Preloaded and non-preloaded intraocular lens delivery system and characteristics: human and porcine eyes trial

Video analysis of optic-haptic-interaction during hydrophobic acrylic intraocular lens implantation using preloaded injectors

OBJECTIVE

To compare the optic-haptic interaction of different hydrophobic acrylic IOLs after using six preloaded injectors.

METHODS

We reviewed the video-recordings of procedures on a total of 388 eyes that underwent phacoemulsification and intraocular lens (IOL) implantation. For six preloaded injectors: multiSert (Hoya Surgical Optics) [System 1], TECNIS Simplicity (Johnson & Johnson Vision) [System 2], TECNIS iTec (Johnson & Johnson Vision) [System 3], AutonoMe (Alcon, Laboratories) [System 4], Bluesert (Carl Zeiss Meditec) [System 5], and Prosert (OphthalmoPro GmbH) [System 6], we noted in each case the time of IOL delivery and made a descriptive observation of IOL insertion and optic-haptic-interaction.

RESULTS

We defined standard haptic behavior where the haptics emerged "folded" from the injector and quickly recovered their pre-implantation appearance. The incidence where the leading haptic emerged in a deformed way for System 1 was 20%, System 2: 19%, System 3: 14%, System 4: 56%, System 5: 24% and System 6: 5%. For trailing haptic deformed behavior, the incidence was 36%, 6%, 4%, 8%, 18% and 2%, respectively for Systems 1 to 6. Optic-haptic adhesion occurred in 2% of cases for System 1, 44% for System 2, 52% for System 3, 48% for System 4, and 11% for System 6 (P < 0.05). Adhesion was not found with System 5.

CONCLUSIONS

We observed different deformed behavior for leading and trailing haptics in the six preloaded systems, some systems had as much as 52% optic-haptic adhesion.

Clinical Evaluation of a Hydrophobic Intraocular Lens Using a Preloaded Automated Injector in a Korean Population

Purpose

This study assessed post-market clinical outcomes of the Clareon monofocal intraocular lens (IOL) preloaded in the AutonoMe Delivery System in a real-world setting of Korean patients.

Methods

This prospective, multicenter, single-arm study in Korea was conducted from July 2020 to December 2021. Patients were ≥20 years old with unilateral or bilateral cataracts who received Clareon IOLs (CNA0T0) preloaded in an automated injector system. Best corrected distance visual acuity (BCDVA) and uncorrected distance visual acuity (UCDVA) were evaluated under photopic conditions. Surgeon delivery system preference was assessed using a survey questionnaire. Glistenings, surface haze, adverse events, posterior capsule opacification (PCO), and Nd:YAG capsulotomy rates were also assessed during the 12-month postoperative follow-up.

Results

Mean ± SD monocular BCDVA was 0.02 ± 0.11 and 0.00 ± 0.10 logMAR at 1 month and 12 months, respectively. BCDVA of 0.2 logMAR or better was achieved by 94.4% and 99.1% of eyes at 1 month and 12 months after implantation, respectively. Mean monocular UCDVA was 0.11 ± 0.14 and 0.07 ± 0.13 logMAR at 1 month and 12 months, respectively. UCDVA of 0.3 logMAR or better was achieved by 97.4% of eyes at 12 months after implantation. Preparation of the automated injector system was rated as "very easy" or "easy" and CNA0T0 IOL delivery was rated as "very controllable" or "controllable" by all surgeons. Only grade 0 glistenings and no surface haze were observed during the 12-month follow-up. No clinically significant PCO or Nd:YAG capsulotomy were reported throughout the study; clinically nonsignificant PCO was reported in 23% of eyes.

Conclusion

This 12-month real-world study of the CNA0T0 IOL and the automated injector system demonstrated excellent visual outcomes and high surgeon satisfaction.

The impact of preloaded intraocular lens implantation system (TECNIS iTec®) in routine cataract surgery in China: a time-motion analysis

OBJECTIVE

To evaluate the impact on surgical efficiency and labor time cost of preloaded intraocular lens (IOL) implantation system compared with manual IOL implantation system in age-related cataract surgery in China.

