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Papers in this Session
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Comparison of Corneal Incision Healing Processes Using Two Motorized Injectors and a Manual Injector Following Phacoemulsification
Authors
Eiichi Nishimura, MD, PhD
Tamaki Sunakawa, MD
Mitsutaka Soda, PhD, MD
Yoshiro Tokunaga, MD
Methods
PEA was performed in 124 cases 193 eyes prospectively through clear corneal incisions (ranging 2.0, 2.2, 2.4, 2.6mm) at Showa University Fujigaoka Hospital from December 2018 to May 2019. After PEA, IOLs were inserted using two motorized injectors (AutoSert, AutonoMe: Alcon) and one manually injector (UltraSert: Alcon). We compared the wound expansion width during surgery and at the end of surgery among 3 groups. All wounds were evaluated postoperatively one day, one week, and one month by ASOCT. We analyzed the incision’s structure at the wound level and scored Descemet’s detachment, bulge, and endothelial gaps.
Results
Comparing the incision width with each injector, there was no significant difference in AutonoMe and AutoSert groups, but significant expansion was observed in the 2.0 mm and 2.2 mm of the UltraSert group. Comparing the injector groups, the AutonoMe group and the AutoSert group were significantly less at 2.2 mm than the UltraSert group. The ASOCT score at 2.2 mm was significantly smaller in the AutonoMe group than in the UltraSert group at 1 day and 1 week after surgery, but there was no significant difference at 1 month after surgery among all groups. It was significantly improved at 1 month after surgery compared with 1 day after surgery in all groups.
Conclusion
The AutonoMe group and the AutoSert group have less wound damage than the UltraSert group. Wound healing significantly improved at 1 month in all groups and there was no difference among all groups.
Eiichi Nishimura, MD, PhD
Tamaki Sunakawa, MD
Mitsutaka Soda, PhD, MD
Yoshiro Tokunaga, MD
Methods
PEA was performed in 124 cases 193 eyes prospectively through clear corneal incisions (ranging 2.0, 2.2, 2.4, 2.6mm) at Showa University Fujigaoka Hospital from December 2018 to May 2019. After PEA, IOLs were inserted using two motorized injectors (AutoSert, AutonoMe: Alcon) and one manually injector (UltraSert: Alcon). We compared the wound expansion width during surgery and at the end of surgery among 3 groups. All wounds were evaluated postoperatively one day, one week, and one month by ASOCT. We analyzed the incision’s structure at the wound level and scored Descemet’s detachment, bulge, and endothelial gaps.
Results
Comparing the incision width with each injector, there was no significant difference in AutonoMe and AutoSert groups, but significant expansion was observed in the 2.0 mm and 2.2 mm of the UltraSert group. Comparing the injector groups, the AutonoMe group and the AutoSert group were significantly less at 2.2 mm than the UltraSert group. The ASOCT score at 2.2 mm was significantly smaller in the AutonoMe group than in the UltraSert group at 1 day and 1 week after surgery, but there was no significant difference at 1 month after surgery among all groups. It was significantly improved at 1 month after surgery compared with 1 day after surgery in all groups.
Conclusion
The AutonoMe group and the AutoSert group have less wound damage than the UltraSert group. Wound healing significantly improved at 1 month in all groups and there was no difference among all groups.
Thermal Response of Several Viscoelastics in Phacoemulsification in a Vacuum-Blocked Surgical Scenario
Authors
Emilie L. Ungricht
Randall J. Olson, MD
Nathan Jensen
Jacob T. Harris
Methods
An AC Ozil hand piece with a temperature probe attached to an Omega Temperature Gauge (OM-EL-USB-TC-LCD) was placed into a chamber with balanced saline solution (BSS), Viscoat, Provisc, Discovisc, or Healon 5. The gauge recorded the temperature at time zero, 10 seconds, 20 seconds, and 30 seconds. The ultrasound was run for 30 seconds with an IOP of 50 mmHg, a vacuum of 0 mmHg, Aspiration of 12 cc/min on a torsional setting at 60% power. A five minute rest period and BSS flow through the hand piece in between trials was established to allow for the hand piece to return to base temperature. 10 trials were obtained for each material being tested.
