Hybrid bimanual technique for aspiration of residual cortex

Abstract

Editor, Aspiration of residual cortical matter, especially if located in the subincisional area, can pose a challenge to the cataract surgeon. Various methods have been described to aid the aspiration of residual cortical matter, including use of bimanual IA systems, J-shaped cannulas (Dewey 2002) and transparent irrigation cannulas (Shimada et al. 2002). We describe a hybrid bimanual technique of aspiration of residual cortical matter that uses a combination of the coaxial and bimanual IA hand pieces and averts the requirement of an additional side port. An informed consent was obtained from all the patients undergoing cataract surgery. The study followed the tenets of the Declaration of Helsinki. Two incisions are made at the start of cataract surgery. A 2.75-mm main port is made using a 2.75-mm blade (Alcon Labs, Fort Worth, TX, USA) for the coaxial phacoemulsification probe (Infiniti System, Alcon Labs, USA) and a side port made two clock hours away from the main port with a 20G MVR blade (Alcon Labs). Following the completion of nuclear and epinuclear phacoemulsification, aspiration of cortical matter is begun using the traditional coaxial hand piece. The hybrid bimanual technique may be used if the surgeon is unable to completely aspirate the cortical matter. The coaxial IA probe connected only to the irrigation tubing is introduced into the anterior chamber through the 2.75-mm main incision. The aspiration hand piece of the bimanual system (Appasamy, India) is inserted in the anterior chamber through the 20G side port. The bimanual aspirating hand piece is used to aspirate the remaining cortical matter (Fig. 1). The tip of the coaxial hand piece is kept just below the interior lip of the valve. This allows for better visualization of the aspiration port of the aspirating hand piece. Hybrid Bimanual irrigation–aspiration being performed using the coaxial hand piece for irrigation and bimanual aspiration hand piece for aspiration. We used this technique in 27 eyes of 27 patients with residual cortex. Cortex could be successfully aspirated in 26 of 27 eyes with the use of the modified technique. One eye that had extensive cortex under the area where the side port was made required conversion to the standard technique of bimanual irrigation and aspiration (IA). No posterior capsular rupture occurred in any of the cases. Residual cortex, especially located in the subincisional area, can pose challenges to the surgeon. Bimanual irrigation and aspiration can greatly ease the removal of residual cortical matter. However, if the surgeon uses a single side port for phacoemulsification, an additional side port needs to be created during the surgery to enable bimanual IA. Our technique obviates the requirement for an additional side port. When the traditional bimanual IA system is used through the two side ports, the larger, main port tends to leak during IA, as it is not occluded by the hand piece. This may lead to surge and instability of the anterior chamber. As the main port is effectively occluded by the coaxial hand piece during IA using our technique, the anterior chamber is more stable during irrigation and aspiration. The only drawback that we experienced with our technique is the occasional inadequate visualization of subincisional cortical matter in the area below the side port as compared to the use of a traditional bimanual IA technique. In such cases, one can make a second side port and shift to the standard bimanual IA technique. In conclusion, the hybrid bimanual technique is a useful modification that can be safely used for aspirating the residual cortical matter during cataract surgery. It combines the benefits of the traditional bimanual IA system with that of the coaxial IA system and at the same time circumvents the need for creation of the second side port.