METHODS

This study was an observational, multicenter, prospective time-motion analysis. IOL preparation time, operation time, cleaning time, number and cost of cataract surgeries in eight participating hospitals were collected. The linear mixed model was used to explore factors associated with the difference in operation time between the preloaded IOL implantation system and the manual IOL implantation system. A time-motion model was constructed to convert the operation time cost saved by using preloaded IOL into economic benefits from hospital and social perspective, respectively.

RESULTS

There were 2,591 cases included in the study (preloaded IOL: 1,591 cases; manual IOL: 1,000 cases). The preloaded IOL implantation system was significant time-saving in both preparation time and operation time compared to the manual IOL implantation system (25.48s vs. 47.04s, P < 0.001 and 353.84s vs. 367.46s, P = 0.004, respectively). An average total of 35.18s can be saved by using preloaded IOL per procedure. The results of linear mixed model showed that the type of IOL was the main factor leading to the difference in preparation time between preloaded IOL and manual IOL implantation system. By switching from manual IOL to preloaded IOL, the model projected additional 392 surgeries can be performed each year and an increase in revenue of $565,282 per hospital, a 9% increase from hospital perspective. And the annual productivity loss saved by using preloaded IOL was $3,006 in eight hospitals from perspective of society.

CONCLUSION

Compared with manual IOL implantation system, the preloaded IOL implantation system reduces lens preparation time and operation time, which increases potential surgical volume and revenue, and reduces the loss of work productivity. This study provides real-world evidence to support the advantages of the preloaded IOL implantation system in improving efficiency of ophthalmic surgery in China.

Clinical Results of Cataract Surgery Using the ARTIS ® PL E Intraocular Lens

Purpose: To compare the clinical outcomes of cataract surgery using the ARTIS ® PL E (Cristalens Industrie, Lannion, France) intraocular lens (IOL) and conventional Tecnis ® ZCB00 (Johnson & Johnson Vision, Santa Ana, CA, USA) IOL.Methods: This retrospective study examined patients who underwent in-the-bag implantation of either an ARTIS ® PL E (33 eyes, group A) or Tecnis ® ZCB00 (45 eyes, group B) IOL after phacoemulsification performed by a single surgeon. Best-corrected visual acuity (BCVA), spherical equivalent, and higher-order aberrations (HOA) were measured 1 and 3 months after cataract surgery.Results: Preoperative BCVA did not differ significantly in groups A and B. Postoperative BCVA at 1 and 3 months improved significantly (p < 0.001) in both groups compared to preoperative baseline BCVA. At 1 and 3 months postoperatively, total HOA, spherical aberration, and coma were significantly lower compared to the preoperative baseline HOA (p < 0.05) in both groups. However, there were no significant differences in the trefoil values 1 and 3 months postoperatively compared to the preoperative baseline in both groups. The absolute refractive error 3 months postoperatively was 0.27 ± 0.20 (group A) and 0.28 ± 0.20 (group B), both within ± 0.50 diopters of the targeted goal diopter; there were no significant differences in the accuracy or predictability of the IOL power calculation in both groups (p = 0.390, p = 0.959). The absolute refractive error 1 and 3 months postoperatively did not differ significantly; there were no significant differences in the stability of both IOLs (p = 0.482, p = 0.372).Conclusions: Conventional cataract surgery using the ARTIS ® PL E IOL significantly increased the BCVA, while obtaining comparable clinical results to the verified Tecnis ® ZCB00 IOL in postoperative visual acuity and HOA.

Clinical safety and efficacy of a preloaded monofocal hydrophobic acrylic intraocular lens in a real-world population

BACKGROUND

This study was designed to evaluate visual, refractive and safety outcomes in eyes after they underwent phacoemulsification and implantation of a preloaded monofocal hydrophobic acrylic intraocular lens.

METHODS

This was a single center observational study conducted at Ashford and St Peter's Hospitals NHS Foundation Trust, United Kingdom. Patients were included if they had cataract extraction with in-the-bag implantation of the EyeCee® One preloaded intraocular lens from August to October 2019. Pre-operative, surgery-related and 2 weeks and 3 months post-operative data was collected. Surgeons at this trust were then asked to complete a feedback form to evaluate their experience of implanting the EyeCee® One.

