CTR Master Class Course

ASCRS 2010, Boston. CTR Master Class Course 11-307.
Course Handout Instructor: Brian Little Faculty: Som Prasad

Introduction Capsular Tension Rings (CTRs) have been available since 1993 in Europe but have only recently gained FDA approval for use in the United States. They have contributed significantly to improved safety and better outcomes in eyes with compromised zonules and consequently are now in more widespread use. They are easy to understand in principle but in practice there are many pitfalls and some unique complications that are associated with their use. This is especially true for the inexperienced surgeon and occasional user. This course covers the different types of CTR's (plain, sutured, segments) and their pre-planned ("cold") and unplanned ("hot") use. It offers some very practical tips and tricks for their reliable and safe insertion and also demonstrates how things can go wrong, how to avoid these problems and what to do when they happen. It is supported by extensive examples and illustrated with high quality video. The experience of the faculty with the use of CTRs is over 20 man-years. Background The first CTR was designed by Drs. Witschel and Legler and presented at the Cataract, IOL, and Refractive Surgery symposium in May 1993. It was an open C-loop design intended to buttress either
missing or weakened zonules by implantation within the capsular bag. Its presence acts to circularize the capsular bag by outward expansion into the capsular fornix under its own elastic recoil. By doing so it diffusely supports the zonules and thereby minimizes capsular phimosis and shrinkage, which is the cause of post-operative decentration and sometimes dislocation of the bag/IOL complex. We need to be mindful that CTRs are only one component of a system, if you like, of zonular support that includes both zonular-friendly surgical techniques and the use of capsular anchors (iris hooks over the rhexis) to reduce further stress on already compromised zonules. When to insert a CTR Cold cases Broadly these are the two situations that call for the use of a CTR. The firrst is the cold or 1 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
ASCRS 2010, Boston. CTR Master Class Course 11-307. Course Handout Instructor: Brian Little Faculty: Som Prasad
planned event when there is pre-existing zonular damage. Typically this would include cases of trauma, pseudoexfoliation, the very elderly and systemic problems such as Marfans. This allows for careful preparation before surgery.
If the patent has had contralateral cataract surgery then pre-operative evaluation should begin with a look at the operation note and then examination of the other eye. If there were problems due to zonular deficiency then you need to know about them beforehand. Signs of capsular phimosis, a wrinkled and shriveled bag or the presence of pseudophacodonesis should all ring alarm bells for the second eye. You then need to pay careful attention to the eye due for surgery. In cases of previous trauma this includes looking for signs of significant iris trauma such as pupil sphincter tears or iridodialysis. You should also perform gonioscopy to detect any angle recession or sometimes, after traumatic iris loss, you can actually view the ciliary process and zonules directly for signs of dehiscence or vitreous prolapse.
2 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
In all these cold cases, with the foreknowledge of already weakened or missing zonules, you should insert a CTR at the beginning of surgery. This means right after hydrodissection but before starting phaco. Hot Cases The second situation is the hot cases which are iatrogenic and result from intraoperative zonular dialysis. This can occur at any stage of surgery from before the rhexis right up to and including IOL implantation.
Inferior dehiscence (a)Healon 5 overfil
(b) Excessive vacuum during phaco
CTR Insertion Techniques CTRs can be introduced either Freehand (Bimanual) or by using a dedicated Injector. Both work well but neither is ideal under all circumstances so it benefits all concerned if the surgeon has the facility to use either technique. Freehand CTR Insertion (Bimanual Technique) before phaco 3 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
