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Refractive Surgery | May 2014

Methods for IOL Insertion and Closure

The high point of every cataract procedure.


Before IOL implantation, I inflate the capsular bag with a cohesive ophthalmic viscosurgical device (OVD) such as Provisc (Alcon) or Healon (Abbott Medical Optics). If the eye has less than 1.00 D of corneal astigmatism, I also perform opposite clear corneal incisions; for higher cylinder correction, I use toric IOLs. The appropriate IOL is then implanted in the capsular bag.

I most frequently implant a monofocal lens, namely the AcrySof SA60 or, if the eye has doubtful macular pigmentary epithelium or age-related macular degeneration, the AcrySof Natural SN60AT with blue-light filter (both by Alcon). Approximately 30% of my patients receive a toric IOL; I use the AT LISA Toric (Carl Zeiss Meditec) and AcrySof Toric lenses. I also implant multifocal lenses, and my preference is for the Lentis Mplus (Oculentis) and AT LISA tri IOLs (Carl Zeiss Meditec). The FineVision (PhysIOL) is also a good choice, but I use it less frequently because of its effect on contrast sensitivity in scotopic conditions.

To implant the AT LISA IOL, I open a 1.8-mm incision and use either the Bluemixs 180 or a preloaded injector (both by Carl Zeiss Meditec). To insert the AcrySof monofocal or toric lenses or the Lentis Mplus, I use a 2.2-mm incision.

I always inject intraocular cefuroxime when closing the incisions, and I wash the ocular surface with povidoneiodine 0.1%, as I had at the beginning of the procedure.

A final remark: I or one of my fellows always checks the condition of the eye at the slit lamp before the patient is discharged, paying special attention to incision stability, the presence of any leakage, and the condition and centration of the IOL. Using the IOL implantation and closure techniques described above, I am satisfied with my results. Endophthalmitis has disappeared from my practice, my outcomes are within ±0.50 D of sphere and about the same for astigmatism, and the majority of patients achieve the vision they had hoped for within 5 days postoperatively.


I always use a wound-assisted IOL implantation technique. With proper cartridge and injection systems, even a hydrophobic acrylic IOL with a 6-mm optic can be inserted through a 2.2-mm incision.

It is important to insert the upper part of the cartridge tip into the corneal incision and to upload the IOL with both haptics aligned centrally and folded onto the optic. The incision should never be smaller than the cartridge; in other words, the IOL should be adequately compressed to open the incision and enter the eye.

Once the IOL is properly implanted, I then remove the OVD from behind and in front of the lens and hydrate the wound lips to close the eye. Usually an injection of cefuroxime 1% is performed to avoid endophthalmitis, according to the European Society of Cataract and Refractive Surgeons (ESCRS) protocol.1

  1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32(3):407-410.


A coaxial MICS surgeon likes to keep the incision small. Today, several companies manufacture IOLs that can be implanted through incisions of 1.8 mm or less, either by wound-assisted injection or by passing the injector tip through the incision and into the anterior chamber. The latter technique provides the best control, and in tricky cases with small pupils, loose zonules, or other capsular complications I prefer to inject the IOL into the bag with the injector opening inside the anterior chamber. If necessary, it is an easy decision to widen the incision the extra 0.2 mm needed to facilitate the safest and most controlled IOL delivery. From the patient’s perspective, the risk of a noticeable increase in corneal cylinder and/or deviation from the planned refraction is negligible compared with the risk of damaging vulnerable ocular structures with uncontrolled IOL injection.

I always hydrate the phaco tunnel and sideport incision and over-pressurize the anterior chamber for a few seconds to ascertain that the wound is watertight. Incisions for iris hooks and astigmatic incisions such as opposite clear corneal incisions are not hydrated, and I have never seen any leakage through these incisions.

The last step of the closure procedure is to inject antibiotics into the anterior chamber. Failure to do so increases the risk for postoperative endophthalmitis fivefold, according to several publications confirming the results of the ESCRS multicenter study published in 2006.1-6

My closing comments are in Final Remarks on page 73.

  1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32(3):407-410.
  2. Lundström M, Wejde G, Stenevi U, Thorburn W, Montan P. Endophthalmitis after cataract surgery: A nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology. 2007;114(5):866-870.
  3. Yu-Wai-Man P, Morgan SJ, Hildreth AJ, Steel DH, Allen D. Efficacy of intracameral and subconjunctival cefuroxime in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2008;34(3):447-451.
  4. García-Sáenz MC, Arias-Puente A, Rodríguez-Caravaca G, Bañuelos JB. Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: ten-year comparative study. J Cataract Refract Surg. 2010;36(2):203-207.
  5. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a northern California eye department. J Cataract Refract Surg. 2013;39(1):8-14.
  6. Myneni J, Desai SP, Jayamanne DGR. Reduction in postoperative endophthalmitis with intracameral cefuroxime. J Hosp Infect. 2013;84(4):326-328.


IOL insertion is easy and safe with a dedicated single-use injector. For implantation of acrylic hydrophilic microincision IOLs, I use an injector that fits through a 1.5-mm incision; the injector does not stress the 1.8-mm corneal incision. In addition to being self-sealing (Figure 1), the microincision ensures that astigmatism is not induced postoperatively.


IOL implantation, in these days, is usually performed under OVD and through an IOL shooter; I have nothing particular to advise here. Each surgeon must find his or her individual way with his or her preferred lens and injector or other implantation system.

