23 EyeWorld Asia-Pacific | September 2024 CATARACT With bimanual I/A, Dr. Kandavel tries to make both ports directly across from each other to maximize the benefit. “I make the left-handed port where comfortable, and I make the right-handed secondary paracentesis directly across from it with consideration for LRIs if present first.” With cortical cleanup, there’s a lot of advantages to being meticulous with the complete cleanup of every last visual fragment, Dr. Kandavel said, but it’s also important to go into the sulcus behind the iris to clean up. Many times, not only will you get access to cortex that you can’t see, but you’ll discover cortex that you were meaning to remove that’s now in the periphery of the bag without you even knowing, he said. Theoretically, the advantages include reducing posterior capsular opacity formation, and that’s essential in refractive lens exchange because there are a lot of cases nowadays where physicians have to make a decision on whether the multifocality of the lens or the optical features are causing certain aberrations in the early postop period, Dr. Kandavel said. In today’s refractive cataract surgery world, surgeons have to be accustomed to offering lens exchange in certain cases. IOL exchange is made more facile by meticulous cortical cleanup because it’s the residual cortex that is a stimulant for capsular fibrosis, making the haptics easier to remove if that’s needed, Dr. Kandavel said. When cortical cleanup is not meticulous, there could be epithelial proliferation and the formation of Soemmerring’s rings, which are collections of large numbers of epithelial cells. They can cause decentration or late-term inflammation. Bimanual I/A is done through smaller incisions, Dr. Kandavel said, adding that he likes to use a reusable handpiece set by MST. It comes in multiple sizes (19-, 21-, and 22-gauge). The 22-gauge is what Dr. Kandavel uses to help with the influx of irrigation. You can even use a different size irrigation handpiece and a smaller size aspiration handpiece if you prefer, he said. “The 22-gauge is approximately 700 microns, so I use a 1-mm sideport incision that’s a fixed thickness to create the two paracentesis ports,” he said. “By having a 1-mm sideport, the chamber stability is much better. You don’t get as much trampolining.” He added that chamber stability is greatly improved in bimanual I/A due to the smaller sideports, and the seal around those ports is considerably tighter, making for a more stable chamber. You do have to increase the bottle height, but because the irrigation is narrow, the effective pressure in the eye is not as high as the machine may indicate. There are a number of other benefits to bimanual I/A, Dr. Kandavel said. “For instance, there are certain cases where we’ll encounter the need for a suture through the main incision. Some surgeons use a nylon suture to secure the main incision when placing an accommodative lens. If you have to enlarge the incision, you can place and even tie the suture after placing the lens, and you can perform I/A through two sideports with the sealed main incision. You get good lens centration without as much fluctuation because you’re not coming in and out of a larger incision where the chamber may be shallow and change the position of the lens; the chamber is rock solid, and you’ve hydrated your main incision or secured it with a suture. You’ve centered your lens, you come straight out of the eye, and the lens stays where you put it.” There are certain cases where there are unstable chambers, like very long or very short eyes, and the facility of having a smaller irrigation handpiece and smaller incision gives the chamber a more solid feel, and it’s more versatile, he said. Another example of an advantage of bimanual I/A, Dr. Kandavel said, is when you’re using it for MIGS procedures. You put in the lens and the MIGS device, and you want to prevent hypotony as much as possible directly after placing the MIGS device because you’ll get egress of blood through Schlemm’s canal and through the device. With bimanual I/A, you can increase the pressure, irrigate the blood out of the anterior chamber, keep the pressure a little higher, and limit the amount of blood in the AC. “I also find the smaller bimanual instruments particularly helpful for aspirating behind the IOL, which I perform in all cases, but especially in MIGS to prevent IOP spikes,” Dr. Kandavel said. Bimanual I/A is also more zonule friendly, Dr. Kandavel said. Because you can get directly across and perpendicular to the cortex, you can strip tangentially and circumferentially to reduce zonular stress. Bimanual I/A is shown here. Source: Cristos Ifantides, MD, MBA
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