Freehand CTR Insertion (Bimanual Technique) before phaco There are a few technical tips that are worth being aware of that are relevant and helpful for whichever technique you are using. If the ring is being inserted prior to phaco then the first essential is to ensure that you have performed a thorough subcapsular cortical-cleaving hydrodissection, as close as possible to the under-surface of the capsule. This way very little cortex will remain trapped by the ring in the capsular fornix and you will also be sure that the nucleus is freely mobile within the capsular bag for easy rotation and minimal zonular stress during surgery. Next it is helpful to open up the subcapsular space with a small amount of OVD under the edge of the rhexis in order to accurately locate the ring in the correct plane. If there is a localised dehiscence then always, if possible, introduce the leading end of the ring pointing towards the defect. By doing so the ring is pushed towards this area of weakness thereby supporting it during CTR insertion. Pointing the ring away from the defect on introduction will cause additional traction or pull which could extend the zonular tear. If at any point during insertion you meet undue resistance then you must stop immediately as the leading end of the ring has probably snagged on the equatorial capsule. If you persist then you are likely either to split the edge of the rhexis (see later) or extend the zonular tear or even push the ring through the capsule. Just come out, repeat the hydrodissection if needed and make absolutely sure that the nucleus rotates freely. Inject some more OVD to open up the subcapsular space and try again. It may also help to insert the ring in the opposite direction to your first attempt.
Leading end under rhexis pointing towards localised dehiscence Bimanual feed of CTR with zonular defect now supported
Trailing end of CTR flexed and controlled with Lester hook
Trailing end of CTR released under the edge of the rhexis
Most iatrogenic zonular tears occur during I&A so the capsular bag is therefore empty and floppy. Inserting a CTR under these circumstances had its own unique challenges. The tendency for the leading end of the ring to snag inside the bag is high because the capsule is slack and has little counter-traction to resist being folded and picked up by the tip of the ring. To reduce the risk of this happening the bag should be over-inflated with a cohesive viscoelastic to put the capsule on stretch. Freehand CTR Insertion (Bimanual Technique) into an empty bag
Top Left: Empty bag with almost 180 dehiscence on the left with bag folded over. Top Right: Bag unfolded and inflated with cohesive OVD. Bottom Left: CTR leading end introduced towards zonular defect. Bottom Right: CTR trailing end tucked under rhexis using suture-tying forceps Freehand CTR Insertion (Fishtail Technique) into an empty bag If the bag is particularly floppy, as in the case of this 93 year old lady, then even with the bag overinflated with OVD the end of the CTR still snags in the fornix, producing the tell-tale tension folds that radiate across the posterior capsule away from the point of entrapment.
In this situation there is another useful freehand technique, shown below, which avoids the necessity to linearly feed the CTR around the internal equator of the bag. It is called the Fishtail technique in homage to the shape of the compressed CTR .
Left: CTR is compressed end-over-end and the head of the fish is inserted through the wound. Right: Under elastic recoil it self-delivers and the apex of the fish is inserted through the wound is guided under the opposite edge of the rhexis
Left: The first end is flexed and delivered under the rhexis while holding the trailing end with forceps. Right: A Sinsky hook is used in the eyelet to control rhexis while holding the trailing end with forceps the flexion and placement of the trailing end
Left: A cyclodialysis spatula is used through the sideport to disengage the end of the rin. Right:The CTR is disengaged and spring open into sideport to disengage the end of the ring the equator of the capsular bag. The other situation in which the Fishtail technique is particularly useful is when a CTR is needed after the lens has been implanted. The normal technique of linear circumferential insertion is unlikely to succeed in this predicament as the lens haptic will almost certainly ensnare the leading end of the ring. Because the Fishtail technique does not require any significant dialing or linear feeding, it lends itself very well to successful and atraumatic CTR implantation under these circumstances. Morcher have designed and produced a CTR specifically for inserting into an empty capsular bag (Type 13A). It has a softly curved and rounded leading end whose eyelet faces centrally so as not to snag on the capsular bag. Morcher Type 13A
Injector for CTR insertion
Top Left: EyeJet Injector system from Morcher. Top Right: Leading end of CTR under rhexis. Bottom Lef: White plunger appears in later stage of insertion. Bottom Right: CTR disengaged from tip by lifting forwards
Cortical Stripping Inevitably some cortical fibres become trapped between the ring and the equatorial capsular bag. These have to be stripped out by a windscreen-wiper motion of circumferential sweeps in either direction combine with gentle central traction.
Stripping cortical fibres trapped by the ring; The eyelet of the CTR pulled centrally by the band of cortical fibres being stripped by side-to-side motion.
