Abstract:
An ocular implant insertion apparatus that includes a plunger driver that is not manually powered and ocular implant insertion methods. There are a variety of instances where an ocular implant is inserted into the anterior chamber, posterior chamber, cornea, vitreous space and/or other portion of an eye. Exemplary ocular implants include, but are not limited to, lenses, capsular tension rings, ocular prosthesis and lamellar transplants.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
       [0001]    This application claims the benefit of U.S. Provisional Application No. 61/733,534, filed Dec. 5, 2012, and U.S. Provisional Application No. 61/801,897, filed Mar. 15, 2013, both of which are incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTIONS 
       [0002]    1. Field of the Inventions 
         [0003]    The present inventions relate generally to apparatus for inserting an ocular implant into an eye. 
         [0004]    2. Description of the Related Art 
         [0005]    There are a variety of instances where an ocular implant is inserted into the anterior chamber, posterior chamber, cornea, vitreous space and/or other portion of an eye. Exemplary ocular implants include, but are not limited to, lenses, capsular tension rings, ocular prosthesis and lamellar transplants. An intraocular lens (IOL), for example, may be inserted into an aphakic eye that has undergone a cataract surgery or may be inserted into a phakic eye during a refractive surgery. One type of lens is a foldable lens. Foldable lenses are formed from soft material such as a silicone elastomer, soft acrylic, or hydrogel and may be inserted into the eye through a small incision. Lens insertion apparatus, which may be used to push a foldable lens into an eye through a nozzle, generally include screw-type insertion apparatus and push-type insertion apparatus. In both cases, the lens insertion apparatus may include a plunger that is used to push a folded lens through the nozzle into the eye by way of an incision that is relatively small, e.g., an incision that is smaller than the diameter of an IOL optic. 
         [0006]    Loading an ocular implant into an inserter can be a troublesome portion of the insertion procedure. The implant may be contaminated, damaged or improperly placed into the inserter by operator, e.g., a surgeon or assistant. Accordingly, in some instances, the insertion apparatus is preloaded, i.e., the insertion apparatus is shipped from the factory with the ocular implant (e.g., an IOL) stored therein. An operator using a preloaded inserter does not place the implant into the insertion apparatus, thereby eliminating the possibility of the aforementioned operator error associated with loading. The IOL or other ocular implant may be stored in an unstressed state and then, prior to the implantation process, folded into a small state prior to being pushed through the nozzle. In some instances, the plunger alone is used to move the lens through the folding and insertion processes. In other instances, insertion apparatus have been configured to fold and move an IOL in stepwise fashion through the use of multiple IOL moving structures. Examples of such insertion apparatus are illustrated and described in U.S. Pat. Pub. Nos. 2011/0082463 and US2001/0007942 and PCT Pub. No. WO 2011/155636, which are incorporated herein by reference. 
         [0007]    The present inventors have determined that conventional ocular implant insertion apparatus are susceptible to improvement. For example, the present inventors have determined that conventional insertion apparatus sometimes require the use of both hands when the plunger is driving the IOL or other ocular implant into the eye. In particular, some conventional insertion apparatus that facilitate precise control of plunger movement employ a rotatable handle that is configured, and connected to the plunger, such that rotation of the handle relative to the remainder of the insertion apparatus results in linear movement of the plunger. One hand is required to rotate the handle, while the other hand is required to prevent rotation of the remainder of the insertion apparatus. As a result, the surgeon does not have a free hand that could be used to control the eye or to operate an instrument that is being employed in conjunction with the insertion apparatus. 
       SUMMARY 
       [0008]    An exemplary ocular implant insertion apparatus includes a housing including an ocular implant storage area and a nozzle, a plunger movable in a distal direction relative to the housing, and a non-manually driven plunger driver that is configured to drive the plunger in the distal direction. 
         [0009]    There are a number of advantages associated with such an insertion apparatus. For example, the use of a plunger driver that is not manually driven allows the surgeon to operate the insertion apparatus with one hand while the ocular implant is being inserted into the eye. As a result, the other hand can be used to control the eye or to operate another instrument. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0010]    Detailed description of exemplary embodiments of the inventions will be made with reference to the accompanying drawings. 
           [0011]      FIG. 1  is a perspective view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0012]      FIG. 2  is a perspective view of the main body of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0013]      FIG. 3  is another perspective view of the main body of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0014]      FIG. 4  is a perspective view of the plunger of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0015]      FIG. 5  is another perspective view of the plunger of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0016]      FIG. 6  is a partial section view showing an aspect of the operation of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0017]      FIG. 7  is a perspective view showing another aspect of the operation of the exemplary IOL insertion apparatus illustrated in  FIG. 1 . 
           [0018]      FIG. 8  is a perspective view of an IOL insertion system in accordance with one embodiment of a present invention. 
           [0019]      FIG. 9  is a side view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0020]      FIG. 10  is a cutaway, perspective view of the IOL insertion apparatus illustrated in  FIG. 9 . 
           [0021]      FIG. 11  is a partial section view of the IOL insertion apparatus illustrated in  FIG. 9 . 
           [0022]      FIG. 12  is a partial section view of the IOL insertion apparatus illustrated in  FIG. 9 . 
           [0023]      FIG. 13  is a partial section view of the IOL insertion apparatus illustrated in  FIG. 9 . 
           [0024]      FIG. 14  is a partial section view of the IOL insertion apparatus illustrated in  FIG. 9 . 
           [0025]      FIG. 15  is a section view of a master cylinder in accordance with one embodiment of a present invention. 
           [0026]      FIG. 16  is a section of the master cylinder illustrated in  FIG. 15 . 
           [0027]      FIG. 17  is a section of the master cylinder illustrated in  FIG. 15 . 
           [0028]      FIG. 18  is a side, partial section view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0029]      FIG. 19  is a section view of a portion of the IOL insertion apparatus illustrated in  FIG. 18 . 
           [0030]      FIG. 20  is a perspective view of a portion of the IOL insertion apparatus illustrated in  FIG. 18 . 
           [0031]      FIG. 21  is a section view of a portion of the IOL insertion apparatus illustrated in  FIG. 18 . 
           [0032]      FIG. 22  is a section view of a portion of the IOL insertion apparatus illustrated in  FIG. 18 . 
           [0033]      FIG. 23  is a partial section view of a portion of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0034]      FIG. 24  is a partial section view of a portion of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0035]      FIG. 24A  is a side view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0036]      FIG. 24B  is a side, partial section view of a portion of the IOL insertion apparatus illustrated in  FIG. 24A . 
