Cataract Surgery Feature story
Preloaded and Motorized
Cataract Surgery Injections
Injectors that are preloaded or motorized may offer safety advantages over manually loaded devices.
By Thierry Amzallag, MD
I
f IOL injection is a precondition to reducing incision
size and limiting surgically induced astigmatism, use of
a preloaded IOL could have several potential benefits.
However, the definition of preloading is ambiguous,
and in practice partial automation is limited to the sur-
geon no longer handling the IOL.
Although we are a long way from push-and-go injection
systems, certain products are getting close. Today, there
are two types of preloaded injectors. The first type includes
injectors that fold the IOL and place the implant in a single
step, like the AcrySert C (Alcon), EyeCee NZ1 (Croma
Pharma), Micro 123 (PhysIOL), and Genium (LCA). These
designs have a flat load and a rigid plunger, and they are
well suited to IOLs with C-loop haptics. However, today
their use is limited to incisions of no less than 2.0 mm. The
second type of injector requires a folding step prior to
placement. These include the Isert (Hoya), Bluemixs 180
(Carl Zeiss Meditec), Accuject Pro (Medicel), and Artis PL
(Cristalens). With these injectors, loading is performed later-
ally, and the plunger has a flexible tip. They are well suited
for IOLs with four-loop haptic designs and are compatible
with microincision cataract surgery (MICS).
Motorized injection is another aspect of automation that
can further enhance surgical performance and safety. It is pos-
sible that it may be combined with preloading in the future.
FACTORS LIMITING THE USE OF
PRELOADED INJECTION
Preloaded injectors improve mechanical reliability, micro-
biologic safety, and the reproducibility and speed of the injec-
tion process. However, two factors limit the generalization of
the preloading concept: economics and mechanical reliability.
Economically, preloaded injectors represent a significant
additional cost for companies that cannot be passed on to
their clients. Also, there are countless patents on injectors,
and the manufacturing process is complex.
Mechanical reliability during automated folding and injec-
tion of IOLs has improved, but the use of plastic parts and
the simultaneous storage of the lens and injector make it dif-
26 Cataract & Refractive Surgery Today EUROPE February 2014
ficult to achieve consistent reproducibility. Additionally, the
gliding ability of these cartridges represents a major chal-
lenge to injection, particularly for MICS. Current cartridges
are most frequently made of polypropylene, which can
cause friction with the IOL—especially with hydrophobic
acrylic materials—if there is no buffer between them.
MINIMIZE FRICTION,
IMPROVE GLIDING ability
For any injection system, friction is the enemy. With
minimal friction, the thrust force is moderate and the
IOL advances easily, smoothly, and safely; however, with
maximal friction, the thrust force becomes excessive,
causing the IOL to stick against the wall of the injector
and the IOL material to compress. Excessive pressure
may cause the cartridge to rupture or damage the pre-
loaded cartridge. If rupture occurs, stress is immediately
transmitted to the incision and to the IOL.
There are three options to reduce friction. The most com-
mon is inclusion of a gliding agent in the polypropylene,
which appears on the surface of the cartridge after steriliza-
tion. Implementation of this option is relatively easy, but the
agent can be visibly deposited onto the surface of the IOL.
These cartridges are usually sterilized with ethylene oxide,
but, when used with IOLs made of hydrophilic acrylic mate-
rials, they must be sterilized with steam in order to reduce
the risk of glyceride monomers or the gliding agent being
released into the storage fluid. This phenomenon has been
mentioned in relation to toxic anterior segment syndrome,
although the mechanism has not been elucidated. A second
option is a surface-coating treatment, such as hydrophilic or
hydrophobic polyvinylpyrrolidone, and a third option is the
use of a plasma technology that changes the surface proper-
ties of the material. Improved gliding capability can limit
mechanical stress on the plunger, improve safety, facilitate
injection, and allow a reduction in incision size.
In addition to increasing the gliding capability of the
injector itself, there are two additional ways to improve IOL
gliding ability during injection: (1) use of an ophthalmic vis-
 Cataract Surgery Feature story

A B C

Figure 1. The AcrySert C has a three-step injection technique: fill (A), pull (B), and push (C).