Complications of CTR There are many potential complications associated with the use of CTRs. Most of them are avoidable if you give sufficient attention to the technical details during implantation. The first challenge is getting them inside the capsular bag, which is easier said than done. If the angle of approach is too shallow then the ring ends up in the anterior chamber angle. If the approach is too steep then the leading end of the ring comes back out of the bag and presents as a peaked pupil the following day. Mentioned earlier was the importance of stopping immediately if any undue resistance is felt or the CTR becomes obviously jammed during insertion. If you persist then you will either split the rhexis or push the leading end of the ring through the capsule, both of which are potentially disastrous. It can be difficult to locate the trailing end of the ring into a flaccid and empty capsular bag and many attempts can result in prolonged surgery without eventual success. In such cases it is easier early on to cut and remove the ring and start again. Another problem can be the difficulty in distinguishing between a zonular dehiscence and a small peripheral PC tear. They can look alarmingly similar. If the ring is inserted through a PC tear then it will end up in the vitreous. Beyond the CTR; The management of profound zonular dialysis The introduction of the capsular tension ring (CTR) in the early 90s represented a significant addition in the surgical armaterium, enabling surgeons to deal effectively with eyes which had significant amounts of zonular deficiency. The CTR was found to be very useful in the management of mild to moderate zonular weakness during cataract surgery and to reduce the risk of intraocular lens (IOL) decentration and tilt postoperativelyi.
Figure 1: Left: A traumatic cataract with zonular dehiscence and a hard nucleus. Right: Decentred lens in a 12 year old boy with Marfans syndrome showing stretched abnormal zonules. The CTR works by redistributing forces to the remaining zonules, so by definition requires a certain degree of zonular support remaining, to enable it to deliver adequate centeration and support of the 9 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
capsular bag. In cases where there is profound zonular loss (Figure 1), such as traumatic lens subluxation, or very abnormal zonules such as Marfans syndrome, a CTR is often not enough to support the capsular bag and it is necessary to use techniques which allow artificial reinforcement of the zonular apparatus, using one or more sutures passed through the ciliary sulcus. The modified CTR (mCTR) To address this issue Cionni developed the mCTRii with a single or double eyelet for suture fixation to the sclera.iii iv. These are available from Morcher (Morcher GmBH, Stuttgart, Germany) as the type 1L and 2L respectively. The mCTR is essentially a CTR to which a small C Segment has been attached, close to the junction of the small C with the ring it is bent forwards, anteriorly displacing the small C segment and its eyelet. Thus the small C segment is in a plane anterior to the ring. This allows the ring to be placed within the capsular bag, with the small C bridging the capsulorhexis edge and its eyelet lying in front of the anterior capsule. A suture can therefore be passed through the eyelet of the small C segment lying in front of the anterior capsule but behind the iris and out through the ciliary sulcus with the knot is placed under a scleral flap.
Figure 2: This diabetic lady presented with a posterior subcapsular cataract in her only seeing eye. Top Left: A 180 degree zonular dehiscence (right side of lens in picture) became apparent as soon as a paracentecis was done. CCC was fashioned and two iris retractors used to support it. Top centre: After phacoemulsification is completed, a mCTR with a 9-0 prolene passed through its central islet is placed into the capsular bag. Top right: The mCTR is rotated into position, allowing the suture to be in the area of maximum instability. Bottom left: after sutures are passed through the sulcus, the knot is tightened to lie in a scleral pocket. Bottom centre: As the suture is tightened the bag recentres and stabilises, as 10 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
evident by the mCTR disappearing out of view under the iris. Bottom right: An IOL is then placed securely in the capsular bag and is well centered. The mCTR was a great advance in the management of lenses with profound zonular lossv, but is not an easy device to use. It is somewhat more rigid than a CTR and is often difficult to place in an unstable bag, before phacoemulsification has been completed as it has to be dialed in. Because of this many surgeons chose to place this device after phacoemulsification had been completed, using iris retractors to support the capsulorhexis (CCC) during phacoemulsification. This is an effective solution but risks an anterior capsule tear, especially when the iris retractors have to draw an eccentric capsular bag to a more central position, exerting significant forces to the point on the CCC where they engage. Moreover, phacoemulsification has to be performed in a capsular bag which has no