           [0037]      FIG. 25  is perspective view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0038]      FIG. 26  is an exploded view of the IOL insertion apparatus illustrated in  FIG. 25 . 
           [0039]      FIG. 27  is a side, partial cutaway view of the IOL insertion apparatus illustrated in  FIG. 25 . 
           [0040]      FIG. 28  is a side view of a portion of the IOL insertion apparatus illustrated in  FIG. 25 . 
           [0041]      FIG. 29  is a section view showing portions of a plunger driver and a case in accordance with one embodiment of a present invention. 
           [0042]      FIG. 30  is perspective view of an IOL insertion apparatus in accordance with one embodiment of a present invention. 
           [0043]      FIG. 31  is a section view of the IOL insertion apparatus illustrated in  FIG. 30 . 
           [0044]      FIG. 32  is a rear perspective view of a portion of the IOL insertion apparatus illustrated in  FIG. 30 . 
       
    
    
     DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS 
       [0045]    The following is a detailed description of the best presently known modes of carrying out the inventions. This description is not to be taken in a limiting sense, but is made merely for the purpose of illustrating the general principles of the inventions. The present inventions are also applicable to a wide variety of ocular implants which, as used herein, refers to any structure, instrumentality or device that is placed into any ocular structure or region. Ophthalmic lenses, capsular tension rings, ocular prosthesis and lamellar transplants are examples of ocular implants. Although the exemplary implementations are described below in the context of an intraocular lens (IOL), the present inventions are also applicable other types of ocular implants, including those yet to be developed. For example, the present inventions are applicable to other types of ophthalmic lenses. Such lenses include, but are not limited to, intraocular contact lenses, phakic IOLs, and other lenses that may be inserted into the eye. Also, movement of the movable components of an insertion apparatus and the IOL towards the eye is referred to herein as movement in the forward (or “distal”) direction and movement away from the eye is referred to herein as movement in the rearward (or “proximal”) direction. 
         [0046]    As illustrated in  FIGS. 1-7 , the exemplary IOL insertion apparatus  100  is a preloaded insertion apparatus and, to that end, an IOL  10  is placed within the insertion apparatus during the assembly process and the insertion apparatus is shipped and stored with the IOL located therein. In the illustrated implementation, the IOL  10  ( FIG. 3 ) includes an optic  12  and a pair of supports  14  and  16  such as, for example, the illustrated pair of haptics. The exemplary IOL insertion apparatus  100  includes an inserter  101 , with a main body  102 , a slider  104 , a plunger  106  and an insertion tube  108  that is mounted on the forward end of the main body after the IOL is in place, and a plunger driver  110  that is operably connected to the inserter, e.g., to the main body and the plunger. The main body  102  and insertion tube  108  together define the housing of the inserter  101 . The slider  104  and plunger  106  are movable relative to the housing and relative to each other. Although the present inventions are not so limited, the exemplary IOL insertion apparatus  100  is substantially similar to the IOL insertion apparatus illustrated in PCT Pub. No. WO 2011/155636, which is incorporated herein by reference in its entirety. Here, however, the plunger  106  is not manually driven as it is in PCT Pub. No. WO 2011/155636 and, instead, is driven by the plunger driver  110  in the manner described below. In other words, the force required to drive the plunger  106  in the distal direction is not supplied by the surgeon and is instead supplied by the plunger driver  110 . 
         [0047]    Referring to  FIGS. 1-3 , the exemplary main body  102  includes a tubular member  112 , a lens placement section  114 , and a slider guide section  116 . The lens placement section  114  protrudes distally from the front end of the tubular member  112 . The insertion tube  108  in the illustrated embodiment has a nozzle  109 , a transition section  111 , and a protector  113  that is positioned over the lens placement section  114 , with interior regions that are in communication with one another so that an IOL can pass therethrough. The insertion tube  108  is connected to the main body  102  by a connector arrangement. The inner diameter of the transition section  111  tapers downwardly from the end adjacent to the protector  113  to the end adjacent the nozzle  109 . The slider guide section  116 , which is configured to allow the slider  104  to move forwardly and rearwardly, may be a pair of slits formed in the tubular member  112  that are parallel to the lens advancement axis A. The slider guide section  116  also extends rearwardly from the distal end of the tubular member  112  to the central portion of the tubular member. 
         [0048]    The exemplary lens placement section  114  ( FIG. 3 ) includes a bottom surface  118 , a pair of side walls  120  respectively located on opposite sides of the bottom surface and extending upwardly from the bottom surface, and a pair of rails  122 . The bottom surface  118  and the side walls  120  are parallel to the lens advancement axis A and the lens advancement axis A is located between the side walls. The side walls  120  each include, near the upper end, an inclined surface  120 A. The rear portions of the side walls  120  include inward protrusions  124  that prevent the IOL  10  from moving in the rearward direction. The lens supporting surfaces of the rails  122  are oriented in a direction that is transverse to the lens advancement axis A and slope away from the axis A in the rearward to forward direction. As such, the stored IOL  10  is tilted relative to the lens advancement axis A, with the forward end of the IOL optic  12  closer to the bottom surface  118  than the rearward end. The lens supporting surfaces of the rails  122  are also located a sufficient distance above the bottom surface  118  to prevent the IOL optic  12  from coming into contact with the bottom surface. 
         [0049]    It should be noted that references herein to “top,” “bottom,” “upward,” “downward” and the like are merely references to the illustrated orientation and/or the relationship of the components relative to one another in the illustrated orientation. For example, the side of the IOL  10  facing the bottom surface  118  is referred to “the downward side” and movement toward the bottom surface is referred to as movement in the “downward direction,” while the opposite side of the IOL  10  is referred to as the “the upward side” and movement away from the bottom surface  118  is referred to as movement in the “the upward direction.” 
