Even the best surgical technicians can have a case where the IOL is misloaded into the injector. It is up to the surgeon to notice this issue before the IOL is completely injected into the eye and then to make the appropriate adjustments so that it still ends up being correct. In this case, the leading haptic of the IOL was protruding from the injector and as it was placed into the eye, it appeared to be facing the wrong direction.
We know that the convention is that the IOL haptics are in the anti-S direction, meaning that the haptics should never look like the letter S. Looking at the picture above, it is clear that if we proceed with IOL placement, we will end up with an IOL that is upside down in the capsular bag.
To address the issue, as soon as I detect that the haptic is facing the wrong direction, I rotate the lens injector to correct that, and then use the chopper to ensure that the haptic goes into the capsular bag. Now the rest of the IOL can be delivered and then placed correctly in the capsular bag. Remember that even if the lens has been loaded by someone else, it is the surgeon who bears the full liability in case things go wrong.
This patient also has floppy iris syndrome from tamsulosin use and the video illustrates how to seal the incisions at the end of the case to prevent iris prolapse.
click below to see how we recover from a misloaded IOL:
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Is it really an issue for the IOL to be implanted wrong sided ? I was told that its not the issue of tilt because they are all uni-planar but since the anterior surface of the IOL is less convex to help in the folding we may result in a mild myopic shift. I had faced this situation and was unfortunately not quick enough to flip it correctly and so had to do it subsequently. The problem I faced was that to flip a 6 mm optic in 4mm AC is tricky and resulted in a mild amount of striate keratitis centrally. So why not leave it if it occurs ?
Dealing with this is ultimately the surgeon’s decision