Implantation under irrigation only is a possible alternative, at least with injector systems, but I have not found an advantage with this modality and no disadvantage with OVD. The latter, for me, provides a wider safety margin in complicated situations. At the conclusion of surgery, I aspirate the OVD and tighten all incisions by swelling them with balanced saline solution.

My closing comments are in Final Remarks on page 73.


The high point of any cataract operation is implanting the correct IOL. To ensure that the procedure is both gentle and reproducible, I use one-piece IOLs that can be implanted under controlled conditions using an injector. In most cases, implantation is accomplished with the use of balanced saline solution; only seldom is it done under the protection of a cohesive OVD. The reasons for this are twofold. First, it ensures the stability and integrity of the wound construction; second, it facilitates the slow and controlled unfolding of hydrophilic and hydrophobic multifocal and toric IOLs.

An irrigation-assisted method of implantation primarily offers one advantage: Postoperative increase in pressure, caused by retained OVD, is virtually ruled out. Furthermore, with a smaller capsulorrhexis (4 to 4.5 mm), there is no risk of the OVD becoming trapped behind the IOL in the capsular bag, leading to a myopic postoperative refraction.

Pressure can be applied to the eye by hydrating the paracentesis. Samuel Masket, MD, has demonstrated and described how watertight occlusion of the paracentesis is best achieved by targeted hydration of the wound’s internal, rather than external, edges (personal communication). The main incision does not need to be hydrated because the wound construction technique I described (see Meticulous Incision Creation, pg 39) remains watertight in 99% of cases.


I am against creating too-small incisions for so-called microincision IOLs. These incisions are stretched significantly during IOL injection, and this causes too much wound damage. I use the AcrySof IQ IOL with the Monarch D Cartridge Injector (both by Alcon) through 2.2-mm incisions.

My opinion is that the main incision should not need stromal hydration at the end of surgery—and certainly not because the incision was over-stretched during IOL injection. I always hydrate my two 1.2-mm sideport incisions used for bimanual irrigation/aspiration; however, I have never had leakage problems from sideports postoperatively.


Implanting an IOL in the capsular bag is the final yet one of the most crucial steps of cataract surgery. As incision sizes get smaller, there are some pearls that I find useful in achieving in-the-bag IOL implantation consistently.

Currently, microcoaxial phacoemulsification through 1.8- to 2.2-mm incisions is popular, and many IOL designs are compatible with these small incisions. Prior to implanting the IOL, it is important to fill the anterior chamber and capsular bag with a cohesive OVD. I top up sodium hyaluronate 1% (Provisc) in the anterior chamber and capsular bag. However, one must be careful to not over-inject the OVD into the capsular bag, as it can offer significant resistance to smooth unfolding of the IOL in its desired location. This becomes particularly important when using a dispersive OVD such as Viscoat or a viscoadaptive OVD such as Healon 5. A small amount of balanced saline solution in the capsular bag allows smooth and predictable unfolding and makes OVD removal from behind the IOL easier at the end of surgery.

Another useful trick is employing wound-assisted IOL implantation with a plunger-type injector. Unlike IOL injection through larger incisions, with a wound-assisted technique the mouth of the cartridge should not be inserted beyond the internal entry but only to mid-incision. A second instrument such as a spatula or Lester hook, introduced through the paracentesis incision, stabilizes the eye and provides counter-traction while the surgeon injects the IOL with the plunger-type injector in the other hand.

The introduction of a motorized IOL delivery system (AutoSert IOL Delivery System; Alcon) has made a significant impact on IOL delivery, increasing predictability and reproducibility, even through small incisions. The AutoSert handpiece allows modulation of initial and final injection velocities. The pause time during injection further enhances the control of IOL delivery in the anterior chamber.

Following IOL implantation, OVD removal from in front of and behind the IOL is extremely important to prevent forward bulge and change in the effective lens position, as either can lead to refractive surprise. This is particularly true for toric IOLs, for which final alignment is performed after OVD removal. I find using bimanual irrigation/aspiration particularly useful for this purpose. The irrigation handpiece is inserted behind the IOL optic with the foot-pedal in position 0, and the aspiration handpiece is kept in front of the optic. OVD is first removed from behind the IOL, then from in front of the IOL.

One of the most important but often ignored steps of cataract surgery is meticulous wound closure. As we shift toward single-plane, clear corneal incisions, the importance of incision geometry increases to achieve self-sealing and to prevent endophthalmitis and the induction of astigmatism.

I perform stromal hydration of all incisions, including the 1-mm paracenteses. In a previous randomized clinical study,1 we reported that performing stromal hydration reduced fluid ingress into the anterior chamber from the extraocular surface. This is particularly useful in the early postoperative period when hypotony is expected.

When performing stromal hydration, both sidewalls and the roof of the incision should be hydrated. The endpoint of hydration is to seal the internal entry of the incision. The cannula should be directed sideways toward the incision sidewall, and care should be taken to prevent Descemet membrane detachments with the jet of balanced saline solution.

Incision integrity at the end of surgery must be carefully evaluated. Often, thermal injury, roof cuts, and short internal entry of the wound site can compromise wound integrity. In such situations, a suture is advisable. There should be no shame in suturing even the smallest of small incisions.

  1. Vasavada AR, Praveen MR, Pandita D, et al. Effect of stromal hydration of clear corneal incisions: quantifying ingress of trypan blue into the anterior chamber after phacoemulsification. J Cataract Refract Surg. 2007;33:623-627.