         [0050]    Turning to the exemplary slider  104  illustrated in  FIGS. 2 ,  3  and  6 , the slider includes a pair of grips  126 , an elongate member  128  with a lens contact surface  130  that is carried within the main body  102  and is slidable relative thereto. The grips  126  are connected to elongate member  128 . The lens contact surface  130 , which is larger than the plunger distal end  144  (discussed below), is used to scoop up the proximal IOL support  16  during the initial folding of the IOL  10 . A lens holder  132  is pivotably mounted on the distal end of elongate member  128  and includes a protrusion  134 . The lens holder  132  controls the initial folding of the IOL  10  during the first step of the lens insertion process. More specifically, as the slider  104  moves distally, the protrusion  134  rides along the tapered inner surface of the transition section  111 , which causes the lens holder  132  to pivot downwardly into contact with the IOL optic  12  to fold the IOL  10 . A protrusion  139  ( FIG. 6 ) may be used to deflect the leading haptic  14 . The slider elongate member  128  also includes a slot  136  through which the plunger rod  138  (discussed below) passes during the second step of the insertion process. 
         [0051]    As illustrated in  FIGS. 4 and 5 , the exemplary plunger  106  includes a rod  138  with a distal rod portion  140 , a proximal rod portion  142 , and a rod distal end  144 . The distal rod portion  140 , which is sized such that it can be inserted through the nozzle  109 , may be connected to, or may be integral with, the proximal rod portion  142 . As illustrated for example in  FIG. 6 , the rod distal end  144  may have a lens contact portion  146  and a recess  148  in which the free end of the proximal IOL support  16  is located during the second step of the two-step process. The exemplary lens contact portion  146  is a planar surface that is perpendicular to the lens advancement axis A, and is provided on a lower portion of the rod distal end  144 . The exemplary recess  148 , which has an opening  150  on one lateral side and a wall  152  on the other lateral side, is located above the lens contact portion  146 . The recess  148  may be formed by cutting (or otherwise removing) material from the rod distal portion  140 , starting at the distal end  144 , or by molding the rod in the illustrated configuration. The wall  152  engages the outer edge of the IOL optic  12  and prevents optic of the folded IOL  10  from entering the recess  148 . The wall  152  also keeps the IOL support  16  within the recess  148 . The distal end of the wall  152  may be in the same plane as the lens contact portion  146  (as shown) or may be located distally beyond the lens contact portion  146 . The proximal rod portion  142  is operably connected to the plunger driver  110  in the manner described below. 
         [0052]    The plunger driver  110  may be secured to and/or supplied with the inserter  101  (including the preloaded IOL  10 ) in a variety of ways. Briefly, and for example, the plunger driver  110  may be a permanent portion of the insertion apparatus  100 . As used herein, a “permanent portion” of an apparatus is a portion that, subsequent to assembly, is not removed during normal usage and cannot be removed without destruction of the associated connector or some other portion of the apparatus. Such an insertion apparatus may, in some instances, be a single use device that is shipped from the manufacturer in a sterile state. Alternatively, the plunger driver  110  may be supplied separately from the inserter  101  and secured to the inserter to form the insertion apparatus  100  at the time of use. Such a plunger driver may be a single-use device, or a reusable device, that is attached to the inserter  101  within the sterile field. A single-use plunger driver may be supplied separately in a sterile state, while a reusable plunger driver will be sterilizable. In some instances, a power cable may be required. The cable (not shown) may be a permanent portion of the associated plunger driver that is shipped in a sterile state (e.g., with the plunger driver or the entire insertion apparatus), or may be a separate device that is connected to the plunger driver within the sterile field. In some instances, a fluid tube may be required to convey liquid or gas from a separate source to the plunger driver. The fluid tube (not shown) may be a permanent portion of the associated plunger driver that is shipped in a sterile state (e.g., with the plunger driver or the entire insertion apparatus), or may be a separate device that is connected to the plunger driver within the sterile field. 
         [0053]    Referring to  FIG. 1 , the exemplary plunger driver  110  includes a housing  154 , a drive mechanism  156  and a linkage  158  that operably connects the drive mechanism to the plunger  106  such that operation of the drive mechanism results in distal linear movement of the plunger from an initial storage position to the fully deployed position ( FIG. 7 ). In some instances, the linkage may be omitted and the drive mechanism may be connected directly to the plunger  106 . 
         [0054]    As alluded to above, a wide variety of drive mechanisms may be employed. Such drive mechanisms include, but are not limited to, torsion springs, linear springs (tension or compression), electric motors, solenoids and other electrically powered devices, hydraulic devices where the fluid is pumped during the procedure, pressurized gas and other pneumatic devices (e.g., a cartridge filled compressed CO 2 , or some other compressed gas, that is connected to a piston or turbine), devices that create gas pressure through exothermic chemical reactions, magnetic devices (either electromagnetic or a permanent magnet), rotating flexible cables (one end associated with the plunger driver and the other end connected to a motor or other source of rotational force) and combinations of such mechanisms (or “hybrid mechanisms”). The configuration of the linkage  158  will depend upon the configuration of the drive mechanism  156 . For example, a screw-thread linkage may be combined with a rotating drive mechanism. Various other exemplary plunger drivers and drive mechanisms are described below with reference to  FIGS. 9-32 . 
         [0055]    The device that is used to actuate the plunger driver  110  will also depend upon the type of drive mechanism that is employed. In the illustrated implementation, the drive mechanism  156  is a torsion spring that may be supplied in a state where it is storing mechanical energy. In other implementations, the torsion spring may be armed at or near the time of use by rotating one portion of the spring relative to another. This may be accomplished by, for example, rotating one portion of the insertion apparatus housing relative to another (e.g., the driver housing  154  is a two-part structure where one part is rotatable relative to the other), rotating a small removable or permanent crank handle that is connected to spring, rotating an oversized grip handle that is connected to the spring and used only for rotating the spring, or using a reusable motor driven crank that can be disconnected from the plunger driver after the spring is armed. Whether the spring is supplied in an armed state or is armed at the time of use, a latch (not shown) may be used to maintain the torsion spring in this state. An actuation button  160  releases the latch in the illustrated embodiment. 
         [0056]    Similarly, the manner in which movement of the plunger  106  is controlled as it is being driven by the drive mechanism will depend upon the type of drive mechanism that is employed. A friction brake (not shown) may be used by the surgeon to selectively control (e.g., stop, start, slow) the movement of the plunger  106 . In the illustrated embodiment, the brake is biased to the engaged state that prevents plunger movement and is released when a button  162  is pressed. In other implementations, the brake is biased to a disengaged stated and the button  162  may be used to apply the brake. In still other implementations, the button  162  may be used to stop movement of the plunger by, for example, disconnecting an electrical drive mechanism from a power source, shunting fluid in context of a hydraulic drive mechanism, or venting gas in the context of a pneumatic drive mechanism. In some implementations, a single button (e.g., the button  162 ) may be used for both actuation and control/braking. 
