 Hi, this is Dr. Lloyd Williams. I am the editor of the Moran Corps International and a practicing cornea specialist in Salt Lake City, Utah. I'm going to be talking to you today about some common intraocular lens or IOL insertion techniques. As a relevant disclosure, I have been a speaker for star surgical, but I do not plan to talk about any of the star surgical lenses per se in this talk. There are three main kinds of lenses that we commonly use during cataract surgery. One is the single-piece lens, commonly made out of acrylic, which is located on the bottom left here. Second one is a three-piece lens, which can be made out of acrylic or PMMA or silicone, and you see one of those located in the center here. And a third is an anterior chamber intraocular lens, and on the right image is the most common of one of those. So we're going to watch an insertion of a one-piece acrylic intraocular lens. This is using a D cartridge, and this is a SN60WF lens, being inserted through a 2.4 millimeter incision. It's important to watch where the lens goes so that you make sure that the haptics go into the capsular bag here. Currently there's provis visceral elastic in the eye, and I'm adjusting the position of the lens using the BSS cannula. With one-piece acrylic lenses, it's essential to make sure that both haptics are actually in the bag and not in the sulcus. If the bag is not intact, you should not use a one-piece acrylic lens. Some cautions with one-piece acrylic lenses, although these are one of the most common lenses used, and in my practice this is definitely the most common lens that I use. They should not be placed in the sulcus due to the possibility of UGH syndrome or UGG syndrome, which is the uveitis glaucoma hyphema syndrome caused by chafing of the haptics on the underside of the iris. They're not appropriate for suturing to the iris. They should only be placed in very special circumstances if the posterior capsule is ruptured, and they may not be appropriate in cases where there's porous zonial function, where the patient may experience subluxation and need future procedures to fixate the lens. This is an image of a patient who had a one-piece acrylic lens in her eye and had had a trauma that dislocated this one-piece acrylic lens. You can also see a corneal laceration. In this case, the one-piece acrylic lens now is going to have to be removed because it's not a lens that could be sutured to the iris. However, if this were a three-piece lens, I could leave the same lens in the eye and suture that to the iris or to the sclera. Now we're going to watch a video of a three-piece IOL placed in the bag. This video is a video of Dr. Walter Stark at the Wilmer Eye Hospital in Baltimore. Here you see him picking up the lens with some Teflon coated forceps, placing it in the inserter, and then he's going to put that inserter into the injector, and we'll see him putting the lens into the bag. It's important to put the lens or put the inserter all the way into the bag, and you notice he started with the inserter rotated, and then as you watch the leading haptic come out of the eye, you're going to keep rotating your inserter so that that leading haptic stays in the appropriate plane, and then when the trailing haptic comes out the lens will be sitting flat. In all cases, you want the haptics to be in a Z configuration with the distal haptic curved this way and the proximal haptic curved this way, and you can see that that's the case in this eye. Some advantages of the three-piece IOL are that it's versatile, it can be placed in the bag or the sulcus, it can be sutured or glued to the iris or sclera, it can be sutured to the iris at a later date in case there's a subluxation, and the haptics can be used as a capsular tension ring or in a similar fashion to a capsular tension ring. Some disadvantages are the implantation can be more difficult to control. Sometimes the lens will sort of pop into the eye or the haptic as it's coming out will rotate in a variety of axes and that can occasionally cause you some problems. Also the one-piece lens material is softer than the three-piece material and tends to unfold more gently. Here's a video of a three-piece lens being placed in the sulcus. Notice that the surgeon in this case myself is enlarging the wound so that the cartridge can be placed all the way into the eye. Now the lens is being pushed into the eye with the insertor. You can see that the leading haptic is curved off to the left and I'm rotating so that it stays curved off to the left and now the trailing haptic is going to come out and in just a moment you'll see that the trailing haptic once the lens unfolded or unfolds is positioned in such a way that it will be curved to the right. I'm using a Sinsky hook to place the to dial the lens into the bag or into the sulcus