RESULTS

One hundred fifty-two eyes were included in the study. Ninety-four (62%) of these eyes had cataract but no concomitant ocular pathology that could potentially affect visual acuity. Three months post-operatively, 98.7% of all eyes had monocular CDVA ≤0.3 logMAR. 100% of the eyes without concomitant ocular pathology achieved this target. The mean CDVA of all eyes in this study improved from 0.43 ± 0.43 logMAR pre-operatively, to 0.05 ± 0.11 logMAR post-operatively (p < 0.05). The mean sphere and spherical equivalent values showed significant improvements (p < 0.05) and (p < 0.05). There were no intraoperative complications and 1.3% of patients reported complications 2 weeks post-operatively. All of the participating surgeons said they would use the EyeCee® One again with 64% providing an overall rating of 'excellent' for their experience of implanting this intraocular lens.

CONCLUSIONS

This study indicates excellent post-operative visual acuity and refractive outcomes in eyes after EyeCee® One implantation. This is accompanied with very little risk of intraoperative and post-operative complications.

Injection time related to intraocular pressure using a CO2 driven preloaded injector: An experimental laboratory study

PURPOSE

Experimental study to measure the intraocular lens (IOL) injection time and injection speed at different intraocular pressure (IOP) settings when using the AutonoMe® injector.

METHODS

In this experimental study, following phacoemulsification in porcine cadaver eyes, a trocar was inserted at pars plana with a connected infusion and IOPs of 20, 50 and 80 mmHg were generated by altering the infusion height. Twelve CO2 gas-driven injectors were used to implant an IOL via a corneal incision of 2.2 mm. For each IOP setting, the duration of the IOL injection and the injection speed was measured by analyzing a video recording of the procedure.

RESULTS

The mean ±SD injection time (seconds) was 4.47±0.50 at 20 mmHg, 4.98±0.55 at 50 mmHg and 5.47±0.20 at 80 mmHg. The mean ±SD injection speed (millimeters per seconds) was 1.36±0.15 at 20 mmHg, 1.22±0.14 at 50 mmHg and 1.10±0.04 at 80 mmHg. There was a significant (p<0.05) difference between the 20 and 80 mmHg groups in mean injection duration and injection speed.

CONCLUSION

The CO2 gas driven injector allows a safe IOL injection even at elevated IOP. Although the implantation time is slightly extended at higher IOPs, this does not seem to be clinically relevant. No IOL damage was observed at these pressure settings.

Experimental Study on Delivery Performance of an Automated Preloaded Intraocular Lens Injector System for Corneal and Sclerocorneal Incisions

Purpose

To evaluate delivery performance of an automated preloaded intraocular lens (IOL) injector systems (AutonoMe) in the porcine eyes.

Methods

In the freshly excised porcine eyes, lens removal and IOL implantation were performed. There were 4 groups (10 eyes per group) with different incision site and size: 2.2-mm and 2.4-mm corneal incisions and 2.2-mm and 2.4-mm sclerocorneal incisions. Delivery performance and wound enlargement of AutonoMe were analyzed and compared with those of iTec and iSert from a previous study.

Results

There were a few minor troubles associated with AutonoMe, such as overriding plunger within cartridge and trapped trailing haptic during IOL insertion, but the incidence was low. Other interactions were not observed, such as IOL adherence to plunger, sudden ejection of IOL, intrawound lens manipulation, IOL behavior, and gross damage to IOL. AutonoMe caused significantly less wound enlargement for both corneal and sclerocorneal incisions than other injector devices. Wound enlargement by using AutonoMe was significantly smaller with 2.4-mm corneal incision than with 2.2-mm corneal incision, but the final incision size was still smaller with 2.2-mm corneal incision. For sclerocorneal incisions, the amount of wound stretch was not different between 2.2 and 2.4 mm incisions.