A B C D

Figure 2. The Hoya injector has a four-step injection technique: fill (A), pull (B), fold (C), and push (D).
A B C D E

Figure 3. The Artis PL has a five-step injection technique: pull (A), wash (B), fill (C), fold (D), and push (E).

A B tate gliding and reduce the pressure required to advance the

C D
Figure 4. The EyeCee NZ1 injector has a four-step injection
technique: fill (A), pull (B), push 1 (C), and push 2 (D).
cosurgical device (OVD) to lubricate the injection cartridge
and (2) viscoinjection, whereby an OVD is used to push the
IOL into the cartridge. The best lubricating OVDs are those
with low contact angles (less than 65°), such as hydroxy-
propylmethylcellulose; however, if the cartridge has good
gliding capacity, it does not matter which OVD is used. With
viscoinjection, the OVD remains in front of the IOL to facili-
plunger. Injectors that use this mechanism of action include
the Accuject, Bluemixs 180, Micro 123, and Artis PL.
Another obstacle to the generalization of preloaded
injectors is the required incision size, which historically is
about 3.0 mm. The internal diameter of the injector tun-
nel must be 1.6 mm for a 2.2-mm incision, 1.25 mm for a
1.8-mm incision, and at most 1.0 mm for a 1.4-mm incision,
but the optic diameter of most IOLs is 6.0 mm. This gives
you an idea of the mechanical stresses exerted on the walls
of the injection tunnel during placement of the implant.
The bevel values may reach 15 N. The cornea is not flex-
ible, and its deformation should not exceed 15% to avoid
irreversible stretching, instability, and induced astigmatism.
It is always preferable to enlarge the incision rather than
to cause trauma. It is even more desirable to find out the
exact dimensions of the cartridge and its capacity.
RECENT IMPROVEMENTS
Many improvements have been made to increase the
microbiologic safety and performance of preloaded injectors.
First, there have been numerous changes to cartridge materi-
als, including the use of polyimide, the improvement of cov-
ering fluids, and the incorporation of surface or plasma treat-

February 2014 Cataract & Refractive Surgery Today Europe 27

Cataract Surgery Feature story

A B C D E

Figure 5. The Bluemixs 180 injector has a five-step injection technique: plug (A), fill (B), pull (C), fold (D), and push (E).
A B C

Figure 6. The Micro 123 injector has a four-step technique: plug (A), wash (B), fill (B), and push (C).
A B C

Figure 7. The Genium has a three-step injection technique: wash (A), fill (B), and push (C).