Results
The average baseline temperature was 23.05 with standard deviation (SD) of 0.76 °C with BSS showing a linear increase of 5.49±1.24 °C, Viscoat increasing 23.12±4.60 °C, ProVisc increasing 17.32±1.65 °C, DisCoVisc increasing 35.96±4.29 °C, and Healon 5 increasing 20.71±3.75 °C. Healon 5 showed increased variability, resulting in 20 trials. The difference in temperature increase between BSS and any OVD was found to have significance (p-value<4.55E-25). DisCoVisc reached temperatures exceeding 60 °C.
Conclusion
CCC has been shown to occur at 60 °C. DisCoVisc reached that threshold in an vacuum-blocked surgical scenario. Healon 5, ProVisc, and Viscoat demonstrated higher temperature changes than BSS, but did not reach the critical threshold for CCC. Understanding the different thermal responses in this scenario enables surgeons to reduce the risk of CCC.
Emilie L. Ungricht
Randall J. Olson, MD
Nathan Jensen
Jacob T. Harris
Methods
An AC Ozil hand piece with a temperature probe attached to an Omega Temperature Gauge (OM-EL-USB-TC-LCD) was placed into a chamber with balanced saline solution (BSS), Viscoat, Provisc, Discovisc, or Healon 5. The gauge recorded the temperature at time zero, 10 seconds, 20 seconds, and 30 seconds. The ultrasound was run for 30 seconds with an IOP of 50 mmHg, a vacuum of 0 mmHg, Aspiration of 12 cc/min on a torsional setting at 60% power. A five minute rest period and BSS flow through the hand piece in between trials was established to allow for the hand piece to return to base temperature. 10 trials were obtained for each material being tested.
Results
The average baseline temperature was 23.05 with standard deviation (SD) of 0.76 °C with BSS showing a linear increase of 5.49±1.24 °C, Viscoat increasing 23.12±4.60 °C, ProVisc increasing 17.32±1.65 °C, DisCoVisc increasing 35.96±4.29 °C, and Healon 5 increasing 20.71±3.75 °C. Healon 5 showed increased variability, resulting in 20 trials. The difference in temperature increase between BSS and any OVD was found to have significance (p-value<4.55E-25). DisCoVisc reached temperatures exceeding 60 °C.
Conclusion
CCC has been shown to occur at 60 °C. DisCoVisc reached that threshold in an vacuum-blocked surgical scenario. Healon 5, ProVisc, and Viscoat demonstrated higher temperature changes than BSS, but did not reach the critical threshold for CCC. Understanding the different thermal responses in this scenario enables surgeons to reduce the risk of CCC.
Risk Factors for Complications in Resident and Attending-Performed Cataract Surgery at a Large Urban Academic Center
Authors
David Y. Lu, MD
Garred S. Greenberg, MD
Isaac M. Chocron, MD
Jimmy K. Lee, MD
Methods
This was a retrospective case series of 2159 eyes from 1529 adult patients undergoing phacoemulsification surgery performed at a large urban academic center in New York City. All cases from 2016 performed by both residents and attendings were included except those in which there was previous history of intraocular surgery in the operated eye. Data on intraoperative complications (vitreous loss, posterior capsular tear, dropped/retained lens), postoperative CME, resident involvement, demographics, usage of prophylactic NSAID drops, and case complexity were determined through chart review. Complex cases were defined as those with CPT code 66982 while simple cases were those coded as 66984.
Results
Intraoperative complications occurred in 2.22% of cases while postoperative CME developed in 1.81% of cases. Residents had significantly higher intraoperative complication rates (4.13%) than attendings (1.90%), even after controlling for other risk factors (RR 2.17, p=0.02). Compared to simple cases, complex cases were associated with higher rates of intraoperative complications (5.24% vs 1.81%, RR 3.13, p<0.001) and CME (3.59% vs 1.61%, RR 2.23, p=0.04) for all cases performed by attendings and residents. Male patient gender increased risk of intraoperative complications (RR 1.92, p=0.03). Prophylactic NSAIDs and attending-performed surgery were not associated with reduced incidence of CME.
Conclusion
Resident-performed cataract surgery is associated with significantly higher rates of major intraoperative complications than similar cases performed by attending surgeons. Complex surgery and male patient gender were also associated with increased intraoperative complication rates. Complex surgery increases risk of postoperative CME.
