cartridges
rather than round.
Kleinmann G, Marcovich AL, Apple DJ, Mamalis N. Linear
deposits on the surfaces of intraocular lenses implanted
through a hexagonal cartridge which mimic
scratches/cracks on the lenses. Br J Ophthalmol 2005;
89:1474–1477
Cartridge Complications
• Cartridge cracking:-
• friction during the transit through
the injector nozzle.
Singh AD, Fang T, Rath R. Cartridge cracks during foldable
intraocular lens insertion. J Cataract Refract Surg. 1998
Sep;24(9):1220-2. doi: 10.1016/s0886-3350(98)80015-1.
PMID: 9768396.

X

7. • Surgically induced astigmatism:-
• Creating an incision necessary for
the removal of cataracts and IOL
implantation
• varying degrees of surgically
induced astigmatism.
• type of injector cartridge or
insertion method used,
Cartridge Complications
Wound stress- greatest
when the IOL passed
through the incision.

8. • Corneal wound is like a slit
• IOL cartridges are like a cylinder
(oval or circular in section).
• Thus, by the law of physics,
insertion of a cylinder through a
slit would always lead to some
stretch or damage to the slit
architecture
Cartridge Complications
• Smaller diameter injector
nozzles
hamper the ease of IOL insertion
• Reducing the thickness of the
nozzle or designing a slit in the
nozzle to buffer the stretch force
would be a good compromise

10. • Manual holding, folding, and insertion techniques have, in recent years,
been largely replaced by the use of novel IOL injection systems.
PRELOADED INJECTORS
 Pre-packaged
 Ready-to-insert
 Preloaded IOL
adopted by many manufacturers.
 Simple
 Safe
 Effective devices
IOL implantation through a
relatively small incision

11. iSert
(Hoya)
AcrySert C
(Alcon)
Tecnis
iTec (J&J)
BLIS
(Bausch
+ Lomb
Injector
System)
AutonoMe
(Alcon)
PRELOADEDINJECTORS

12.  One step, ready to insert
 Optimized design for small incision size
 Smooth passage of the IOL
 No risk of damage to haptic or optic
 Smooth folding and unfolding of the haptic
 Convenient and cost effective use
CHARACTERISITCS OF AN IDEAL
PRELOADED INJECTOR

13. • Implantation through smaller
incision
• Shorter duration of wound
healing,
faster recovery
• Microbiologic safety
Kokuzawa S, Suemori S, Mochizuki K, Hirose Y, Yaguchi
T. Aspergillus tubingenesis endophthalmitis after cataract
surgery with implantation of preloaded intraocular lens. Semin
Ophthalmol 2014; 29(4): 218-21.
Advantages of Preloaded Injectors
• IOL is already loaded instill
(OVD) ready for insertion.
• Avoids potential mistakes such as
loading the lens incorrectly
• Enhanced surgical outcomes
deployed directly from the
manufacturer to the eye,
minimizing the risk for IOL damage
through handling
• Intraoperative aberrometry

15. • BLUEJECT
• BLUEMIXS® 180
• MONARCH III
• AutonoMe
• UNFOLDER Platinum
• UNFOLDER Emerald
• INJ 100
B+L J&J
ZEISS
Alcon
IOL
Implantation
systems

16. Injectors
Cartridg
es

17. Injectors
• Hand piece – Titanium alloy material - reusable
• Y-tip plunger rod assists in lens manipulation
• Cartridge lock allows for secure loading in the correct position
• Lens injecting mechanism : Screw-style insertion
• Incision size : 2.2- 2.8mm
• Sterilization - Flash autoclave or steam sterilization

18. Cartridg
es
Incision size
2.2
2.8
2.8

19. UNFOLDER Platinum series & 1VIPR30
Designed for
Tecnis 1 Monofocal
Tecnis Toric
Tecnis MF(multifocal)
Tecnis MF Toric
Tecnis Symfony (EDOF)
Tecnis Synergy

20. UNFOLDER Emerald series & EmeraldC30
Designed for
Tecnis 3 piece
Sensar 3 piece

21. UNFOLDER
Platinum series DK 7796
UNFOLDER
Emerald series T/ XL
Injectors
Cartridg
es
1MTEC30 Emerald C
1VIPR30
Tecnis 3 piece
Sensar 3 piece
Tecnis Toric
Tecnis MF Toric
Tecnis 1
Tecnis MF
Tecnis Symfony Tecnis Synergy

22. • Syringe type systems
• 1.8 mm incision
• Large loading chamber
Preloade
d &
Disposabl
e
• 2.0
Injector
• 2.2
Injector
• 2.4
Injector