equatorial support. In this situation the bag can be quite floppy, and the tendency of the bag to flop increases as more of the lens matter is removed, emptying the bag and permitting more movement. There is a risk of engaging this floppy bag with the phaco probe resulting in a capsular tear. The mCTR (like a CTR) cannot be used in the presence of a capsular tear, and if a tear occurs after its placement, it should ideally be removed. Removing an mCTR is difficult because of its rigidity and the overall bulk of the device. The Capsular Tension Segment (CTS) To address the difficulties encountered whilst using the mCTR, Ahmed introduced the capsular Tension Segmentvi. The CTS is also made of PMMA. It is a partial ring spanning 90 degrees with a raised single eyelet centrally, which is designed to sit anterior to the anterior capsule. Because of its small size it can be placed into the anterior chamber, and positioned in the area of zonular dehiscence and then placed into the capsular bag, without the need to dial it inside the bag. This allows atraumatic placement and can be done at any stage after capsulorhexis. It provides broad support in the lens equatorial plane. A suture can be passed through the central eyelet, which sits in front of the anterior capsule, using a similar technique as described for suturing an mCTR. More than one CTS device can be used in eyes with very extensive zonular loss. The CTS is a very versatile device. It can be supported with an iris retractor passed through the central islet, when temporary placement is desired. This is useful in difficult situations where one is not confident of preserving the capsular bag. If things do not go as per plan, it can be easily removed by grasping the central islet using intraocular forceps and sliding it out of the phaco incision. If things proceed as per plan, it can be sutured in as a permanent support. Also, more than one CTS device can be used if there is extensive zonular loss pre-existing, or indeed an additional CTS placed if zonular dehiscence extends intraoperatively. Similarly in a case where a CTR is initially thought to be adequate, if during surgery it becomes apparent the bag is still unstable, a CTS can be added in the area of maximum instability to provide support and restore the centeration of the capsular bag. Therefore, one is not pre-committed to placing more devices than are necessary, but on the other hand, one is able to add support as required.
Surgical Technique CCC: It is essential to achieve a CCC in these cases. Ensure that the CCC is central and not too large (5?6mm is adequate). Keep in mind that the centre of an eccentric lens (as in Marfans) may actually be close to the iris margin when starting surgery. Judiciously placed flexible iris retractors can be used to support the CCC as it is being fashioned and also (at least partially) draw the lens centrally. Do not engage the point at which the CCC edge is being developed with a retractor as this predisposes to the tear running unpredictably. It is more controlled to tear the capsule at least one clock hour past the point at which the iris retractor is going to engage the CCC, before engaging the CCC with the retractor. This allows the tear to proceed away from the point at which the CCC is drawn out by the retractor. A large CCC can allow devices such as the CTS or CTR to slip out of the bag during surgery. Insertion of CTS: The CTS can be placed at anytime after capsulorrhexis. A 9-0 prolene suture on a double armed Ethicon CIF-4 (or Alcon PC-9) needle can be passed through the central eyelet before placing the CTS, allowing the CTS to be sutured into the sulcus immediately after placement. This is sometimes difficult, as there is minimal room between the anterior capsule and iris. If this is the case, or if the situation is such that one is uncertain about preserving the capsular bag, it is possible to temporarily support the CTS with an iris retractor passed through the central islet. If retractors were used to support the CCC, often one of these can be redeployed to support the CTS. Once phacoemulsification is completed, the anterior capsule can be pushed back with viscoelastic creating space behind the iris for suture passage.
Figure 3: Left: CTS has been positioned in the bag, with central segment bridging the CCC edge and central eyelet placed anterior to the CCC. The upper retractor is still engaging the CCC edge, but the lower one has slipped off the CCC edge during CTS insertion and is therefore removed. Centre: the same pair of forceps shown in figure 5 are used. The angled tip forceps in the left hand holds the CTS islet, whilst the straight ended forceps in the right hand grasps the iris retractor and passes the hook through the eyelet. Right: The retractor is tightened resulting in a well centred and supported lens. Phacoemulsification: Phacemulsification is done using low parameters (slow-motion technique). Use a low bottle height, avoiding high vacuum levels. If the bag is seen to be flopping during removal of nuclear matter, it is useful to stop phaco and insert a CTR to expand the bag equatorially, before completing phacoemulsification. 12 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