David Y. Lu, MD
Garred S. Greenberg, MD
Isaac M. Chocron, MD
Jimmy K. Lee, MD
Methods
This was a retrospective case series of 2159 eyes from 1529 adult patients undergoing phacoemulsification surgery performed at a large urban academic center in New York City. All cases from 2016 performed by both residents and attendings were included except those in which there was previous history of intraocular surgery in the operated eye. Data on intraoperative complications (vitreous loss, posterior capsular tear, dropped/retained lens), postoperative CME, resident involvement, demographics, usage of prophylactic NSAID drops, and case complexity were determined through chart review. Complex cases were defined as those with CPT code 66982 while simple cases were those coded as 66984.
Results
Intraoperative complications occurred in 2.22% of cases while postoperative CME developed in 1.81% of cases. Residents had significantly higher intraoperative complication rates (4.13%) than attendings (1.90%), even after controlling for other risk factors (RR 2.17, p=0.02). Compared to simple cases, complex cases were associated with higher rates of intraoperative complications (5.24% vs 1.81%, RR 3.13, p<0.001) and CME (3.59% vs 1.61%, RR 2.23, p=0.04) for all cases performed by attendings and residents. Male patient gender increased risk of intraoperative complications (RR 1.92, p=0.03). Prophylactic NSAIDs and attending-performed surgery were not associated with reduced incidence of CME.
Conclusion
Resident-performed cataract surgery is associated with significantly higher rates of major intraoperative complications than similar cases performed by attending surgeons. Complex surgery and male patient gender were also associated with increased intraoperative complication rates. Complex surgery increases risk of postoperative CME.
Ex-Vivo Comparative Assessment of Commercially Available Preloaded Monofocal IOL Injectors
Authors
Inder P. Singh, MD
George M. Lau, OD
Methods
All tests were performed by a single cataract surgeon. Three preloaded injectors (MX60PL, Bausch & Lomb; PCB00, Johnson & Johnson; AU00T, Alcon) and one non-preloaded injector (BLIS-R1, Bausch & Lomb) were used in the study. All injectors were prepared and advanced into the nozzle and held in the compressed state for 3, 5, and 15 minutes prior to delivery. A 2.4mm clear corneal incision was created for each condition in artificial aphakic eyes and all IOLs were delivered into the bag. IOL preparation time, IOL delivery speed/control, OVD usage, IOL position in the bag, IOL optic quality, and need for second instrument were all assessed for each condition. All cases were video recorded.
Results
MX60PL and AU00T had the quickest Injector loading time and PCB00 was the slowest in the preloaded group (average time: 18.11, 18.83, 22.7 secs respectively). The non-preloaded control, BLIS-R1 took the longest time at 35.3 secs. All injectors demonstrated good delivery speed, control, and minimal OVD usage for preparation (~0.23ml). All IOLs were successfully delivered into the capsular bag, except for one case with PCB00 that was delivered partially outside. Two cases needed a second instrument (PCB00-partial delivery, AU00T-stuck haptic). BLIS and MX60PL were easier to insert into the wound, PCB00 was not as smooth, and AU00T required more force because of the plunger design.
Conclusion
In this ex-vivo study, all preloaded injectors demonstrated good efficiency when compared to the non-preloaded control injector. All preloaded injectors showed good delivery control and speed, but only MX60PL had no complications with in the bag delivery and did not require a second instrument.
Inder P. Singh, MD
George M. Lau, OD
Methods
All tests were performed by a single cataract surgeon. Three preloaded injectors (MX60PL, Bausch & Lomb; PCB00, Johnson & Johnson; AU00T, Alcon) and one non-preloaded injector (BLIS-R1, Bausch & Lomb) were used in the study. All injectors were prepared and advanced into the nozzle and held in the compressed state for 3, 5, and 15 minutes prior to delivery. A 2.4mm clear corneal incision was created for each condition in artificial aphakic eyes and all IOLs were delivered into the bag. IOL preparation time, IOL delivery speed/control, OVD usage, IOL position in the bag, IOL optic quality, and need for second instrument were all assessed for each condition. All cases were video recorded.
Results
MX60PL and AU00T had the quickest Injector loading time and PCB00 was the slowest in the preloaded group (average time: 18.11, 18.83, 22.7 secs respectively). The non-preloaded control, BLIS-R1 took the longest time at 35.3 secs. All injectors demonstrated good delivery speed, control, and minimal OVD usage for preparation (~0.23ml). All IOLs were successfully delivered into the capsular bag, except for one case with PCB00 that was delivered partially outside. Two cases needed a second instrument (PCB00-partial delivery, AU00T-stuck haptic). BLIS and MX60PL were easier to insert into the wound, PCB00 was not as smooth, and AU00T required more force because of the plunger design.
