IOL Inserter
Here's what's available and how to tell if it's right for you.
INTRODUCTION BY R. BRUCE WALLACE III, M.D., F.A.C.S.

Cartridge inserters are rapidly replacing insertion forceps as the preferred choice for intraocular lens delivery -- and with good reason. These devices allow sterile delivery and greater control in IOL release, and they make it possible to insert the IOL through an unenlarged 2.75- to 3.0-mm phaco incision. Perhaps equally important, IOL cartridge inserters can improve surgical speed by eliminating the need for surgeons to load the IOL; a skilled OR technician can assemble the cartridge inserter before or during a cataract procedure, allowing the surgeon to move smoothly and swiftly from lens removal to IOL placement. In this day of lowered reimbursement for surgical procedures, this kind of OR efficiency can be a significant factor in economic survival.

The first cartridge inserter -- the Bartell injector system for insertion of the first foldable IOL (the STAAR "Mazzaco Taco" silicone plate haptic IOL) -- appeared almost 20 years ago. Since then, numerous insertion devices have evolved, accompanying a vast number of foldable IOLs made with a variety of optic materials and haptic designs.

IOL injectors are generally easier to use if the IOL is made of a single material (for example, plate haptics or single-piece acrylics). In fact, the challenge for industry engineers has been to design user-friendly, predictable IOL injector systems for three-piece IOLs, which some surgeons prefer because they can be implanted in either the capsular bag or the ciliary sulcus with excellent centration. Today, a number of these injectors are available, making it possible for surgeons to deliver three-piece lenses, including the trailing haptic, in much the same way they deliver a one-piece IOL.

More improvements in IOL inserters are certain to follow. For one thing, as phaco incisions continue to get smaller, we'll need insertion devices to deliver IOLs through incisions as narrow as 1.0 mm. These injectors will also be an important adjunct to phakic IOL surgery.

With so many developments occurring, and so many companies competing in the marketplace, keeping track of the latest IOL inserter technology can be a challenge. To make that job easier, this article provides a helpful overview of the latest IOL injection systems and their accompanying IOLs.

	AMO's Unfolder Silver-Z system features a "push-then-twist" mechanism that simplifies implantation.

Advanced Medical Optics (AMO)

AMO currently offers two new advanced delivery systems for silicone and hydrophobic acrylic IOLs:

The Unfolder Emerald Series. The Emerald is designed exclusively for use with the SENSAR with OptiEdge hydrophobic acrylic IOL (AR40e). The Unfolder Emerald delivers a three-piece, 6-mm hydrophobic acrylic IOL through an unenlarged phaco incision as small as 2.6 mm. Features include:

• a conical tip that won't change wound architecture
• a highly polished rod tip, designed to preserve the optic surface
• enhanced tip design that facilitates haptic release and control
• a new, wider thread design that requires fewer twists for efficient IOL advance
• a longer rod tip for easy one-step, in-the-bag IOL placement.

The Unfolder Emerald Series should be used in conjunction with the Emerald C small incision cartridge.

The Unfolder Silver Series. This series of delivery systems is designed for use with AMO's second-generation silicone PhacoFlex (SI40) and ClariFlex IOLs, as well as the ARRAY Multifocal SA40N.

The newest member of the series, the Unfolder Silver-Z, features a unique push-then-twist mechanism that simplifies IOL delivery. According to AMO, this simple-to-use system is ideal for those transitioning from forceps to an insertion system. The instrument is a two-step system, minimizing rotation and manipulation for in-the-bag delivery of a three-piece silicone lens.

Other features of the Unfolder Silver-Z system include the blue silicone Soft Tip sheath -- a patented rod sleeve that's placed on the tip of the Unfolder rod to provide maximum control of IOL delivery. (Other silicone IOL injector systems often deliver the IOL in a fast or even explosive manner.) The Silver-Z system also features a conically shaped cartridge tip that won't change the architecture of the incision and allows implantation through a 2.8-mm phaco incision.

For more information about AMO's Unfolder Implantation Systems call (800) 366-6554 or contact your AMO representative.

Alcon's Monarch II IOL Delivery System can deliver AcrySof single-piece IOLs one step, in-the-bag.

