Comments on: Pulp fiction of optic crack - The imperative irony of reloading a preloaded intraocular lens.

Dear Editor,

We recently published a paper titled “Pulp fiction of optic crack - The imperative irony of reloading a preloaded intraocular lens.”[1] In that article, we have mentioned the usage of Alcon D cartridge of Alcon Monarch system for reloading the preloaded injectable Hoya iSert® intraocular lens (IOL) for injecting through a 2.2-mm incision, which led to an optic crack in the mid-periphery of the IOL after the preloaded Hoya iSert® IOL was ejected outside the globe due to the unanticipated movement of the patient’s head during topical phacoemulsification surgery.[1] We mentioned in that paper, that another option in such scenarios would be to increase the wound size to 3.5 mm or larger, to enable insertion of the foldable polyacrylic IOL, which has an optic diameter of 6.0 mm, by utilizing lens forceps, but at the cost of losing the benefit of a small section (such as better wound healing and low surgically induced astigmatism).[234] However, we would like to propose a slight modification in the IOL insertion technique by utilizing a 2.8-mm incision in case a similar situation is encountered.

Recently, when we encountered a similar situation [Fig. 1], keeping in mind the bitter past experience, we decided to extend the incision from 2.2-mm to 2.8-mm for using the Alcon C cartridge with the same IOL [Figs. 2 and 3]. The IOL insertion was uneventful without any complications [Figs. 4 and 5]. Postoperative uncorrected visual acuity was 20/20 with no surgically induced astigmatism, good wound integrity, and clear cornea from day one.

Figure 1

Image showing the release of the preloaded injectable toric Hoya iSert® yellow IOL outside the globe due to unanticipated patient head movement during topical phacoemulsification surgery

Figure 2

IOL inspection showing the good condition of the premium toric IOL with no damage to the optic and haptics

Figure 3

(a-c) Image showing the proper loading technique of the premium toric Hoya iSert® yellow IOL into the C cartridge (red arrow) of Alcon Monarch system for passage through the 2.8-mm incision

Figure 4

Image showing appropriate implantation of the IOL within the capsular chamber without any entrapment of either optic or haptics of the premium toric Hoya iSert® yellow IOL in the C cartridge

Figure 5

Image showing a well-centered toric IOL in the capsular bag after dialing it in its precise axial alignment

Though one can argue that to arrange a standby IOL of similar power, in view of anticipation of such incidents, arranging standby premium toric IOLs is difficult in routine surgical practice.[4] Still, we encourage people to arrange standby IOLs whenever possible. However, in the event of not being able to do so, this slight modification in the technique emphasized by us, will prevent any mishap with preloaded injectable IOLs, if similar situations are encountered during 2.2-mm incision phacoemulsification surgeries, without compromising on the benefits of the small section of cataract surgery.