and in this case I'm being very careful to make sure that both haptics are actually placed in the sulcus. Once I have that done I'm going to push the lens as I just did there posteriorly so that the optic of the lens is behind the anterior capsule and both of the haptics of the lens are placed in the sulcus. In this case this is a patient who's had a vitrectomy and due to a posterior capsule rupture you can see that as I'm putting the three-piece lens in I am rotating the insertor so that the haptic is going into the in the direction that I want and then as the lens moves further and further into the eye I'll keep rotating it to make sure that the haptic stays where I want it to be. Now the lens has popped into the eye and I've left the trailing haptic outside of the eye. In this case this is a lens which will be used for iris suturing as there is no capsular support at all in this eye. Here's a brief example of fixating. I'm not going to show the whole process as that's the subject of other videos but that same lens I'm holding it with a micro grasper and I'm suturing it to the iris by passing a suture under the haptic and out the cornea and it can be tied with a seepser or mechanal suture. Anterior chamber lenses are another approach to placing a lens in the eye after cataract surgery. Their indications are to be used in limited or zero capsular support such as some cases of pseudo exfoliation, trauma, or Marfan syndrome. They can also be placed where the capsule has been lost during surgery such as if you have a complication and or such as if you had to do an intra-capsular cataract extraction and they can be placed as a secondary intraocular lens in patients with Afakia. They're contra-integrated in patients with no iris support such as trauma where the iris is lost or aniridia. They're contra-indicated in angle closure in patients with Fuchs dystrophy or an otherwise unhealthy corneal endothelium. Some cases of uveitis they may not be indicated. Pediatrics or shallow anterior chambers because you don't want the vault of the lens to push it up against the endothelium and cause endothelial damage. ACIOLs require larger wounds because they're generally made out of PMMA or polymethyl methacrylate which is not a foldable material so the wound needs to be large enough to accommodate the entire lens. They can cause iris cell loss and sometimes pseudo-fakic bolus caretopathy known as PBK. They can cause iris tuck or an irregular pupil if they're improperly positioned. They can cause chronic uveitis, glaucoma, pupil block and angle closure glaucoma. But in several studies it was shown that there was not a definitive improvement in using ACIOLs versus scleral sutured or iris sutured IOLs. Neither was definitively better in terms of complications. So some special surgical techniques required for placing an ACIOL you'll need to enlarge the wound and fill the chamber with viscoelastic. If there's vitreous in the anterior chamber you'll need to perform an anterior vitrectomy or a paris planar vitrectomy. You need to constrict the pupil with myocall or myostat prior to putting in the lens. You should perform an iridectomy to prevent pupillary block. You should use correct sizing of the lens. These lenses need to be sized unlike the lenses that we place in the capsule bag like the one piece acrylics. And the correct size is usually white to white plus one millimeter. You should use a power three diopters approximately less than if you're placing the lens in the in the capsule bag. You should insert the leading haptic carefully without catching the iris and pushing the iris off to the side so you want that leading haptic to go right into the angle. And generally these are placed horizontally with respect to the patient. This is a video of a ACIOL insertion which was provided by Dave Crandall. He's using a sheet's glide to help which is that thin piece of plastic to help him guide the lens in. And so he's lifting up the wound edge. You can see that this is a much larger wound than in the previous insertions that we showed you. And he's sliding that that anterior chamber IOL across the eye and into the opposite angle. Then he'll take the sheets glide out and he's using a kuglen hook to make sure that as he pulls the sheets glide out he does not pull the lens out with it. Now at this point he'll want to the eye is still full of viscoelastic so he'll want to tuck the edges of the lens into appropriate position and make sure that the pupil is round and the iris isn't pushed off to one side. And that's placement of an ACIOL. So those are three common types of intraocular lenses and how to place them in an eye. Thanks for watching this video. I'm Lloyd Williams and we appreciate your support of the Moran Corp international and we wish you all the best in your career as an ophthalmologist.