Conclusion

The wound enlargement caused by the automated preloaded insertion system, AutonoMe, was smaller than that of other preloaded injectors for both corneal and sclerocorneal incisions. There were a few minor technical events during IOL insertion, but the overall incidence was low.

Muscle Tissue as a Surrogate for In Vitro Drug Release Testing of Parenteral Depot Microspheres

Despite the importance of drug release testing of parenteral depot formulations, the current in vitro methods still require ameliorations in biorelevance. We have investigated here the use of muscle tissue components to better mimic the intramuscular administration. For convenient handling, muscle tissue was used in form of a freeze-dried powder, and a reproducible process of incorporation of tested microspheres to an assembly of muscle tissue of standardized dimensions was successfully developed. Microspheres were prepared from various grades of poly(lactic-co-glycolic acid) (PLGA) or ethyl cellulose, entrapping flurbiprofen, lidocaine, or risperidone. The deposition of microspheres in the muscle tissue or addition of only isolated lipids into the medium accelerated the release rate of all model drugs from microspheres prepared from ester-terminated PLGA grades and ethyl cellulose, however, not from the acid-terminated PLGA grades. The addition of lipids into the release medium increased the solubility of all model drugs; nonetheless, also interactions of the lipids with the polymer matrix (ad- and absorption) might be responsible for the faster drug release. As the in vivo drug release from implants is also often faster than in simple buffers in vitro, these findings suggest that interactions with the tissue lipids may play an important role in these still unexplained observations.

Preloaded vs manually loaded IOL delivery systems in cataract surgery in the largest ambulatory surgery center of northwestern China: an efficiency analysis

BACKGROUND

To compare the efficiency of preloaded vs manually loaded IOL (P-IOL vs M-IOL, respectively) delivery systems in cataract surgery in the largest ambulatory surgery center of Northwestern China.

METHODS

A total of 200 cases were included in this prospective, observational study. Time and motion data were collected in a one- or two-operating room (1-OR or 2-OR, respectively) scenario. A model of the efficiency and revenue implications of introducing a preloaded delivery system for IOLs in cataract surgery was used to estimate the changes in cataract throughput and hospital revenue through transitioning from the M-IOL delivery system to the P-IOL system.

RESULTS

In the 1-OR scenario, the mean total case time was 16.9 min using P-IOL, which was a 7.7% reduction compared with M-IOL (P < 0.01). In the 2-OR scenario, the mean total surgeon time was 10.8 min using P-IOL, which was a 7.8% reduction compared with M-IOL (P < 0.05). By switching from M-IOL to P-IOL, annual throughput will increase by 5.2% (960 cases) in the 1-OR scenario and 7.7% (1440 cases) in the 2-OR scenario, accompany by an increase in revenue of approx. 284,352 USD in the 1-OR scenario and approx. 426,528 USD in the 2-OR scenario.

CONCLUSION

This report is the first of a comparison of two IOL delivery systems in China using different settings in the scenario. IOL delivery with preloaded systems is time saving in both the 1-OR scenario and the 2-OR scenario. Moreover, switching from the M-IOL delivery system to the P-IOL system holds potential to increase cataract throughput and hospital revenue.

Clinical Evaluation of a Novel Preloaded Intraocular Lens Delivery System During Routine Cataract Surgery

Purpose

To evaluate the clinical handleability and acceptability of a novel preloaded intraocular lens (IOL) delivery system for implantation of the TECNIS ZCB00 IOL (Johnson & Johnson Surgical Vision, Inc., Santa Ana, CA, USA) during routine small-incision cataract surgery.

Subjects and Methods

In this prospective, open-label, noncomparative, unilateral or bilateral, multicenter study, adult subjects with unilateral or bilateral cataracts scheduled for IOL implantation were enrolled. Surgeons and surgical technicians completed per-eye day-of-surgery and end-of-surgical-day questionnaires. The primary endpoint of the study was the rate of acceptable overall clinical performance of the preloaded IOL delivery system. Other endpoints included additional responses from the questionnaires, preimplantation incision size, and safety.