ments to replace gliding agents. Second, there have been
several changes to sterilization methods. Third, the majority
of preloaded injectors are now compatible with MICS.
Newer MICS-compatible designs are also available. The
Isert and the Artis PL require the surgeon to fold the IOL,
thus allowing injection through a microincision. With the
AcrySert C, several features were changed simultaneously
to improve performance and reproducibility. Also, certain
preloaded injectors including the Accuject allow injec-
tion of IOLs made of hydrophilic and hydrophobic acrylic
materials. This product uses the viscoinjection principle
and includes a silicone deformable plunger tip. The load-
ing chamber, equipped with sealing fins, is large enough to
accommodate a variety of IOLs, and the injection tunnel
is tough enough for most lenses. In its hydrophilic version,
the loading chamber is kept in a separate moist container,
and the injection tunnel and the body are dry. In its hydro-
phobic acrylic version, the whole device is kept dry. The
MDJ preloaded injector (MDJ) includes an appendage for
folding a hydrophobic or hydrophilic IOL in the loading
chamber, which is then withdrawn before injection.
INJECTORS FOR HYDROPHOBIC ACRYLICs
Below is an overview of the injectors for hydrophobic
acrylic IOLs that we have experience with.
AcrySert C. This preloaded injector (Alcon) allows
one-handed manual injection of the AcrySof IOL, free-
ing the surgeon’s second hand to stabilize the eye and
position the IOL. The first version of this injector, the
AcrySert B, was reliable but required an incision size of
3.2 mm. The AcrySert C is compatible with a 2.2-mm
incision without a bevel and 2.6 to 2.8 mm if inserted into
the anterior chamber. It requires a three-step technique
(See Injection Steps for Hydrophobic Acrylic IOLs; Figure 1).
If the injection is performed in the anterior chamber
with an incision of 2.6 or 2.8 mm, the IOL is released direct-
ly into the capsular bag. If used with a 2.2-mm incision, I
use a wound-assisted technique:
1. Create the 2.2-mm incision;
2. Pressurize the anterior chamber with an OVD;
3. Fill the loading chamber with an OVD up to the mark;
4. Remove the tab blocking the IOL from right to left;
5. Push the IOL slowly with your palm on the plung-
er up to the mark;
6. Apply the bevel firmly at the edge;
7. With a manipulator, exert counter-pressure through
the service incision;
8. Inject slowly, firmly, and without stopping;
9. Push the plunger until it stops; and
10. Position the IOL with a second instrument.

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 Cataract Surgery Feature story

Isert. The Isert 251 is a preloaded injector designed for

Injection Steps for Hydrophobic
the NY 60 IOL (Hoya), and the Isert 250 is designed for the
Acrylic IOLs
company’s nontinted IOL models. The injector comes with
AcrySert C
a base and includes a plunger, two sliders, a safety release,
1. Fill: fill the loading chamber with ophthalmic
and a flange. There are four main steps for injection (See
viscosurgical device (OVD) up to the mark
Injection Steps for Hydrophobic Acrylic IOLs; Figure 2).
2. Pull: pull the tab that is blocking the IOL from
Because of the cleft at the end of the injection tunnel,
right to left
which is designed to control release of the IOL, the injec-
3. Push: slowly push on the plunger with palm
tor should not be used with a wound-assisted technique.
Isert
A version for the toric IOL (Isert 351) is also available.
1. Fill: fill the loading chamber with OVD or
Artis PL. This injector, designed for the Artis one-
balanced saline solution
piece IOL (Cristalens), consists of a cartridge with wings
2. Pull: pull on the IOL cover
that contains the implant and an IOL-blocking system.
3. Fold: prefold the IOL using lateral sliders
There are five steps for injection (See Injection Steps for
4. Push: after freeing the injector from its base, press
Hydrophobic Acrylic IOLs; Figure 3).
the plunger and engage and tighten the threads
HPI Injector. The HPI Injector (Aaren Scientific) has
as the IOL is released; this requires two hands
the same characteristics as the Isert and is designed to
Artis PL
inject the NC1 one-piece hydrophobic acrylic IOL (Aaren
1. Pull: pull from left to right with the left hand on
Scientific).
the tab
ITec Injector. This injector (Abbott Medical Optics
2. Wash: rinse the loading chamber and the
Inc.) is marketed for incision sizes between 2.2 and 2.4
injection tunnel with balanced saline solution
mm and is designed for the monofocal, multifocal, and
3. Fill: fill the loading chamber and the tunnel with
toric Tecnis IOL models (Abbott Medical Optics Inc.).
an OVD
The recommended injection steps are described in
4. Fold: fold the IOL by closing the blades until you
Injection Steps for Hydrophobic Acrylic IOLs.
hear a click
EyeCee NZ 1. The EyeCee NZ 1 is one of the rare injec-
5. Push: push slowly on the one-handed plunger
tors designed for a three-piece IOL made of hydrophobic
and inject the IOL into the anterior chamber
acrylic material. It comes as a single unit including the
ITec Injector
injector, the IOL, and a stabilization system at the end of
1. Fill: inject OVD through the protective cap
the injection tunnel. Four steps are required for its use (See
2. Pull: pull off the protective cap
Injection Steps for Hydrophobic Acrylic IOLs; Figure 4).
3. Push: push the plunger to move the implant
under the design on the cartridge; wait 2 to 5
INJECTORS FOR HYDROPHILIC ACRYLICs
minutes for lubrication
Bluemixs 180. The Bluemixs 180 is designed to inject the
4. Screw: completely advance the IOL by pushing
CT Asphina 509MP and 409 MP IOLs (Carl Zeiss Meditec),
the plunger up to the black reference mark; in
lenses with negative and neutral aspheric designs, respec-
1 minute, inject the IOL by rotating the plunger
tively, and the AT LISA/AT LISA Toric and AT Torbi IOLs
clockwise
(Carl Zeiss Meditec). There are five steps for injection (See
EyeCee NZ 1
Injection Steps for Hydrophilic Acrylic IOLs; Figure 5).
1. Fill: fill the loading chamber with an OVD via the
The injector is compatible with 2.2-mm incisions
posterior opening designed for this purpose
by inserting the bevel into the anterior chamber and
2. Pull: pull on the stabilizing tab of the IOL
1.8-mm incisions with a wound-assisted technique.
3. Push 1: push the button to position the IOL
Micro 123. The cartridge and IOL are stored in a
injection
container in a humid environment, and the body of the
4. Push 2: after pressing the plunger to engage
injector, including the plunger and the deformable tip,
the threads, tighten the plunger to release the
are kept dry. It is designed to inject the Micro AY IOL
implant; because it is a three-piece implant, the
(PhysIOL), and there are four injection steps (See Injection
injector must be rotated counterclockwise after
Steps for Hydrophilic Acrylic IOLs; Figure 6).
release of the first haptic, then the plunger pulled
The Micro 123 injector can be used with a 2.2-mm
out to inject the second haptic
incision if it is introduced into the anterior chamber and
1.8-mm if it is kept at the edge.
Genium and Genium micro. As the smallest injec-