ALCON

For IOL implantation, Alcon currently offers its Monarch II IOL Delivery System. The Monarch II System is compatible with both AcrySof single-piece IOLs, which can be delivered one step, in-the-bag, and AcrySof multi-
piece IOLs. The proprietary cartridge design allows for smooth, sterile implantation; you rotate the knob of the plunger for controlled delivery of the lens.

The Monarch II system comes in three cartridge configurations. (See table below.)

For more information about Alcon's Monarch II IOL Delivery System, contact Mike Southard, Global Vice-President of Marketing, Surgical Division, at (817) 551-4815.

Bausch & Lomb

Currently, Bausch & Lomb manufactures three inserter platforms:

Mport. The newest Mport model -- the Mport SI -- is designed to implant three-piece silicone IOLs such as B&L's Soflex and Soflex SE. According to the company it delivers the IOL in a planar fashion every time, through an incision as small as 2.8 mm. (The previous generation of Mport required at least a 3.2-mm incision.) It's designed to improve safety and predictability by minimizing the amount of manipulation needed during implantation.

	Bausch & Lomb's Mport SI delivers a three-piece IOL in a planar fashion through an incision as small as 2.8 mm.

Other advantages, compared with the previous model:

• design improvements that lessen resistance and increase surgeon comfort
• the use of a new plastic/blooming agent that makes lens delivery more consistent
• a remolded cannula tip that provides more lubrication to the IOL, allowing a smoother transition into the eye.

B&L will be marketing this injector along with its new square-edge silicone IOL (the Solflex SE) as the SofPort System. According to B&L, this is the first integrated, single-use, single-handed, planar-delivery, multipiece IOL insertion platform.

B&L expects most customers to prefer the new injector whether they adopt the Soflex SE or not, so all B&L-assembled silicone IOL implanters will be using the Mport SI by early 2004.

Passport II. This injector is designed specifically for the C11UB plate silicone IOL.

Microsert II. The Microsert II is designed for surgeons who prefer a two-handed technique; it comes with a separate cartridge to implant three-piece silicone IOLs. (B&L is currently developing an even more advanced version of this inserter.)

For more information about B&L inserter systems, contact Blake D. Michaels, Director of Marketing, Cataract Products (U.S.) at (909) 971-5151.

STAAR Surgical

STAAR Surgical's MicroSTAAR injectors were designed specifically for easy loading and smooth delivery of STAAR IOLs through small incisions. They're made of an autoclavable plastic that can be resterilized for multiple uses, and they come with either a micrometer advance (twist style) or a syringe advance (plunger style) for fast and easy insertion. They're sold sterile in cartons of 10.

	STAAR Surgical's MicroSTAAR injectors come with either a micrometer advance (twist style) or a syringe advance (plunger style).

MicroSTAAR Injectors. Most STAAR injectors are available in two formats:

• MSI-TM (twist) / MSI-PM (plunger). This inserter is used to deliver silicone three-piece (6.3-mm optic) lenses. (Cartridge: AQ.)
• MSI-TR (twist) / MSI-PR (plunger). This inserter delivers silicone single-piece lenses. (Cartridge: MTC-60c.)
• MSI-TS (twist) / MSI-PS (plunger). This inserter only delivers silicone single-piece lenses with a 5.5-mm optic. (Cartridge: AQ.)
• MSI-PF (plunger only). Delivers Collamer single-piece lenses. (Cartridge: SFC-25.)

MicroSTAAR Cartridges. STAAR offers three different inserter cartridges for its three-piece and single-piece IOLs:

• AQ. This mini-wing style cartridge is designed to insert STAAR three-piece style lenses through an incision as small as 2.8 mm. It features a 45° beveled edge and two asymmetrical slits at the cartridge tip.
• MTC-60c. This micro-tip cartridge (also mini-wing style) is designed to insert STAAR single-piece lenses through an incision size as small as 3.0 mm. It features a 60° beveled edge and no slits.
• SFC-25. This cartridge is a funnel cartridge designed to insert STAAR Collamer single-piece lenses through an incision size of 2.5 mm. The SFC-25 features a 45° bevel cut and no slits.