         [0057]    Other aspects of plunger movement that can be controlled by way of the button  162 , footswitch or other control instrumentality include the speed and direction of the plunger. In particular, the control instrumentality (which may take the form of multiple separately actuated instrumentalities) may be used to increase or decrease the speed of the plunger and/or to change the plunger direction of movement from forward to reverse and from reverse to forward. The manner in which such control may be accomplished will depend upon the drive mechanism employed. For example, motors and other electrically powered drive mechanisms may be controlled with conventional power control techniques. 
         [0058]    The insertion apparatus  100  may also be configured such that, upon actuation of the drive mechanism  156 , the plunger will move to a predetermined location proximal of the nozzle  109  prior to assumption of control by the surgeon. For example, the insertion apparatus  100  may be configured such that plunger  106  moves distally until the plunger distal end  144  reaches the proximal end of the folded IOL  40  (note the IOL location in  FIG. 6 ). The movement of the plunger  106  may then be automatically stopped, i.e., stopped without additional action by the surgeon, and additional movement will require an action by the surgeon (e.g., pressing button  162 ). 
         [0059]    Operation of the exemplary insertion apparatus  100 , where the IOL is pushed out of the apparatus and into the eye, is referred to herein as a “push-out” or “insertion” process. The slider  104 , which has a pair of finger grips  126 , performs the first step in the insertion process, i.e., folding a previously unstressed IOL into a particular configuration, and may therefore be referred to as one example of a first lens push-out mechanism. The exemplary slider  104  pushes the IOL  10  distally as it folds the IOL. In other implementations, the first “push-out” mechanism may perform the first step of the “push-out” process by simply folding an IOL without moving it distally. The exemplary plunger  106  performs the second step in the insertion process, i.e., pushing the folded IOL through a tapered lumen and then into the eye, and may therefore be referred to as one example of a second lens push-out mechanism. The IOL moves along a lens advancement axis A during the insertion process. In the illustrated implementation, distal movement of the plunger  106  commences upon actuation of the drive mechanism  156  through operation of the button  160 , and is subsequently controlled through operation of the button  162 . Thus, the present inventions allow the surgeon to perform the second step with one hand. In particular, the present inventions allow the surgeon to both hold the insertion apparatus  100 , and control movement of the plunger  106 , with the same hand. 
         [0060]    It should be noted here that, in some instances, it may be desirable to heat the IOL prior to and/or during the push-out process to increase the flexibility of the IOL. Heat may be supplied in a variety of ways. For example, those embodiments of where the plunger driver  106  creates heat (e.g., those that employ an exothermic chemical reaction), the heat may be transferred to the region of the insertion apparatus (e.g., a portion of the insertion tube) in which the IOL is located. A heat pipe is one example of device that could transfer heat from the drive mechanism to the region in which the IOL is located. Alternatively, a separate heating element may be employed. In those instances where the plunger driver  106  is electrically powered, some of the electricity stored in or delivered to the insertion apparatus may be used to power the heating element (e.g., a heating coil or other resistance based heater). Such a heating element could be embedded in and extend around, for example, the protector  113  of the insertion tube  108 . 
         [0061]    It should also be noted that heating elements may be employed in ocular implant insertion apparatus that do not include a powered plunger driver. For example, a heating element may be provided on manually powered insertion apparatus such as those described in U.S. Pat. Pub. Nos. 2011/0082463 and US2001/0007942 and PCT Pub. No. WO 2011/155636. 
         [0062]    Turning to  FIG. 8 , the exemplary IOL insertion system illustrated therein includes an exemplary IOL insertion apparatus  200 , with an inserter  101  (described above) and a plunger driver  210 , and power supply and control unit  170 . The plunger driver  210  and control unit  170  drive the plunger, and control the movement thereof, through the use of apparatus including, but not limited to, electric motors, solenoids and other electrically powered devices, hydraulic devices where the fluid is pumped during the procedure, pressurized gas and other pneumatic devices, devices that create gas pressure through exothermic chemical reactions, magnetic devices, and rotating flexible cables (one end associated with the plunger driver and the other end connected to a motor or other source of rotational force). Operation of the control unit  170 , which is connected to the insertion apparatus  200  by a cable  172  and a connector  174 , is responsive to the button  162 , a touchscreen  176 , and/or a footswitch  208  to facilitate control of the plunger in the manner described above. For example, the control unit  170  may include electrical power supply and power to an electric motor that drives the plunger may be controlled by a processor in the control unit in response to operation of the button  162 , touchscreen  176 , and/or footswitch  208 . Wireless control may also be employed. The control unit  170  would be a reusable device, while the insertion apparatus could be either a single use or a reusable device. 
         [0063]    Another exemplary IOL insertion apparatus is generally represented by reference numeral  300  in  FIGS. 9 and 10 . The exemplary insertion apparatus  300 , which is shown in  FIG. 9  within a case  20 , includes an inserter  301  and a plunger driver  310 . The inserter  301  ( FIG. 10 ) is substantially similar to the inserter  101  and similar elements are represented by similar reference numerals. To that end, the inserter  301  includes components, such as a main body  302  with a tubular member  312 , a slider  304 , a plunger  306  ( FIG. 14 ) and an insertion tube  308 , that operate in the manner described above with reference to inserter  101 . For example, the slider  304  includes grips  304   a  and an elongate member (not shown) that moves with the grips to fold an IOL as is discussed above with reference to  FIGS. 2 ,  3  and  6 . The case  20 , which includes an enclosure  22  and a cover  24 , protects the inserter  301  and prevents erroneous operation thereof in the manner described in PCT Pub. No. WO 2011/155636. 
         [0064]    Turning to the plunger driver, the exemplary plunger driver  310  illustrated in  FIGS. 9 and 10  employs a drive mechanism that is a hybrid device that includes a hydraulic drive mechanism which is powered by a spring. The plunger driver  310  includes a master cylinder  314 , with a cylinder body  316  and a piston  318  ( FIG. 11 ) within the cylinder body, and a slave cylinder  320 , with a cylinder body  322  and a piston  324  located within the cylinder body. An external driver housing  326  to which, or in which, the plunger driver components are mounted is also provided. The inserter  301  is also mounted to the driver housing  326  by way of the tubular member  312 . The piston  318  is driven by a spring  328  ( FIG. 11 ) that is also located within the cylinder body  316 . A tube  330  connects the master cylinder  314  to the slave cylinder  320 . A cap  332  is used to close the end of the cylinder body  316 , after the piston  318  and spring  328  have been inserted, during the assembly process. The plunger driver  310  also includes a fluid port  334  that receives the hydraulic fluid (e.g., sterile saline) during the priming process, as is discussed below, and an actuation handle  336 . 