Results

The study included 91 eyes that underwent cataract surgery and IOL implantation using the preloaded delivery system and were available for the 1-day postoperative visit. Five surgeons and 14 surgical technicians from four investigational sites participated in the study. The rate of acceptable overall clinical performance was 100% (91/91) of eyes, with most responses (78/91; 85.7%) being the highest possible rating of 5 (very satisfied). Favorable responses by most surgeons and surgical technicians regarding additional endpoints further highlighted the handleability and acceptability of the preloaded delivery system. No ocular adverse events or lens findings (ie, no cases of IOL instability, haptic breakage, IOL marking, or crimping) were reported.

Conclusion

The results of this study demonstrated that this preloaded IOL delivery system was safe and effective during routine small-incision cataract surgery.

Trial Registration

German Clinical Trials Register identifier, DRKS00014757.

[Clinical experience with the Clareon® IOL and the AutonoMe® implantation system]

BACKGROUND

The AutonoMe® implantation system with a preloaded, monofocal, aspherical, hydrophobic Clareon® intraocular lens (IOL) has recently become available. The aim of this analysis was the most comprehensive review of intraoperative and postoperative outcomes to date.

METHODS

Prospective evaluation of intraoperative features in all eyes scheduled to have cataract surgery with Clareon® IOL implantation using the AutonoMe® implantation system between December 2017 and September 2018 with follow-up at 4-6 weeks. Inclusion of all patients, regardless of comorbidities and accompanying ocular surgery.

RESULTS

A total of 391 eyes were evaluated for the intraoperative analysis and 144 eyes were evaluated for postoperative follow-up. There was one IOL-associated intraoperative complication in which the posterior haptic was not correctly loaded and should not have been implanted. The best corrected distance visual acuity (BCDVA) increased from a mean of 0.33 logMAR (SD 0.21) preoperatively to 0.09 logMAR (SD 0.21) postoperatively, independent of ocular comorbidities. The BCDVA in patients without ocular comorbidities increased from 0.27 logMAR (SD 0.13) preoperatively to 0.03 logMAR (SD 0.05) postoperatively. Using the SRK®/T formula 87.5% of all eyes had a refractive error of ≤0.5 D and 98.0% had a refractive error of ≤1 D 4-6 weeks after surgery.

CONCLUSION

This study showed that using the recommended safety guidelines, the AutonoMe® system enables safe implantation of the IOL. The Clareon® IOL showed good postoperative visual outcomes and refraction results using the SRK®/T formula.

In vivo and in vitro results of an automated preloaded delivery system for IOL implantation in cataract surgery

PURPOSE

To compare the corneal tissue trauma after the use of an automated preloaded injector and a manual injector and assess scanning electron microscope (SEM) and atomic force microscope (AFM) features of both injector cartridges.

SETTING

Ophthalmology Clinic and Laboratory of Stem Cells and Regenerative Medicine University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy; DESIGN: Prospective randomized clinical study METHODS: Forty eyes of 40 patients for phacoemulsification were divided into two groups: implantation of intraocular lens was performed with AutonoMe automated delivery system (AutonoMe group: 20 eyes) and Monarch III injector system (Monarch group: 20 eyes). In vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) were performed before surgery, at 1 h, 1 day and 1 month post-operatively. In addition, SEM and AFM were performed on cartridges of both injector systems after injection of the IOL.

RESULTS

A greater increase in central corneal thickness and corneal thickness at the incision site were observed in Monarch group versus AutonoMe group 1 h and 1 day post-operatively (p < 0.05). Endothelial cell count loss was significantly higher in Monarch group compared with AutonoMe group (p < 0.05) at 1 and 24 h. AS-OCT showed less endothelial misalignment at 30 days (p < 0.05), and IVCM showed less tunnel inflammation at all time points (p < 0.05) in AutonoMe group compared with Monarch group; roughness analysis at AFM of the AutonoMe cartridge was significantly lower compared to Monarch D cartridge (p < 0.05).

CONCLUSIONS

The AutonoMe injector provided less corneal tissue trauma compared with Monarch III injector. The AutonoMe cartridge showed lower roughness at AFM compared to the Monarch D cartridge.