23. • Blueject2.0
(+4.0 to +24.0 D)
• Blueject2.2
(+24.5 to +30.0 D)
• Blueject2.4
(+30.5 to +34.0 D)
• Large loading chamber
• Unrestricted access for IOL loading
• Safety ontrolled and linear
injection
• For a wide variety of hydrophilic
ZEISS MICS IOLs
Preloade
d

24. Blueject
Designed for
CT® Lucia 611P/
611PY
CT® Lucia 211P

25. Blueject
Designed for
CT® Lucia 611P/
611PY
CT® Lucia 211P

26. Bluemixs® 180
Designed for
AT LARA® 829 MP
AT LISA® Tri 839 MP
AT LISA® 809 MP
909 M
CT ASPHINA
409 MP/ 509 MP
AT Torbi 709 MP

27. Bluemixs® 180
Designed for
AT LARA® 829 MP
AT LISA® Tri 839 MP
AT LISA® 809 MP
909 M
CT ASPHINA
409 MP/ 509 MP
AT Torbi 709 MP

29. Monarch® II
• “C” cartridge
• 2.4 mm incision
• “C” cartridge
• 2.4 mm incision: through the
wound
• “D” cartridge: smaller
• 2.2 mm incision: wound assisted
smaller plunger tip
Monarch ® III

30. IOL INJECTORSFOR Monarch® SYSTEMS
Screw thread injector
MONARCH IIB, IIIC IIID

31. Monarch® II
• “C” cartridge
• 2.4 mm
• “D” cartridge:
• 2.2 mm
Monarch ® III
33%

33. B C D
“B” Cartridge
• Incision size :
3mm
• All 3 Piece IOLs
• Special order
Single
pieceIOLs
(+35 to + 40 D)
“C” Cartridge
• Incision size : 2.4mm
• All Single Piece IOLs ( +6 to +34 D)
“D” Cartridge
• Incision size :
2.2mm
• THIN Single
Piece IOLs
(+6 to +26 D)
Big Compact Dimunitive

34. Monarch®III &C Cartridge
Designed for
ACRYSOF

35. Monarch®III &D Cartridge
Designed for
ACRYSOF IQ
PanOptix/ Toric

37. AutonoMe Device

38. AutonoMe Device

39. AutonoMe Device
Designed for
CLAREON

40. AutonoMe Device
Designed for
CLAREON

43. BLIS (Bausch+Lomb Injector
System)
Designed for
enVista

44. COMPLICATIONS
 Trapped trailing haptic
 Haptic optic adhesion
 Misdirected leading haptic
 Twisted haptic
 Overriding plunger
 Trauma to IOL: damage to IOL haptic/optic:

45. COMPLICATIONS
 Damage to IOL haptic/optic:
 poor IOL injector design and packaging
Nguyen DQ, Saleh TA, Pandey SK, Bates AK. Irregularities on the surface of single-piece AcrySof SA60ATintraocular lenses.
J Cataract Refract Surg 2006;32(3):495–498
 Inappropriate manual handling and loading,
Vrabec MP, Syverud JC, Burgess CJ. Forceps-induced scratching of a foldable acrylic intraocular lens.
Arch Ophthalmol1996;114(6):777
 Overriding injector plungers,
 Friction during IOL passage through the injector nozzle
- type of viscoelastic medium used for loading and IOL injection
Myers TD, Olson RJ. Comparison of the effects of viscoelastic agents on clinical properties of the unfolder
lens injection system. J Cataract Refract Surg 1999;25(7):953–958

46. INJECTOR
CARTRIDGE
Systems
Alcon
B+L
ZEISS
J&J
UNFOLDER
Platinum
UNFOLDER
Emerald
1MTEC30 EMERALDC
1VIPR30
Monarch III AutonoMe™
D cartridge Device
BLIS INJ100
BLUEJECT™ BLUEMIXS®180

47. • IOL manufacturers are keenly working on the development of better
preloaded IOL delivery systems.
• The focus is on making IOL size, design, and thickness more compatible with
the disposable plunger and cartridge assembly.
• In the near future, all IOL implantations will be performed through preloaded
IOL delivery systems.
• The healthy competition among manufacturers to achieve the best system
will not only provide us with flawless IOL delivery but will also make these
products more cost-effective

48. • Foldable IOLs have helped alter the face of cataract surgery by improving
healing time, limiting complications and making phacoemulsification the
standard procedure over extracapsular surgery, all in the span of 3 decades
• Advancements in cataract surgery have necessitated the availability of
intraocular lens preloaded delivery systems that can safely, effectively and
predictably deliver IOLs in the eye.
• Preloaded delivery systems simplify and reduce procedural variability
during surgery preparation.
Clearly, cataract surgery continues to improve
in all areas, with a bright future for improved
vision and a happy patient.

49. Vision
Leadership in the Eye Care Domain
Mission
Vision Care Par Excellence
smithsnehalsute@yahoo.com