Anterior chamber stability: It is critical to maintain the stability of the anterior chamber during all stages of the procedure. The anterior chamber can collapse when the phaco probe is withdrawn. This can be minimised by injecting viscoelastic through a sideport, whilst the irrigation on the phaco is still on (position 1), and then gradually easing off the irrigation as the injection of viscoelastic proceeds. This viscoelastic-BSS exchange technique allows the phaco probe to be then withdrawn, out of an anterior chamber which is now supported by viscoelastic, avoiding collapse. Vitreous presentation: With the above techniques, it is surprising how much can be done without disturbing the vitreous. A viscoelastic such as Viscoat, is able to tamponade vitreous behind an area of zonular dehiscence, and often it is possible to work in the AC using low parameters without vitreous presenting. However, in cases where there is vitreous in the AC pre-operatively or vitreous presents during surgery in spite of the above precautions, it must be dealt with as soon as it is seen to present. AC manoeuvres with vitreous present in the AC are not safe. Remember that the other end of the vitreous gel is attached to the retina (at least in the region of the vitreous base, even in eyes with a posterior vitreous detachment), and thus manoeuvres which pull on vitreous carry the risk of precipitating retinal tears. A bimanual anterior vitrectomy using two side port incisions (avoiding the main phaco incision) supplemented by triamcinolone to stain the vitreous is recommended. Once the anterior chamber is free of vitreous, management of the lens can recommence.
Figure4: Triamcinolone is used to stain vitreous presenting through a zonular dehiscence and then a bimanual anterior vitrectomy through two paracentecis incisions is utilised to remove vitreous from the anterior chamber. (Same case as in Figure 3) Combined CTR and CTS: These two devices are often used in combination. A CTR can be placed before or after removal of lens to provide circumferential support and expansion of the capsular bag at the equator when a CTS is already in place. Also, in cases where a CTR has been placed already, but it becomes apparent during surgery that the bag is still unstable a CTS can be positioned to provide additional support. In essence, the combination of the CTS and CTR provide similar support as a mCTR, but provide increased flexibility and handling. 13 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
Scleral suturing: Before scleral sutures are passed a partial thickness sclera pocket, starting at the limbus and extending 2mm towards the fornix is fashioned. This needs to be 3?4 mm wide to allow room for manoeuvres within it. If one has pre-planned the use of a CTS (or mCTR), it is useful to fashion the scleral pockets prior to opening the eye, as scleral dissection is easier in a firm eye. However it is possible to create these pockets later on if required. There are two techniques used to pass theses sutures. For either, first place a cohesive viscoelastic between the iris and anterior capsule, to create space in the area and plane where the needle needs to be passed. An ab-externo technique uses a 26 or 27 g hypodermic needle passed in from outside, at 1.5mm behind the limbus, in the scleral pocket which has already been made. The hypodermic needle tip is then advanced centripetally in between the iris and the anterior capsule, taking care not to engage either structure. One arm of the Prolene needle is then passed in through the main corneal incision with the tip being guided into the lumen of the hypodermic needle. This is then drawn out and allows the CIF-4 needle to be railroaded out of the eye, whilst it is engaged within the hypodermic needle. The process is then repeated with the other arm of the suture and the needle passed out about 1mm separating it from the first pass. The needles are then cut-off and two suture ends drawn out of the scleral pocket. A knot is then fashioned, and this slides into the scleral pocket as it is tied, leaving no exposed Prolene. This technique ensure precise suture placement, but does require good access to enable the handling of the hypodermic needle outside the eye. It works well in the inferior and temporal quadrants, but can be more difficult in the superior or nasal quadrants due to the nose and superior orbital rim restricting access. In these situations an abinterno approach is more applicable. The CIF-4 needle is passed in through the main corneal incision and proceeds behind the iris and anterior capsule in the region of the central eyelet of the CTS. This is then guided through the sclera, making sure that iris or capsule is not engaged (watch for movement of either structure whilst advancing