In addition to the development of more sophisticated and diverse IOLs, an array of cutting-edge IOL injectors have emerged to optimize surgical workflow and enable smooth, controlled lens implantation. Options have expanded from insertion forceps to cartridge inserters to preloaded injectors, giving surgeons a wider selection based on their unique preferences and needs.

While manual, reusable devices have widespread popularity, single-use delivery systems offer multiple potential benefits. Preloaded IOL inserters have the potential to reduce total case time and IOL manipulation that can result in damage to the optic surface, contamination or a loading error. Both manual and preloaded delivery systems are offered by numerous companies, often in conjunction with companies’ IOL products. Here’s a look at the choices.

IOL DELIVERY SYSTEMS

Johnson & Johnson Vision

Johnson & Johnson Vision offers multiple categories of IOL insertion devices. Both the TECNIS iTec Preloaded (Figure 1) and TECNIS Simplicity delivery systems are screw-style inserters that facilitate the convenience of IOL touch-free implantation of the TECNIS Monofocal one-piece IOL, via a 2.2- to 2.4-mm incision into the capsular bag. These devices can insert optics with powers from 5.0 D to 34.0 D in 0.5-D increments. The Tecnis Simplicity delivery system is the newer-generation injection system that has been FDA approved to allow BSS fill instead of viscoelastic fill within the cartridge.

Reusable Johnson & Johnson Vision delivery system options include the UNFOLDER and One Series Ultra. The UNFOLDER group contains three unique delivery devices: the Platinum 1, Emerald XL and the Silver (Table 1).

Hoya

In 2009, Hoya was the first company to introduce preloaded lens delivery systems in the United States. The company later entered into a partnership with Bausch + Lomb to distribute and commercialize its product line. All available Hoya inserters consist of single-use preloaded devices that accompany their selection of IOLs and allow for controlled IOL unfolding. The iSert Preloaded IOL system is a screw-type injector that inserts through an incision as small as 2.4 mm; it has powers in 0.5-D increments from 6.0 to 30.0 D.

Hoya also offers the Vivinex series, which includes the iSert, Toric and multiSert. These injectors all utilize a 2.2-mm incision for delivery. The Vivinex iSert and Vivinex multisert are available in 0.5-D increments from 6.0 to 30.0 D, while the Vivinex Toric is available from 10.0 to 30.0 D, with 1.0 to 6.0 D of cylinder power at the IOL plane. The Vivinex multisert is unique in that it offers dual-insertion functionality as either a two-handed screw or a one-handed plunger, thus allowing the surgeon to alter technique based on need or preference. The multisert also contains an adjustable insert shield, which allows for precise depth management of the injector tip.

Alcon

Alcon offers both a reusable screw-type manual IOL delivery system series, the Monarch, and multiple single-use preloaded options, including Acrysert, Autosert, Ultrasert and AutonoMe, to implant its ArcySof lenses. The manual Monarch series, originally introduced in 1998, has undergone multiple iterations leading to the most recent version introduced in 2007, the Monarch III. The Monarch III is readily identified by its blue color and smaller plunger, which is necessary for compatibility with smaller D cartridges (Table 2).

When considering single-use preloaded devices, both the Ultrasert and AutonoMe IOL delivery systems offer the latest in implantation technology. The Ultrasert (Figure 2) combines a spring-controlled plunger mechanism to allow for smooth advancement with a depth guard nozzle that is designed to minimize wound stretch and control insertion depth. This inserter is compatible with 2.2 mm-3.2 mm incisions and AcrySof IQ IOLs.

The newest single-use preloaded device from Alcon, the AutonoMe IOL delivery system, utilizes a CO₂-powered, single-handed delivery system. The CO₂-powered delivery mechanism enables consistent lens folding and precise plunger advancement with a speed that is varied by the degree of surgeon finger depression, allowing the second hand to remain free. The plunger has a maximum advancement speed of 3 mm/s and can be used in incisions as small as 2.2 mm. This delivery system is currently unavailable in the United States.

Bausch + Lomb

The manual screw-type Bausch + Lomb Injector System (BLIS) is designed exclusively for use with the company’s enVista IOLs. BLIS is a reusable hand piece consisting of a body and plunger that are compatible with single-use disposable cartridges. This delivery system and its associated cartridges can be used with incisions as small as 2.2 mm.

Bausch + Lomb also offers single-use injector systems such as the SimplifEYE (Figure 3). The injector is designed to be used with B + L’s enVista IOLs — both monofocal and toric. In fact, the company says the enVista toric preload (MX60PT) will be the first preload toric in the U.S. market.

The SimplifEYE injector utilizes a screw plunger and comes in a 10-pack to minimize storage space. The IOL is preloaded in a cartridge that snaps onto the injector body, with OVD applied through a port in the front end. Both the device and IOL can be inserted through incisions as small as 2.2 mm.

PRELOADED VS MANUAL LOADING

Preloaded: features and benefits

Manual loading of IOLs for injection at the time of cataract surgery has been a mainstay for decades. Over the years, IOL inserters have evolved to allow for smooth insertion through increasingly smaller incisions, all with precise control. With the development of preloaded IOL injectors, surgeons have more options than ever to customize their IOL and delivery system based on patient needs and surgeon preferences.

Studies by Jones et al and Chung et al, in 2016 and 2018, respectively, show that preloaded IOL injectors offer streamlined IOL implantation by eliminating the need to manually load IOLs into the lens inserter. Often, all that is needed for use is for the technician to insert the appropriate BSS or viscoelastic into the cartridge and remove the lens stop to allow for surgeon use. While not every IOL type is accompanied by a preloaded injector option, companies are increasingly providing preloaded IOL delivery system options.

The studies above also showed that preloaded IOL injectors have the potential to offer numerous benefits, from maintaining lens integrity to reducing time and stress. By eliminating manipulation of the IOL with a preloaded system, the risk of IOL damage, contamination or inappropriate IOL loading is minimized. This can also increase operating room efficiency by decreasing time required for IOL loading, particularly in high-volume cataract practices. Preloaded systems also offer ease of mind to both the technician and surgeon, as different IOLs and manual injector systems can require different loading techniques into varied cartridges that all require mastery for optimal IOL implantation.

Manual still matters

Manual loading of IOLs remains a useful skill and a necessary component of a well-equipped operating room. Preloaded delivery systems are only offered in a limited selection of IOLs, which may not include the specific IOL selected for any given patient.

Additionally, surgical plans may change while in the operating room if unforeseen compromised anatomy is encountered, thus requiring a change in IOL selection. Consequentially, manual loading techniques will likely remain in some capacity even as our selection of preloaded delivery systems expand.

Ultimately, cataract surgeons can look forward to an increasing variety and volume of IOL options and injector systems that can be tailored for optimal outcome in any surgical case. OM

About the Authors

Cassandra C. Brooks, MD, is an ophthalmology resident, PGY4, at Duke University Eye Center, Durham, N.C. E-mail her at Cassandra.brooks@duke.edu

Preeya K. Gupta, MD, is associate professor of ophthalmology at Duke University School of Medicine, Cornea and External Disease Division Duke University Eye Center in Durham, N.C. E-mail her at Preeya.gupta@duke.edu.

Disclosures: Dr. Gupta is a consultant to Alcon, Allergan, Kala, Johnson & Johnson Vision, New World Medical, Novartis, Oyster Point, ReGenTree, Sight Sciences, Sun Pharmaceuticals, TearLab and Zeiss.