         [0065]    Referring to  FIG. 11 , the plunger driver also includes a tube  338  with an inlet associated with the master cylinder  314  and an outlet associated with the slave cylinder  320 . A multi-position valve  340  controls the flow of fluid through the tube  338 , and a one-way valve  342  controls the flow of fluid through the port  334 . The valve  340  includes a rotatable control shaft (not shown) that is connected to the handle  336  by a hub  344 . As such, the user can control the valve  340  by moving the handle  336  as is discussed below. It should also be noted here that the diameter of the master cylinder body  316  is substantially greater than the slave cylinder body  322 . The increased diameter facilitates the use of a master cylinder  314  that is shorter than the slave cylinder  320 , thereby reducing the overall length of the apparatus. A rod  346  connects the piston  324  to the inserter plunger  306 . 
         [0066]    One example of a process for priming the plunger driver  310  is illustrated in  FIGS. 11-13 . This process will in most instances take place while the inserter  301  is located within the case  20  ( FIG. 9 ). In the illustrated example, a syringe  30  is used to prime the plunger driver  310 . The syringe includes a barrel  32 , a plunger  34  and a hub  36 , and is shown filled with hydraulic fluid F. After the handle  336  has been moved to the position illustrated in  FIG. 11  (or “priming position”), which causes the valve  340  to direct fluid flow from the fluid port  334  to the master cylinder  314  and prevent fluid flow to the slave cylinder  320 , the syringe hub  36  may be connected to the port  334 . Next, as shown in  FIG. 12 , the syringe plunger  32  may be depressed, thereby driving fluid F past the one-way valve  342  and into the master cylinder  314  by way of the valve  340 . The fluid F will push the piston  318  to its primed position and compress the spring  328 . Movement of the piston  318  also creates a fluid storage volume  348  in which the fluid F is stored when the apparatus  300  is primed. 
         [0067]    Turning to  FIG. 13 , the handle  336  may then be moved to the position illustrated therein (or “primed position”), which causes the valve  340  to prevent flow out of the master cylinder  314 . The syringe  30  may then be removed. The case  20  and plunger driver  310  may be configured so as to allow the handle  336  to move from the priming position ( FIGS. 11 and 12 ) to the primed position ( FIG. 13 ) while the insertion apparatus is in the case, but to also prevent the handle from moving to the drive position ( FIG. 14 ) while the insertion apparatus is in the case. To that end, the hub  344  includes a protrusion  350  that is free to move as the handle moves from the priming position to the primed position, and then engages an abutment (not shown) within the case  20  when the handle reaches the primed position. 
         [0068]    The primed insertion apparatus  300  may then be removed from the case  20  so as to permit forward movement of the slider  304 , which moves the IOL to the transition section of the insertion tube  308  as discussed above with reference to  FIGS. 3 and 6 , as well as additional movement of the protrusion  350 . The plunger driver  310  may then be actuated, and the plunger  306  driven to its extended position, by moving the handle  336  to the drive position illustrated in  FIG. 14 . The corresponding rotation of the hub  344  will cause the valve  340  to open the fluid path that extends through the tube  338  from the master cylinder  314  to the slave cylinder  320 , and to prevent backflow into the port  334 . The compressed spring  328  will drive the piston  318  toward the tube  330 , thereby driving the fluid F into the slave cylinder  320  so that the piston  324  moves distally through the cylinder body  322  and the plunger moves through the insertion tube  308  to the illustrated location. 
         [0069]    Another apparatus for priming a spring-based master cylinder arrangement is illustrated in  FIGS. 15-17 . The master cylinder  314   a  includes a cylinder body  316   a , a piston  318 , a spring  328  and a cap  332   a . The cylinder body  316   a  and cap  332   a  include inner and outer threads, respectively, so that rotation of the cap results in longitudinal movement of the cap relative to the cylinder body. The pre-use state is illustrated in  FIG. 15 . Fluid may be supplied to the storage volume  348  prior to shipping, or by way of port in the manner described above. With the valve (e.g., valve  340 ) set to prevent fluid from the master cylinder  314   a , the cap  332   a  may be rotated to the position illustrated in  FIG. 16 . The longitudinal movement of cap  332   a  compresses the spring  328  against the piston  318 , whose movement is prevented by the fluid, thereby pressurizing the fluid and priming the actuator. The valve may then be opened so that the energy stored in spring  328  can be used to drive the piston  318 , as is illustrated in  FIG. 17 . 
         [0070]    Another exemplary IOL insertion apparatus is generally represented by reference numeral  400  in  FIGS. 18 and 19 . Insertion apparatus  400 , which includes an inserter  401  and a plunger driver  410 , is substantially similar to insertion apparatus  300  and similar elements are represented by similar reference numerals. Like inserter  101 , the inserter  401  includes components such as a main body  402  with a tubular member  412 , a slider  404  with grips  404   a , a plunger  406  and an insertion tube  408  which operate in the manner described above with reference to inserter  101 . Here too, the plunger driver employs a drive mechanism that is a hybrid device which includes a hydraulic drive mechanism that is powered by a spring. A case, such as case  20  in  FIG. 9 , may be employed. 
         [0071]    The exemplary plunger driver  410  includes a master cylinder  414 , with a cylinder body  416  and a piston  418  within the cylinder body, and a slave cylinder  420  with a cylinder body  422  and a piston  424  located within the cylinder body. The inserter  401  is also mounted to a slave cylinder  420  by way of the tubular member  412 . An external housing (not shown), similar to the housing  326  in  FIG. 10 , may be employed in some instances. The piston  418  is driven by a spring  428  that is also located within the cylinder body  416 . A fluid path  430  connects the master cylinder  414  to the slave cylinder  420 . A cap  432  is used to close the end of the cylinder body  416 , after the piston  418  and spring  428  have been inserted, during the assembly process. The plunger driver  410  also includes a fluid port  434  (e.g., the illustrated Luer connector) with a one way valve  442  that receives the hydraulic fluid (e.g., saline) during the priming process, as is discussed below, and an actuation handle  436 . Fluid flows directly into the master cylinder  414  through the port  434 . A valve  440 , which controls flow from the master cylinder  414  to the slave cylinder  420  by way of the fluid path  430 , is operably connected to the handle  436 . 