February 2014 Cataract & Refractive Surgery Today Europe 29

Cataract Surgery Feature story

Injection Steps for Hydrophilic acrylic IOLs

Bluemixs 180
1. Plug: remove the loading chamber containing the IOL from its container and connect it to the body of the
injector opposite the injection tunnel
2. Fill: inject OVD into the loading chamber and the tunnel via the orifice designed for this purpose
3. Pull: pull on the IOL stabilizer from left to right
4. Fold: fold the IOL using the cartridge with wings until you hear a click
5. Push: push slowly on the deformable plunger to advance the IOL into position for one-handed injection

Micro 123
1. Plug: connect the dry body of the injector to the cartridge in the container; only one direction is possible,
and it is not necessary to touch the deformable tip
2. Wash: rinse the upper opening of the cartridge and the IOL thoroughly
3. Fill: via the same opening, inject the OVD
4. Push: push once on the plunger to facilitate IOL injection; do not let the IOL stagnate in the loading chamber or
the injection tunnel

Genium and Genium micro

1. Wash: with the tip of the bevel, rinse the loading chamber with balanced saline solution
2. Fill: after verifying the position of the implant and after purging the syringe to avoid any air bubbles, inject a small amount
of OVD with the tip of a cannula; perform injection on both sides of the implant, then again when removing the cannula
3. Push: pushing on the plunger, move the implant toward the folding zone; once the superior haptics are folded
onto the optic with the plunger-folder, fold the optic and move it into the injection zone; next, introduce the
bevel, tilt the injector, and position it directly in the capsular bag until the tip of the plunger arrives at the level of
the bevel; after the optic is released into the anterior chamber, retract the plunger to inject the superior haptics
with an additional thrust

