Other early challenges
Another challenge early on was trying to avoid a “flick,” or having the injector move rapidly once the stent has been fully inserted.
I have learned to avoid this flick by removing the second instrument from the eye after the slider has been advanced 50%. I then let the eye return to its normal position and ensure that I am not applying any torque to the eye. Only after confirming this do I continue to slide the injector and complete insertion.
In a few cases, I struggled with patients’ prominent cheekbones, which can make it difficult to use the injector at the right angle (the reason I now count this among the features to avoid in early patients).
I also had difficulty maintaining proper control of the eye without applying a lot of pressure and traction on the corneal wounds. It also was easy to forget to maintain forward pressure (or bias) as I injected the implant, sliding the injector anteriorly.
The beauty of this surgery is that it is minimally invasive and forgiving. It does not cause a tremendous amount of trauma or collateral damage to the eye.
If the surgeon is not happy with placement and location of the implant, it is very easy to remove it, reload the injector, and re-insert the implant. If the surgeon is not happy with the placement and feels that the stent is too short in the subconjunctival space or perhaps too close to the cornea in the anterior chamber, the surgeon should remove it and insert it again.
It is much easier to take the extra time in the operating room to make sure the implant is in the ideal position than to be unhappy with the position and learn after surgery that the implant is too short in the subconjunctival space or too close to the iris or cornea in the anterior chamber. To remove the implant (which the surgeon should also play with in the practice lab), simply use microsurgical forceps to purchase the tip of the implant in the anterior chamber and gently pull, with one slow motion, the implant out of the eye.