         [0072]    Referring more specifically to  FIG. 19 , each of the pistons  418  and  424  in the exemplary plunger driver  410  includes a rigid base and a resilient seal. The piston  418  includes a cup-shaped resilient member  418   a  that prevents fluid leakage and a rigid cup-shaped support member  418   b  that carries the resilient member and anchors the spring  428 . The piston  424  includes a cup-shaped resilient member  424   a  that prevents fluid leakage, a rigid cup-shaped support member  424   b  that carries the resilient member, and a longitudinally extending plunger guide  424   c.    
         [0073]    The valve  440  in the illustrated implementation is a self-sealing valve that includes a fluid lumen  450 , a valve seat  452  and a valve element  454  that moves in and out of contact with the valve seat to close and open the valve. The valve element  454  is carried on a post  456  that is itself carried by a diaphragm  458 . The diaphragm  458  has a conical portion  460 , which carries the post  456  and biases the valve element  454  to the closed position, an outer o-ring seal  462 , and an inner o-ring seal  464  that surrounds a flow restrictor  466 . The handle  436  may be used to open the valve  440 . To that end, the handle  436  pivots about a pin  468  and includes a lever  470 . Movement of the handle in the direction of arrow A opens the valve  440 , and the amount of movement controls the magnitude of the flow and the velocity of the plunger  406 . 
         [0074]    As illustrated for example in  FIGS. 20 and 21 , the plunger guide  424   c  includes an aperture  425  near the end of the support member  424   b , and the plunger  406 , which is otherwise similar to plunger  106 , includes a depressible projection  407  that is biased to the outwardly deployed state. The plunger  406  and slider  404  are operably connected such that movement of the slider  404  from the pre-use position illustrated  FIG. 18  to the use position (note slider  304  in  FIG. 14 ) results in movement of the plunger  406  relative to the plunger guide  424   c  from the position illustrated in  FIGS. 19 and 20  to the position illustrated in  FIG. 21 . When the projection  407  reaches the aperture  425 , it will pop into the aperture to connect the plunger  406  to the plunger guide  424   c . Thereafter, forward movement of the piston  424  will result in forward movement of the plunger  406 . 
         [0075]    The exemplary plunger driver  410  may be primed with a syringe in a manner similar to the plunger driver  310  when the plunger driver is in the state illustrated in  FIG. 21 . The force associated with the fluid F being driven into the cylinder body  416  drives the piston  418  back and compresses the spring  428 , thereby creating a fluid storage volume  448  ( FIG. 22 ) in which the fluid F is stored under pressure. The force associated with the fluid F being driven into the cylinder body  416  also helps to maintain the valve  440  in its closed state. Thereafter, movement of the handle  436  in the direction of arrow A will open the valve  440 , so that fluid can be driven from the master cylinder  414 , through the path  430  and flow restrictor  466 , and into the slave cylinder  420  to drive the piston  424  and plunger  106   a . It should be noted that the speed of the plunger  406  may be varied by varying the magnitude of handle  436  movement. The amount of fluid stored in the fluid storage volume  448  is sufficient to drive to the plunger  406  to its fully deployed position and, should the user desire to cease plunger movement prior to the fully deployed position, releasing the handle  436  will allow the valve  440  to return to the closed state to which it is biased. 
         [0076]    Hybrid plunger drivers that include a hydraulic drive mechanism powered by a spring, such as those illustrated in  FIGS. 9-22 ,  24 A and  24 B may be supplied in a primed state with the fluid in the master cylinder and the spring compressed. Structures may be provided to prevent inadvertent actuation of such a driver. Referring to  FIG. 23 , the exemplary IOL insertion apparatus  400   a  is essentially identical to apparatus  400 . Here, however, the storage volume  448  in the plunger driver  410   a  is prefilled with the fluid F during assembly and the spring  428  is pre-compressed. The fluid port  434  may be omitted (as shown), or capped during assembly, depending upon the manner in which fluid is provided to the volume  448 . To prevent movement of the piston  418  prior to use, the exemplary master cylinder  414   a  includes a lock  479  which consists of a post  480  that is secured (e.g., welded) to the piston, a cap  432   a  with a aperture for the post, and a pin  482  that extends through a hole  484  in the post. The pin  482  abuts the surface of the cap  432   a , thereby preventing movement of the post  480  and piston  418 , and is held by friction. The pin  482  may be pulled at the time of use so that the piston  418  will move, and fluid will flow, upon rotation of the handle  436 . 
         [0077]    Turning to  FIG. 24 , the exemplary IOL insertion apparatus  400   b  is essentially identical to apparatus  400 . Here, however, the apparatus is a separable two-piece structure that may be assembled at the time of use. The master cylinder  414   b  of the plunger driver  410   b  is prefilled with fluid F during assembly and the spring  428  is pre-compressed. A normally closed valve  441   b  is aligned with the O-ring seal  464  (note  FIG. 19 ). The slave cylinder  420   b  includes a projection  443   b , through which the flow restrictor  466  extends, which is configured to open the valve  441   b  when the master and slave cylinders are attached to one another at the time of use. To that end, the slave cylinder  420   b  includes one or more connectors (e.g., connectors  445 ) that mate with corresponding connectors (e.g., apertures) on the master cylinder  414   b . The spring-based insertion apparatus described with below may also be configured as two-piece separable structures. 
         [0078]    Another exemplary IOL insertion apparatus is generally represented by reference numeral  400   c  in  FIGS. 24A and 24B . Insertion apparatus  400   c , which includes an inserter  401  and a plunger driver  410   c , is substantially similar to insertion apparatus  400  and similar elements are represented by similar reference numerals. For example, the inserter  401  includes components such as a main body  402  with a tubular member  412 , a slider  404  with grips  404   a , a plunger  406  and an insertion tube  408  which operate in the manner described above with reference to inserter  101 . Here too, the plunger driver employs a drive mechanism that is a hybrid device which includes a hydraulic drive mechanism that is powered by a spring. A case, such as case  20  in  FIG. 9 , may be employed. The plunger  406  and plunger guide  424   c  are configured, and operate in conjunction with the slider  404 , in the manner described above. 