tors currently available, the cartridge and body of the
Genium and Genium micro injector are one unit, thus
reducing the overall volume. The thrusting and folding
systems are also one unit (a plunger-folder). Additionally,
the injector, made entirely of polypropylene, has three
zones. The storage zone has a flat posterior section to
hold the implant; the conical folding zone is responsible
for folding the IOL when the plunger is pushed; and the
injection zone, designed to deliver the IOL into the cap-
sular bag, is equipped with a beveled end to facilitate its
insertion through the incision.
The plunger tip is bifurcated, allowing easy handling and
guidance of the IOL from the loading chamber into the
injection tunnel. Its rigidity along the axis of injection and
flexibility along the perpendicular axis allow optimal thrust
and a reduction in volume in the injection tunnel. During
injection, the two tips join in the injection tunnel while the
implant is folded. It can then be introduced into the ante-
rior chamber.
The lateral surfaces of the injector result in flat injection
in every case, and the IOL is delivered into the capsular bag
without any rotation. Three steps are required for injection
(See Injection Steps for Hydrophilic Acrylic IOLs; Figure 7).
MOTORIZED INJECTIONS
With preloaded injectors, the surgeon must manage
injection control (ie, how fast the plunger advances). A large
amount of energy builds up in the injector during folding
and when the IOL passes from the loading chamber into
the injection tunnel and anterior chamber. IOLs made of
hydrophobic acrylic material, especially higher-power lenses,
generate more friction on the injector walls and contribute
to an increase in mechanical stress. In certain cases, the bevel
pressure may increase to 15 N before collapsing when the
IOL is released. In others, the IOL can be injected outside the
eye or shoot like a dart into the anterior chamber.
The Intrepid Autosert (Alcon) is a one-handed motorized
injector allowing consistent and preset speed for advancing
the plunger, regardless of counter-pressure. As a result, the
advancement of the IOL is completely controlled until its
release into the anterior chamber. The IOL cartridge is posi-
tioned within the housing. Three parameters are chosen by
the surgeon (Figure 8): the initial speed of the plunger, the
length of the pause that allows the IOL material to deform
prior to injection, and the final injection speed.
The benefits of this system include automatic position-
ing of the preinjection, an adjustable and fixed speed,

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Cataract Surgery Feature story

Take-Home Message
• There are two types of preloaded IOL injectors:
those that fold the IOL and place the lens in one
step, and those that require a folding step prior to
placement.
• Motorized injectors can further enhance surgical
performance and safety.
• It is possible that motorized injection may be
combined with preloading in the future.

Figure 8. The control screen of the Intrepid Autosert.

adjustable duration of the preinjection pause, complete

speed control, and a free hand to stabilize the eye and
position the IOL. This is particularly useful for two-
handed injections using a wound-assisted technique.
Compared with manual IOL injectors, the consistent
injection speed avoids blockage of the IOL in the incision.
Comparing motorized and manual injectors, Allen2
demonstrated better incision preservation with the
motorized device and significantly less stretch when a
rapid final speed (4 mm/sec) was used.

CONCLUSION
Preloaded injectors represent a step toward safe and
rapid IOL injection, and recent advances have increased the
safety, reliability, and reproducibility of these procedures
and maintained incision sizes similar to those required with
manually loaded injectors. There are, however, some pit-
falls, and surgeons must follow the manufacturer’s instruc-
tions carefully. Motorized injectors hold promise for addi-
tional benefits as they become more widely available.  n

Thierry Amzallag, MD, is a cataract surgeon

at the Ophthalmic Institute of Somain, France.
Dr. Amzallag may be reached at e-mail: thierry.
amzallag@institut-ophtalmique.fr.
1.  Amzallag T. Implantation intraoculaire, in Chirurgie de la cataracte, Arné J-L, Turut P, Amzallag T, eds. Paris:
Masson;2005:167-198.
2.  Allen D, Habib M, Steel D. Final incision size after implantation of a hydrophobic acrylic aspheric intraocular lens:
new motorized injector versus standard manual injector. J Cataract Refract Surg. 2012;38(2): 249-255.

32 Cataract & Refractive Surgery Today EUROPE February 2014