the needle tip). The tip is aimed out in the area of the scleral pocket, and the process repeated with the other am of the suture. The knot is fashioned as in the ab-externo technique. Suture placement is potentially less precise than that achieved using the ab-interno technique, however with care, good placement can be achieved. Care must be taken not to over tighten the suture, as this can draw the bag too far towards the side where the suture is. If the suture is being passed after phacoemulsification, it is best tightened and knotted after the IOL has been inserted into the bag, allowing easier judgement of centeration. Intraocular manoeuvres: From the above description of surgical techniques employed it is obvious that precise intraocular manoeuvres are required at many different times during surgery. These include supporting a subluxed lens in the correct plane during CCC, precise placement of devices such as the CTS, the need to sometimes grasp and reposition or remove a CTS or indeed remove a CTR. Conventionally, these have been done using instruments such as a dialling hook, or Kuglen Hook and forceps such as McPhersons. Custom designed micro forceps allow these steps to be done in a more controlled and precise manner. One such instrument set is now available from Optico (Optico limited, Hitchin, Herts, UK). This consists of a 23 g pair of forceps with a curved shaft allowing the tip of the forceps to be in the correct surgical plane, whilst the handle rests comfortably in the hand in a normal pen-holding position. One has an angled tip allowing the surgeon to grasp structure below the 14 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom
instrument and allow better visualisation, whilst the other has a straight tip to help grasp structures lying in an antero-posterior plane, or two handle sutures in the eye. Special coating on inner surface of tip facilitates optimal gripping (23g PRASAD Micro Grasping Forceps Part no. 50-203 and 23g PRASAD Micro Tying Forceps Part no. 50-204)1. These two forceps can be used in combination to allow controlled bimanual manipulations in the anterior chamber. For example, when dealing with a subluxed lens; they can be used to hold the lens with one hand whilst manipulating the capsule with the other, to engage the ends of iris retractors onto capsule, or to manipulate a capsule tension segment into the correct position. Finishing steps: Viscoelastic is removed using bimanual irrigation?aspiration using a low bottle height. Miochol is used to close the pupil, this ensures that no stray vitreous strands are left in the anterior chamber. If in doubt about presenting a vitreous a small amount of triamcinolone can be reinjected into the anterior chamber to identify it, and removed by gentle irrigation aspiration. There is a very low threshold for suturing corneal incisions as anterior chamber stability is very important. Conclusion With careful technique and the uses of appropriate devices a stable, well centred, in the bag, intraocular lens position can be achieved even in eyes with extensive zonular dehiscence or abnormality. i Jacob S, Agarwal A, Agarwal A, et al. Efficacy of a capsular tension ring for phacoemulsification in eyes with zonular dialysis. J Cataract Refract Surg 2003; 29:315321. ii Cionni RJ, Osher RH. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. J Cataract Refract Surg. 1998 Oct;24(10):1299?306. iii Moreno-Montanes J, Sainz C, Maldonado MJ. Intraoperative and postoperative complications of Cionni endocapsular ring implantation. J Cataract Refract Surg 2003; 29:492497. iv Ahmed II, Crandall AS. Ab-externo scleral fixation of the Cionni modified capsular tension ring. J Cataract Refract Surg 2001; 27:977981. v Bahar I, Kaiserman I, Rootman D. Cionni endocapsular ring implantation in Marfan's Syndrome. Br J Ophthalmol. 2007 Nov;91(11):1477?80. Review. vi Hasanee K, Ahmed II. Capsular tension rings: update on endocapsular support devices. Ophthalmol Clin North Am. 2006 Dec;19(4):507?19. Review. 1 Dr Prasad has no financial interest in these products.

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ASCRS 2010, Boston. CTR Master Class Course 11-307.

Course Handout Instructor: Brian Little Faculty: Som Prasad

2 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

Inferior dehiscence (a)Healon 5 overfil

(b) Excessive vacuum during phaco

Trailing end of CTR flexed and controlled with Lester hook

Trailing end of CTR released under the edge of the rhexis

4 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

5 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

6 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

Injector for CTR insertion

7 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

8 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

11 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

15 | Brian Little eye.surgeon@mac.com ; Som Prasad sprasad@rcsed.ac.uk; United Kingdom

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