         [0079]    The exemplary plunger driver  410   c  includes the above-described master cylinder  414 , with a cylinder body  416  and a piston  418  within the cylinder body, and a slave cylinder  420  with a cylinder body  422  and a piston  424  located within the cylinder body. The slave cylinder  420  may be a permanent part of the insertion apparatus, or a removable part in the manner discussed above with reference to  FIG. 24 . The inserter  401  is mounted to the slave cylinder  420  by way of a connector tube  421 . An external housing (not shown), similar to the housing  326  in  FIG. 10 , may be employed in some instances. The piston  418  is driven by a spring  428  that is also located within the cylinder body  416 . A valve  440   c , including a handle  436   c  that allows the user to open and close the valve, connects the master cylinder  414  to the slave cylinder  420  and establishes a controllable fluid path therebetween. A bracket  423  mounts the slave cylinder  420  to the valve  440   c.    
         [0080]    Referring more specifically to  FIG. 24B , the valve  440   c  is a self-sealing valve that includes a housing  441 , a fluid lumen  450   c , a valve seat  452   c  and a valve element  454   c  that moves in and out of contact with an o-ring seal  453  on the valve seat to close and open the valve. The valve element  454   c  is movable between a closed position, a fully open position, and a plurality of partially open positions therebetween. The other end of the fluid lumen  450   c  is sealed with an o-ring seal  453   a . The valve element  454   c  includes a post  456   c , a valve member  458   c  and a spring support  460   c . A spring  461  biases the valve element to the closed position. A flow restrictor  466   c  establishes a fluidic connection between the fluid lumen  450   c  and the slave cylinder  420 . In the illustrated implementation, the flow restrictor  466   c  is a needle valve, including an inlet port  467   a , a main portion  467   b  and an outlet port  467   c , that may be preset to the desired amount of restriction. The actuator handle  346   c  pivots about a pin  468   c  and includes a lever  470   c  that presses on the valve element  454   c . Movement of the handle  436   c  in the direction of arrow A overcomes the biasing force of the spring  461  and opens the valve  440   c , and the amount of movement controls the magnitude of the flow and the velocity of the plunger  406 . 
         [0081]    The exemplary plunger driver  410  may be primed with hydraulic fluid from a syringe in the manner described above. To that end, the valve housing  441  includes a connector  434   c  for a fluid port (e.g., the Luer connector  434  with the one way valve  442  illustrated in  FIG. 19 ). An aperture  417  in the cylinder body  416  allows flow from the connector to the fluid storage volume  448 . 
         [0082]    It should also be noted that, in other implementations, other types of valves may be employed in place of those described above with reference to  FIGS. 9-24B . Other exemplary valves that may be employed include solenoid actuated valves that are connected to a button. 
         [0083]    Another exemplary IOL insertion apparatus is generally represented by reference numeral  500  in  FIGS. 25 and 26 . The exemplary insertion apparatus  500  includes an inserter  501  and a plunger driver  510 . The inserter  501  is substantially similar to the inserter  101  and similar elements are represented by similar reference numerals. To that end, the inserter  501  includes components, such as a main body  502  with a tubular member  512 , a slider  504  with grips  504   a , a plunger  506  and an insertion tube  508  that together operate in the manner described above with reference to inserter  101 . A case similar to case  20  may be employed to prevent erroneous operation of the insertion apparatus. 
         [0084]    The exemplary plunger driver  510  illustrated in  FIGS. 25 and 26  is a spring-driven device that includes a drive portion  514  and a control portion  520 . The drive portion includes a housing  516 , a piston  518  that is connected to the plunger  506  and to the control portion  520  (as discussed below), and a spring  528 . The piston  518  has an elongate piston body  518   a , abutments  518   b  and  518   c  and a connector  518   d  at the other end for the plunger  506 . The circular abutment  518   b  is in contact with the spring  528  and slides along the inner surface of the housing  516 . Abutment  518   c  connects the abutment  518   b  to the piston body  518   a . In other implementations, the plunger and piston may be formed as a single, integral unit. The control portion  520  includes a housing  522 , a rack  524  that is secured to the piston  518 , a brake  526 , a gear train  528  that connects the brake  526  to the rack  524 , and a rotary damper  530  that limits the forward acceleration of the gear train (and components connected thereto) without necessitating an increase in spring force. In the illustrated implantation, the main body  502 , housing  516  and housing  522  are commonly formed by a two-part structure consisting of housing part  523   a  and housing part  523   b  ( FIG. 26 ). 
         [0085]    The piston  518  has portions located within, and moveable relative to, both the drive portion  514  and a control portion  520 . Referring to  FIG. 27 , the drive portion housing  516  includes an aperture  515  and the control portion housing  22  includes a corresponding aperture  523  through which the piston  518  extends. The aperture  515  is smaller than the abutment  518   c , which limits the distance that the piston  518  can travel. 
         [0086]    As illustrated in  FIGS. 26-28 , the exemplary brake  526  has a drum  532 , a friction element  534  (e.g., a rubber O-ring), and an actuator  536 . The actuator  536  includes an engagement element  536   a  that is connected to a button  536   b  by a lever  536   c . The engagement element  536   a  engages the friction element  534  on the drum  532 , while the lever  536   c  is pivotably mounted on the gear axle  540   b  (discussed below) and is biased by a spring  536   d  to an orientation that results in the engagement element  536   a  engages the friction element  534  with sufficient force to stop spring driven movement of the piston  516  and plunger  506 . The exemplary gear train  528 , which is a two-stage gear train, includes gears  538   a ,  538   b  and  538   c . Gear  538   a  and brake drum  532  are both mounted on axle  540   a , which is the axle of the rotary damper  530 , and gears  538   b  and  538   c  are mounted on axel  540   b . Gear  538   a  meshes with gear  538   b . Gear  538   c  engages the rack  524  such that linear movement of the piston  518  results in rotation of the gear  538   c . Conversely, slowing or preventing rotation of the brake drum  532  slows or prevents spring driven linear movement of the piston  518 . The gear train  528  allows the torque input to the rotary damper  530  to be minimized, and also minimizes the amount of braking force required to prevent rotation of the gears and forward movement of the rack  524  and piston  518 . The two-stage gear train gear train  528  also facilitates a smaller device as compared to a device with a single gear connected to the brake and rack. 
