Phakonit: Incisions and use of a pressurized inflow system

Abstract

We would like to congratulate Tsuneoka and coauthors1 for their article on ultrasmall-incision bimanual phacoemulsification through a 2.2 mm incision. We have followed their interesting work to reduce the incision size in cataract surgery, and we consider Tsuneoka and Agarwal the pioneers of this technique in this era of renewed, worldwide interest in bimanual microincision phacoemulsification.2–4 In the article, the authors mention that the surgeon sits at the patient's head, holding the phacoemulsification handpiece in the right hand when working in the right eye and in the left hand when working in the left eye. Although we are convinced that for bimanual phacoemulsification the surgeon must learn how to perform many maneuvers with his or her nondominant hand, we have found that surgeons usually feel more comfortable holding the phacoemulsification handpiece in their dominant hand. One of us (F.V.) has performed phakonit through a 1.5 mm incision using a MicroFlow®, 30-degree, sleeveless needle (Bausch & Lomb) and an irrigation chopper designed by him (Vejarano irrigation chopper, Gusor Ltda.) The main incision is always located temporally and the side port, between 2 and 3 clock hours to the left (Figure 1). We have performed 48 cases using the Storz Premiere system (Bausch & Lomb) with very good results. We think the transition to phakonit may be easier if the surgeon holds the instruments with the hand he or she is used to.Figure 1.: (Vejarano) Main incison is temporal and the side port, almost 3 clock hours to the left. Vejarano irrigation chopper and MicroFlow tip are in place inside the anterior chamber.Moreover, the authors mention that using a 20-gauge irrigation hook and a bottle elevated to 110 cm, the infusion flow may not keep up with the aspiration flow if there are no nuclear particles on the phaco tip. We use the Vejarano irrigation chopper, 0.9 mm in diameter, introduced through a 1.0 mm side-port incision. This instrument allows an inflow of 30 cc/min using intraocular pressure control-pressurized inflow in the Storz Premiere system at 80 mm Hg. We have found that using it along with the MicroFlow tip provides a very stable anterior chamber throughout the procedure with minimal surge. Injecting air into the infusion bottle has been suggested by Agarwal and coauthors,5 but we have not had to use an additional device since the phacoemulsification unit that we use has this capability. The pressurized inflow system included in the Storz Premiere system is very easy to use and very helpful in keeping a steady and adequate inflow into the anterior chamber. Since several phacoemulsification units have this possibility, surgeons can use it in phakonit cases. Felipe L. Vejarano MD Alejandro Tello MD Alberto Vejarano MD Popayán, Colombia