Streamlining Cataract Surgery With a HOYA iSert^® Preloaded IOL Implantation System

Surgeons are finding the iSert System improves safety, efficiency and predictability.

Dr. Koch: Our discussion today focuses on how to increase productivity and profitability in our ambulatory surgery centers. Specifically, our panel will address products, processes and partnerships that help us improve efficiency while delivering optimal care. Let's begin by discussing a new product, the iSert Preloaded IOL Implantation System (HOYA Surgical Optics), and its impact on the work we do.

Dr. Patterson: The iSert is a unique device that delivers features we have been wanting for years. The implant, which is preloaded in an injector, ensures sterility and reduces the risk of lens damage from mishandling. Not only does the iSert eliminate steps in our surgical routine, it also ensures consistent IOL delivery. In addition, contamination is not an issue, because the first time the implant is outside the device, it is inside the eye. I think it is a remarkable advance.

Enhanced Safety

Dr. Koch: To prepare the iSert, you insert viscoelastic, then gently push the sleeve forward and start screwing it into the eye. No one has to touch it, which minimizes any opportunity for cross-contamination, which, in turn, minimizes the risk of inflammation.

Dr. Tyson: Although we don't see much endophthalmitis, toxic anterior segment syndrome (TASS) is a serious concern, and the closed, preloaded iSert system helps eliminate some of the risk of TASS in the OR.

Dr. Koch: TASS was first described during a time when we used metal cannulas to inject viscoelastic. The industry immediately switched to disposable cannulas when it was determined improperly cleaned cannula tips were contributing factors. Yet many of our IOLs are injected with a cartridge that goes into a metal injector that is difficult to clean. If every trace of dried BSS or viscoelastic isn't removed from the injector tips, we run the risk of injecting something into the eye that should have been removed during cleaning. With a disposable system, we avoid the potential for having a contaminant enter the eye with the lens.

I think of the iSert as having three significant and beneficial characteristics: safety, efficiency and predictability. We've talked about safety, now let's discuss efficiency.

Creating Efficiency, Minimizing Stress

Dr. Koch: In our center, loading a lens routinely takes 30 to 60 seconds, but if there's any sort of delay, it can take 3 or 4 minutes. With the iSert, after the viscoelastic is injected into the tip, the preparation for injection runs 3 to 4 seconds. How does this impact your efficiency?

The HOYA iSert preloaded aspheric IOL system uses a four-step procedure. (1) injecting viscoelastic into the fusion port; (2) advancing the IOL to the proximal end of the inserter; (3) pushing the plunger forward and rotating it to advance the IOL; and (4) rotating the iSert's body counterclockwise to implant the IOL.

Dr. Wiley: Surgical advancements over the past 10 years have helped us become more efficient. With more recent advances, however, we're achieving better outcomes but adding more time. ORange intra-operative aberrometry [Wavetec Vision] has helped increase precision in IOL choice and placement, but has added a minute or two to the case. In addition, I would expect the new femto-phaco technology to increase safety and efficacy, however this will likely increase case time due to potential inefficiency and flow disruption. To be able to gain a minute or a minute-and-a-half—10% to 20% of our OR time—with the iSert is valuable, particularly as the complexity of our cases increases.

Dr. Tyson: As we reduce our case times, our scrub nurses have less time to perform their tasks. When the lens is preloaded, the nurse doesn't feel so rushed.

Dr. Koch: A distracted nurse is not a helpful nurse, and loading the lens is a stressful task for nurses. They know you need something at a certain time, and if they have difficulty preparing it for you, it makes them uncomfortable. Ultimately, everything that happens with the lens falls on them. Have your nurses comment to about the preloaded lens?

Dr. Patterson: Trying to load a lens properly and quickly is stressful. Generally, the nurse prepares the lens while I am doing the phaco, and these days, some cataracts come out fairly quickly. So someone may need to wet the cornea for me, and I may need to change the phaco handpiece to the irrigation and aspiration (I/A) handpiece on my own because the nurse is still loading the lens. What's more, every time I inject a lens into an eye and something goes wrong—the hap-tic is bent or torn, for example—the nurse realizes it may have been because the lens was loaded improperly. We all know that once a lens goes into an eye and it is damaged, it is difficult to remove. Relieving the nurses of that stress is a tremendous benefit.

Dr. Koch: In my office, the nurses open the iSert injector and place it on the table while I am doing my I/A. They don't even look at the lens while I'm doing the cataract operation. When I get to I/A, they open the lens, and they have it ready for me by the time I am ready to inject it. It's that quick.

Mr. Sheffler, you manage numerous surgery centers. What has been your experience with the nursing staff and the surgeons who use the iSert system?

Mr. Sheffler: One of the nicest features of the iSert, which is available with a variety of different hydro-phobic IOLs, is that the lens model and power is printed on the injector, so the surgeon can confirm that he has the correct lens before injecting it. Our surgeons perform 35,000 cases a year and, occasionally, the wrong box is selected. Having the lens model and power printed on the injector reassures the surgeon he is using the correct implant for a specific case.

Dr. Waltz: All of these features are important, but especially when we operate in an environment where we may have different assistants. If you've worked with an assistant for 20 years, she's very good at what she does. Sometimes, however, I operate in places where I have a different assistant every time. In those situations, the benefits of the iSert are even more apparent.

Inventory Advantage

Dr. Waltz: Another advantage to the iSert System is that there are fewer pieces to inventory. With the traditional set-up, we have a metal casing for the injector, but just as importantly, we have the cartridges, and occasionally, these get out of sync. I have actually run out of cartridges at various facilities because we usually think about them in terms of whole boxes. If the whole box is not there, all of a sudden, you have an issue. The iSert is all one piece, and one piece equals one lens equals one insertion.

Dr. Wiley: That is a great point. If you are using toric or multifocal lenses, you can have six or seven different cartridges, and I have lost track of how many different ICL cartridges are available. Maintaining the proper inventory of cartridges and injectors can be difficult. Having the lens and injector packaged as one unit is much more convenient.

Value of Predictability

Dr. Koch: How important is predictability in our cataract surgeries?

Dr. Tyson: When we look at what makes an OR efficient, it's not how fast we perform one small task, but how smoothly the entire day goes. There is a beauty to the iSert packaging, but what I really like is how it works. The screw-drive mechanism delivers the lens in a controlled fashion, and the delivery is the same, over and over again. When lens delivery is the same every time, you pick up speed during the day because you're not making any extra movements to counteract a surprise. The iSert goes in easily, the lens delivery is the same every time, you place the lens where you want it, and you move on to the next case. When everything goes smoothly, that calm transfers to the other staff members. The adrenaline level never increases, and your day is much more relaxed.

Dr. Waltz: The importance of predictability can't be overstated for our well-being and that of our staff. As surgeons, we invest a lot of money and time controlling predictability because we know how unsettling an unforeseen problem can be.

Welcome Addition to the OR

Dr. Koch: Our life in the OR and our nurses' lives are affected by safety, efficiency and predictability. I believe the iSert System is a welcome addition to the products we use in our operating rooms. People who have used it have been very excited about it and are finding it difficult to remember a time when we did not have a preloaded IOL.