         [0087]    The spring  528  is compressed during the assembly process and may be maintained in the compressed state in a variety of ways. For example, the brake  526  may be configured such that the piston  518  will not move unless a significant amount of force (i.e., a force greater than that associated with shipping, handling, etc.) is applied to the button  536   b . Alternatively, or in addition, the case may be configured so as to prevent depression of the button  536   b  during storage. Another alternative is placing a removable wedge-like structure (not shown) between the underside of the button  536   b  and the adjacent portion of the inserter  501 . Still another alternative is a pin (not shown) that may be inserted through a hole in the housing and into the region where gears  538   a  and  538   c  mesh to prevent rotation thereof. 
         [0088]    Structures that act directly on the piston and/or spring to prevent expansion of the compressed spring may also be employed during shipping and storage. For example, and referring to  FIGS. 25 and 26 , the exemplary drive portion housing  516  includes a pair of longitudinally extending apertures  542   a  and  542   b . A wedge-like structure (not shown) that extends the length of the aperture and engages the circular abutment  518   b  on the piston  518  may be inserted into one or both of the apertures  542   a  and  542   b . Turning to  FIG. 29 , the exemplary drive portion  514   a  and case  20   a  are configured to maintain the spring  528  in the compressed state and prevent movement of the piston. Here, the case  20   a  includes a rigid member  21  that projects into the storage area, and the drive portion housing  516   a  include a slot  517  that is located adjacent to the circular abutment  518   b , and is offset from the piston body  518   a  and abutment  518   c . In the illustrated implementation, the rigid member  21  is a generally U-shaped metal structure that is molded into the bottom wall  20   b  and rear wall  20   r  of the case  20   a . In still other implementations, a master cylinder that is pressurized at the time of use (similar to that illustrated in  FIGS. 15-17 ) may be employed. 
         [0089]    Another exemplary IOL insertion apparatus is generally represented by reference numeral  600  in  FIGS. 30-32 . The exemplary insertion apparatus  600  includes an inserter  601  and a plunger driver  610 . The inserter  601  includes a main body  602  with a tubular member  612 , a plunger  606 , and an insertion tube  608  that together operate in the manner described above with reference to inserter  101 . Unlike other inserters described herein, the inserter  601  does not include a slider. The lens is pushed from the storage area and though the insertion tube  608  with the plunger  606 . A case similar to case  20  may be employed to prevent erroneous operation of the insertion apparatus, as is discussed below. The exemplary plunger driver  610  is a spring-driven device that includes a drive portion  614  and a control portion  620 . 
         [0090]    The drive portion  614  in the illustrated embodiment includes a housing  616 , a rotatable hub  617  located within the housing, a piston  618  that located within the tubular member  612  and connected to a mounting member  606   a  on the plunger  606  and to the rotatable hub  617 , a spiral torsion spring (or “mainspring”)  628 , and a winding arbor  629 . The rotatable hub  617  includes a disk  617   a , a cylindrical member  617   b , and an externally threaded member  617   c . The winding arbor  629  includes a disk  629   a , a handle  629   b  and an axle  629   c . The outer end of the mainspring  628  is secured to the hub cylindrical member  617   b  and the inner end of the mainspring is secured to the arbor axle  629   c . The rotatable hub  617  is connected to the piston  618  by way of an internally threaded member  618   a  at one end of the piston that engages the threads on the externally threaded member  617   c . The piston  618  is also keyed to the outer surface of a guide  619  in such a manner rotational motion of the piston is prevented and longitudinal movement is permitted. Thus, rotational motion of the hub  617  is translated into linear movement of the piston  618  and plunger  606 . 
         [0091]    The exemplary control portion  620  prevents, and selectively allows upon user action, rotation of the hub  617 . To that end, the control portion includes a brake  626  and a brake control apparatus  636 . The brake  626  has an engagement element  626   a , that is connected to the brake control apparatus  636  by an elongate member  626   b , and a spring  626   c  that biases the brake to the rotation prevention position illustrated in  FIG. 31 . The spring  626   c , which is compressed between the drive portion housing  616  and an abutment  626   d  on the elongate member  626   b , exerts sufficient force on the engagement element  626   a  (by way of the elongate member) to prevent rotation of the hub  617 . The control apparatus  636  includes a pair of finger tabs  636   a  that are pivotably mounted on the tubular member  612  with arms  636   b  and pivot pins  636   c . The finger tabs  636   a  are also secured to a flexible V-shaped member  636   d  that is itself connected to the brake elongate member  626   b . Movement of the finger tabs  636   a  toward one another increases the length of the V-shaped member  636   d  which, in turn, drives the brake elongate member  626   b  in the direction of arrow A and separates the engagement element  626   a  from the hub disk  617   a . The hub  617  will then be rotated by the mainspring  628 . 
         [0092]    During assembly, and with the brake  626  preventing rotation of the hub  617 , the winding arbor  629  is rotated to wind the mainspring  628 . Rotation of the axle  629   c  rotates the associated end of the mainspring  628  while rotation of the other end is prevented by virtue of its connection to the hub  617 . When the winding is complete, the winding arbor disk  629   a  may be fixedly secured to the housing  616 , thereby prevent rotation of the winding arbor  629 , by mechanical fasteners, adhesive, welding or other suitable instrumentalities. 
         [0093]    The insertion apparatus  600  may be shipped and stored in a manner that prevents unwinding of the mainspring  628  prior to use. For example, the housing  616  and hub disk  617   a  may be provided with apertures that will be aligned with one another after the mainspring  628  is wound, and pins may be inserted through the apertures to prevent rotation of the hub  617  relative to the housing. A blocking structure that prevents the finger tabs  363   a  from moving toward one another may be provided as part of a case that is similar to case  20 , or as a separate device. A case that prevents longitudinal movement of the piston  618  in a manner to that similar to the case described above with reference to  FIG. 29  may also be provided. 
         [0094]    Numerous other modifications and/or additions to the above-described preferred embodiments would be readily apparent to one skilled in the art. For example, insertion apparatus in accordance with the present inventions may consist of a re-usable, non-manually powered inserter that is combined with an IOL cartridge (either a preloaded cartridge or a cartridge that is loaded at the time of the surgical procedure) to form the insertion apparatus. Such a cartridge may include a IOL storage region where the IOL is stored in a flat, unstressed state, a nozzle, and a tapered region therebetween. The present inventions are also applicable to inserters without sliders, as is alluded to above, and any of the insertion apparatus described herein may be reconfigured so as to exclude sliders. Alternatively, the plunger drivers and sliders described above may be reconfigured such that the plunger drivers drive the slider in addition to the plunger at the time of use. It is intended that the scope of the present inventions extends to all such modifications and/or additions.