Conclusion
In this ex-vivo study, all preloaded injectors demonstrated good efficiency when compared to the non-preloaded control injector. All preloaded injectors showed good delivery control and speed, but only MX60PL had no complications with in the bag delivery and did not require a second instrument.
Comparative Analysis of Visual Outcomes and Implantation Behavior of Three Preloaded Monofocal Hydrophobic Acrylic IOL : –Six Months Results
Authors
Bharti Kashyap, MS
Birendra Prasad Kashyap, MS
Dr.Bibhuti Kashyap, MD, DNB
Nidhi Gadkar, MS, DNB
Methods
This was a non randomized and comparative study of 150eyes (75 patients) with cataract & no other ocular or neurological co-morbidities under going cataract surgery who were divided into three Gr of preloaded aspheric hydrophobic acrylic IOLs Gr-1 Ozonated Vivinex (iSERT), Gr-2 Tecnis PCBOO (iTEC) & Gr-3 AutonoMe Clareon The required Axial Length was between 22&25mm. 6months post op Outcomes Measures Included (UDVA) & (CDVA), Spherical Equivalent (SE), Miyata grades of Glistening (0=No,1=mild,2=Moderate &3=severe),Morphological objective PCO estimation.Intra and Inter group pre vs post implantation change in incision width & Implantation behavior was also compared
Results
UDVA LogMAR Gr-1(mean±SD ;0.03±0.1),Gr-2(0.02±0.1)& Gr-3(0.03±0.14)P=1.00,95% CI=0.02,0.02)-CDVA LogMAR Gr-1 (mean±SD 0.03±0.07),Gr-2(mean±SD 0.02±0.06) & Gr-3(mean±SD 0.02±0.1),P=0.21,95%CI=-0.03,0.01),Residual SE(diff= -0.406,p=0.395,95%CI( -1.35,0.537) ,Intra gr pre-post implantation Mean change in incision width sig more in all grs Gr-1=-.15,p=.000,95%CI(-.16,-.15),Gr-2 =-.16, P=.00,95%CI(-.16,-.17)Gr-3=-.13,P=.000,95%CI(-.14,-.13),Inter Gr Incision width Change Non Sig in all Gr,Gr1&2 (diff M=-.01,p=.43,95%CI=(-.009,-.15) Gr1&Gr3(diff M=.0004, p=.86,95%CI(-.004,-.003)Gr2 &3(diff mean= .013,p=.62,95%CI(.012,.014) Among All the 3 Grs Glistening & PCO non sig ²=.187,p=.99,& ²=1.68,P=.43
Conclusion
6months Visual outcomes of this study shows no Significant difference in visual outcomes among the three groups .The per-operative Inter Group change in Incision width &Incidence of delivery of folded leading haptic is Comparable in all three Groups
Bharti Kashyap, MS
Birendra Prasad Kashyap, MS
Dr.Bibhuti Kashyap, MD, DNB
Nidhi Gadkar, MS, DNB
Methods
This was a non randomized and comparative study of 150eyes (75 patients) with cataract & no other ocular or neurological co-morbidities under going cataract surgery who were divided into three Gr of preloaded aspheric hydrophobic acrylic IOLs Gr-1 Ozonated Vivinex (iSERT), Gr-2 Tecnis PCBOO (iTEC) & Gr-3 AutonoMe Clareon The required Axial Length was between 22&25mm. 6months post op Outcomes Measures Included (UDVA) & (CDVA), Spherical Equivalent (SE), Miyata grades of Glistening (0=No,1=mild,2=Moderate &3=severe),Morphological objective PCO estimation.Intra and Inter group pre vs post implantation change in incision width & Implantation behavior was also compared
Results
UDVA LogMAR Gr-1(mean±SD ;0.03±0.1),Gr-2(0.02±0.1)& Gr-3(0.03±0.14)P=1.00,95% CI=0.02,0.02)-CDVA LogMAR Gr-1 (mean±SD 0.03±0.07),Gr-2(mean±SD 0.02±0.06) & Gr-3(mean±SD 0.02±0.1),P=0.21,95%CI=-0.03,0.01),Residual SE(diff= -0.406,p=0.395,95%CI( -1.35,0.537) ,Intra gr pre-post implantation Mean change in incision width sig more in all grs Gr-1=-.15,p=.000,95%CI(-.16,-.15),Gr-2 =-.16, P=.00,95%CI(-.16,-.17)Gr-3=-.13,P=.000,95%CI(-.14,-.13),Inter Gr Incision width Change Non Sig in all Gr,Gr1&2 (diff M=-.01,p=.43,95%CI=(-.009,-.15) Gr1&Gr3(diff M=.0004, p=.86,95%CI(-.004,-.003)Gr2 &3(diff mean= .013,p=.62,95%CI(.012,.014) Among All the 3 Grs Glistening & PCO non sig ²=.187,p=.99,& ²=1.68,P=.43
