22 EyeWorld Asia-Pacific | September 2024 About the Physicians Cristos Ifantides, MD, MBA | Tyson Eye, Cape Coral, Florida | cristosmd@gmail.com Rom Kandavel, MD | Colvard-Kandavel Eye Center, Encino, California | valleyeyedoctor@gmail.com Relevant Disclosures Ifantides: Alcon, Bausch + Lomb, Johnson & Johnson Vision Kandavel: Alcon, Glaukos This article originally appeared in the June 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. CATARACT I wish I had … Boris Malyugin, MD, PhD, Refractive Editorial Board member, shared what he wishes he had: I am dreaming that the femtosecond laser IOL power adjustment technology will be available sooner rather than later. Although we do have the LAL (RxSight), using the femtosecond laser for that purpose seems to be more promising. Another advantage of bimanual I/A presents when you can use your secondary incision for other purposes, such as IOL manipulation for a toric lens or for centration, he said. CTR placement can be made easier, and you can use it for Malyugin ring removal because it is sometimes advantageous to have a second approach to disengage one of the scrolls from the iris. Dr. Ifantides agreed that bimanual I/A may be particularly helpful for more complex surgeries. It’s good for small pupils because if you have to sweep underneath the iris, you want something that is more elegant, he said. It’s smaller, and you can go underneath the iris and into the bag easier. “Additionally, sometimes with a small pupil, you need to use a second instrument to try to visualize the bag if you’re doing coaxial,” he said. “With this, you could use the irrigation portion of the bimanual to move the iris around a bit and visualize while you’re sweeping for cortex.” Dr. Ifantides said bimanual I/A may also prove advantageous for special lenses that end up needing a larger wound. For example, when using the IC-8 Apthera (Bausch + Lomb) and needing to increase wound size, Dr. Ifantides has run into problems going back into the eye with coaxial and having a bigger wound than the sleeve allows for. You can get egress of fluid around the sleeve, which shallows the chamber, and the iris can come out if you’re not careful, he said. You can avoid that by using bimanual. “After you put in the lens, you have an enlarged wound, you can hydrate the main wound and switch to bimanual for the removal of the viscoelastic,” he said. Types and tips The biggest barrier is the additional cost. MST has a reusable product. Dr. Kandavel said he has used the same handpiece for years. There is a cost savings if you don’t have to pay for an additional irrigation handpiece, he said. In some cases, the handpiece is included with the phaco pack, but other times it’s a la carte, so it can be as much as $10–20 for the irrigation handpiece. It’s important with reusable bimanual I/A to have very good cleaning protocols because you can have residual cortex and potential TASS without the correct cleaning routines. You also want to be mindful if you’re using a reusable system, that there are no barbs on the irrigation side. “Alcon makes a coaxial handpiece that transforms into a bimanual handpiece, but unlike true bimanual handpieces, you don’t have to create that third incision,” Dr. Kandavel said. That allows the benefit of bimanual I/A without creating another incision. “The only disadvantage with that is that you have to put the infusion through the main incision, so the bimanual aspect of it only has the advantage of going through one sideport. It doesn’t necessarily give you the same access of having two sideports with true bimanual.” Dr. Ifantides also uses a reusable bimanual I/A by MST. He added that Alcon makes a disposable and detachable polymer tip. For the paracentesis, he said that it helps to make it slightly bigger than 1 mm so that you don’t stretch it out as much when maneuvering with bimanual if you enlarge,, and it seals easier with less likelihood of leaking. Dr. Ifantides also recommended speaking to “the people who support your machines and telling them that you’re interested in getting into bimanual because some settings can be adjusted to improve the performance.” He added, “the machine assumes you’re using coaxial, so if you switch to bimanual, you should adjust that.” Additionally, Dr. Ifantides said that companies are usually good with sending trial sets if you’re interested in trying different products. That’s nice because you can do that before you pull the trigger, he said.
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