Performing cataract surgery with preloaded IOLs

Surgeons recount the benefits of these IOL injector systems.

Have you ever needed to perform “intraocular acrobatics?”

No, it’s not a new Olympic sport. Rather, it’s the way Cynthia Matossian, MD, FACS, ABES, characterizes the maneuvers she had to undergo during a cataract procedure to correct an implant her staff gave to her loaded backward. While she was able to turn the IOL right-side up and the surgical result was fine, the situation added both time and stress to the case.

Had the lens she was using been available in a preloaded IOL injector, the “acrobatics” could have been avoided. Preloaded IOL injectors “add many benefits to the operating room efficiency, to surgeons and to the scrub nurses,” says Dr. Matossian, founder and medical director of Matossian Eye Associates in Doylestown, Pa., and Hopewell, N.J.

Preloaded IOL injectors represent a significant advance in cataract surgery. Although not all lenses are available to be used with a preloaded IOL injector, the technology provides major benefits to the cataract surgeon and staff.


Preloaded IOL injectors, as the name indicates, eliminate the need to manually load an IOL into a lens inserter before inserting the lens into the capsular bag. Instead, the IOL comes preloaded into a delivery cartridge from the manufacturer.

Prior to placing the implant into the eye, the technician injects an appropriate viscoelastic device or balanced salt solution into the cartridge, removes any lens stop or locking system then passes the lens delivery device to the surgeon to inject the IOL into the eye.

Various manufacturers offer these devices in the United States, including the following:

  • UltraSert Pre-loaded IOL Delivery System (Alcon)
  • iSert Preloaded IOL System (Hoya)
  • Tecnis iTec Preloaded Delivery System (J&J Vision)
  • Pre-loaded Injector (Lenstec)


A major advantage of preloaded IOL injectors is the lack of human intervention, which helps ensure that the IOL enters the capsular bag without any flaws. Neither the surgeon nor scrub tech/nurse needs to touch the lens prior to insertion, eliminating the risk of optic or haptic damage. After being sterilized and shipped from the factory, the next thing the IOL encounters is the capsular bag, says Dr. Matossian. She uses the Tecnis iTec with the Model PCB00 monofocal one-piece acrylic lens.

“A closed system is really of significant value,” asserts Wesley K. Herman, MD, founder of Vision Quest, Dallas, Texas. Using an injector, he notes, avoids catching the haptics or scratching the optic.

Folding the haptics isn’t as crucial of a step, because there is room for variation, says Zarmeena Vendal, MD, owner of Westlake Eye Specialists in Texas. Dr. Vendal uses the Alcon UltraSert, having switched from exclusively using Alcon’s manual inserter.

“The haptics of the lens being folded in variable ways doesn’t matter,” she says. “It’s only if the optic of the lens is folded incorrectly or scratched that you have a big problem. The optic of the lens in a preloaded lens cartridge isn’t touched. I know with certainty that lens is not going to be scratched regardless of which location I am operating at or the experience of the surgical tech.”


In a practice handling a high volume of cataract procedures, increasing efficiency in each procedure could allow for additional cases. In such a high-volume setting, the team can save significant time by using a preloaded IOL injector system. If a high-volume surgeon can save 20 or 30 seconds per case, “that adds up to real time,” says Ravi D. Goel, MD, clinical spokesperson for the AAO.

Preeya K. Gupta, MD, associate professor of ophthalmology, cornea and refractive Surgery, Duke University Eye Center, Durham, N.C., uses the preloaded Tecnis iTec (J&J Vision). She estimates that this saves her about one minute per procedure. With 15 to 20 cases on days when she operates, the saved time can help her handle additional cases and create a better workflow and work environment. Dr. Gupta’s staff can use the saved time to perform tasks such as cleaning instruments and trays instead of preparing the lens.

“Additionally, both the surgeon and OR nurse have confidence that the IOL is in pristine condition and ready to implant at the exact time needed,” Dr. Gupta says.

For Sumit (Sam) Garg, MD, vice chair of clinical ophthalmology, medical director and associate professor, cataract, corneal & refractive surgery at Gavin Herbert Eye Institute, University of California, Irvine, using a preloaded IOL injector is quicker than loading the lens himself or relying on a resident to load the lens. Also, he notes that the ergonomics of the preloaded IOL injectors — in his case, the Tecnis — feel quite similar to the traditional cartridge and injection systems.


“Mastering how to load a wide variety of lenses can be inordinately challenging for the scrub nurses,” Dr. Matossian says. And, if the lens is loaded incorrectly and the surgeon delivers a damaged lens, the consequences to both the patient and the practice can be “rather severe,” she notes.

The manipulations that the surgeon has to perform to explant the lens could damage the eye and lead to complications, she says. For the practice, such a mistake may lead to a prolonged case time, additional cost to the ASC and perhaps the inability to use an agreed-upon advanced technology lens, resulting in a refund to the patient.

These systems also allow nursing staff at multispecialty surgical facilities to assist more easily in cataract surgeries. Dr. Goel says that it is “a wonderful benefit to have preloaded lenses as an option when cataract surgeons may not have access to specialized ophthalmic staff.”

Dr. Matossian says that some hospital-owned ASCs don’t allow scrub nurses to load the lenses, requiring instead that the surgeon perform this task. This is an inefficient use of a surgeon’s time, she says. Even if a scrub nurse can load the lenses, that may not be a panacea, especially if the nurse is presbyopic. What’s more, some surgeons, says Dr. Matossian, operate with the OR lights dimmed or even off, compounding the visual issues. And the clear haptics of the commonly used single-piece acrylic lenses can exacerbate the strain.

Dr. Matossian also points to surgeons who use the Alcon ORA intraoperative aberrometer to confirm implant power. This eliminates the time a scrub tech normally has to load the lens during cataract removal. With that gone, notes Dr. Matossian, the physician may have to wait while the tech loads the lens and then hands it to her for insertion. The preloaded IOL removes that pressure and stress.


One hindrance to adopting preloaded IOL injectors is simply the lack of lenses available with these devices. To date, only monofocal implants are available preloaded, but companies such as J&J Vision have pipeline devices that will allow premium implants to be preloaded, notes Dr. Gupta. She suggests that companies aspire to have injectors for premium IOLs, such as multifocal and toric lenses, because these implants are particularly sensitive to scratches or aberrations in the optic.

“It’s a reasonable, good technology that is nice to explore,” adds Dr. Goel. But “you’re not going to have a paradigm shift until every single lens is available on that platform. Even then, patient safety is paramount, and I will not enter an OR unless the surgical team is well versed in loading IOLs.”

Dr. Matossian, who performed those intraocular acrobatics, anticipates a day when she could have every lens available with preloaded IOL injector systems. “I look forward,” she says, “to having 100% of all implants preloaded.” OM