Conclusion
6months Visual outcomes of this study shows no Significant difference in visual outcomes among the three groups .The per-operative Inter Group change in Incision width &Incidence of delivery of folded leading haptic is Comparable in all three Groups
Incidence of Corneal Abrasion after Use of Hydrogel Ocular Sealant in Cataract Surgery
Authors
Zachary Mendelson, MD
Mohammad H Dastjerdi, MD
Methods
We performed a retrospective chart review of all patients who underwent standard cataract surgery with intra-operative use of hydrogel ocular sealant over a 20 month period. Fisher’s exact test was used to compare the results of our institution’s experience with the results of the FDA clinical trial.
Results
One hundred and twenty-nine patients met inclusion criteria. Of the 129 patients, 19 (14.7%) had a post-operative corneal abrasion on post-operative day 1. Statistical analysis of the data yielded a significant difference (P<0.0001).
Conclusion
In our institutional experience incidence of corneal abrasion after use of hydrogel ocular sealant in standard cataract surgery was significantly higher than previously reported.
Zachary Mendelson, MD
Mohammad H Dastjerdi, MD
Methods
We performed a retrospective chart review of all patients who underwent standard cataract surgery with intra-operative use of hydrogel ocular sealant over a 20 month period. Fisher’s exact test was used to compare the results of our institution’s experience with the results of the FDA clinical trial.
Results
One hundred and twenty-nine patients met inclusion criteria. Of the 129 patients, 19 (14.7%) had a post-operative corneal abrasion on post-operative day 1. Statistical analysis of the data yielded a significant difference (P<0.0001).
Conclusion
In our institutional experience incidence of corneal abrasion after use of hydrogel ocular sealant in standard cataract surgery was significantly higher than previously reported.
Survey Regarding Operating Room Waste – Ophthalmologists’ Opinions about the Carbon Footprint of Phacoemulsification
Author
David F. Chang, MD
Methods
An online survey regarding O.R. waste and supply reuse was designed by the Ophthalmic Instrument Cleaning and Sterilization task force, which is comprised of representatives from ASCRS, AAO, and OOSS. The survey link was sent by email to members of ASCRS, AAO, and OOSS. An informational paragraph listing the surgical items that are regularly reused at the Aravind Eye Care System (AECS) in India was included. Published data on the comparative endophthalmitis rate and carbon footprint of cataract surgery at the AECS was included.
Results
89% are concerned about global warming, 93% felt that trash from cataract surgery was excessive and 80% believe we should reuse more supplies and instruments. At least 90% believe that manufacturers should utilize recycled packaging materials, provide more reusable supplies and instruments, and permit more surgeon discretion for reuse in their IFU. For the following items, the percentage of surgeons unwilling to consider reuse are phaco tips (5%), IA tips (7%), tubing and irrigating solution (15%), cannulae (19%), unused sutures (33%), metal blades (20%), gowns (27%), commercial intraocular drugs (<3%), compounded solutions (8%), topical meds (<1%); only 8% prefer disposable instruments.
Conclusion
The vast majority want manufacturers to reduce surgical waste and carbon footprint by offering more reusable supplies, drugs, and instruments. The majority believe that regulatory agencies and manufacturers’ IFUs are major drivers of O.R. waste and 90% believe that they should permit more surgeon discretion over reuse of these products.
David F. Chang, MD
Methods
An online survey regarding O.R. waste and supply reuse was designed by the Ophthalmic Instrument Cleaning and Sterilization task force, which is comprised of representatives from ASCRS, AAO, and OOSS. The survey link was sent by email to members of ASCRS, AAO, and OOSS. An informational paragraph listing the surgical items that are regularly reused at the Aravind Eye Care System (AECS) in India was included. Published data on the comparative endophthalmitis rate and carbon footprint of cataract surgery at the AECS was included.
Results
89% are concerned about global warming, 93% felt that trash from cataract surgery was excessive and 80% believe we should reuse more supplies and instruments. At least 90% believe that manufacturers should utilize recycled packaging materials, provide more reusable supplies and instruments, and permit more surgeon discretion for reuse in their IFU. For the following items, the percentage of surgeons unwilling to consider reuse are phaco tips (5%), IA tips (7%), tubing and irrigating solution (15%), cannulae (19%), unused sutures (33%), metal blades (20%), gowns (27%), commercial intraocular drugs (<3%), compounded solutions (8%), topical meds (<1%); only 8% prefer disposable instruments.
Conclusion
The vast majority want manufacturers to reduce surgical waste and carbon footprint by offering more reusable supplies, drugs, and instruments. The majority believe that regulatory agencies and manufacturers’ IFUs are major drivers of O.R. waste and 90% believe that they should permit more surgeon discretion over reuse of these products.
Comparative Assessment of the Corneal Incision Enlargement of Four Preloaded Intraocular Lens Delivery Systems
Authors
Thomas Kohnen, MD, PhD
Patricia Wolfe, PhD
Victor M. Hernandez, PhD
Methods
Sixteen (16) preloaded IOLs (20.0 D-21.0 D) per treatment group were delivered into the anterior chamber of human cadaver eyes through a 2.0 mm (Vivinex) or 2.2 mm (AutonoMe, UltraSert, and iTec) incision size. Corneal incision morphology was evaluated using optical coherence tomography (OCT) and incision sizes were measured using ASICO incision gauges before and after IOL delivery. Differences in mean incision enlargement between delivery devices were evaluated using a paired t-test.
Results
AutonoMe (0.29±0.03 mm) and UltraSert (0.29±0.03 mm) had the smallest average incision enlargement compared with iTec (0.31±0.03 mm) and Vivinex (0.36±0.06 mm). Vivinex had the largest corneal incision enlargement and was significantly larger than AutonoMe (p=0.001), UltraSert (p=0.001) and iTec (p=0.002). Representative OCT images of pre- and post-implantation incisions (cross sectional images of cornea) showed more incision gaping, corneal stromal damage and distortion for delivery systems with the largest incision enlargement: Vivinex and iTec.
Conclusion
The new AutonoMe preloaded delivery system protects the corneal incision during IOL implantation and causes smaller incision enlargement and less corneal stromal damage compared to iTec and Vivinex. Further clinical studies are necessary to confirm the effect of incision enlargement on wound healing and post-operative corneal morphology.
Thomas Kohnen, MD, PhD
Patricia Wolfe, PhD
Victor M. Hernandez, PhD
Methods
Sixteen (16) preloaded IOLs (20.0 D-21.0 D) per treatment group were delivered into the anterior chamber of human cadaver eyes through a 2.0 mm (Vivinex) or 2.2 mm (AutonoMe, UltraSert, and iTec) incision size. Corneal incision morphology was evaluated using optical coherence tomography (OCT) and incision sizes were measured using ASICO incision gauges before and after IOL delivery. Differences in mean incision enlargement between delivery devices were evaluated using a paired t-test.
Results
AutonoMe (0.29±0.03 mm) and UltraSert (0.29±0.03 mm) had the smallest average incision enlargement compared with iTec (0.31±0.03 mm) and Vivinex (0.36±0.06 mm). Vivinex had the largest corneal incision enlargement and was significantly larger than AutonoMe (p=0.001), UltraSert (p=0.001) and iTec (p=0.002). Representative OCT images of pre- and post-implantation incisions (cross sectional images of cornea) showed more incision gaping, corneal stromal damage and distortion for delivery systems with the largest incision enlargement: Vivinex and iTec.
Conclusion
The new AutonoMe preloaded delivery system protects the corneal incision during IOL implantation and causes smaller incision enlargement and less corneal stromal damage compared to iTec and Vivinex. Further clinical studies are necessary to confirm the effect of incision enlargement on wound healing and post-operative corneal morphology.