Cataract Surgery Focus on Iols for Microincisions

APRIL 2006 I CATARACT & REFRACTIVE SURGERY TODAY I 27 A dvances in technology have greatly improved ophthalmologists’ ability to approach difficult cases with confidence. With the advent of capsular tension rings, iris and capsular hooks, and numerous viscoelastic devices, cataract surgery has become safer and more predictable. Among the most important recent technological advances, however, have been those refining the delivery of ultrasound energy and those stabilizing the anterior chamber during surgery. Ultrasound delivery underwent an industry-wide revolution with the introduction of micropulse technology. With micropulsing, effective cavitation is maximized while the total use of energy is lowered. The result is improved surgical control, less intraocular inflammation, and clearer corneas. The more recent ability to “shape” the ultrasound pulse (Whitestar ICE Technology; Advanced Medical Optics, Inc., Santa Ana, CA) allows yet lower ultrasound times and energy levels with greater followability and hold. Chamber stability has been optimized through software modulations (CASE technology; Advanced Medical Optics, Inc.) that anticipate postocclusion surge and reverse peristaltic flow through the tubing. The result is a virtually still intraoperative chamber. The usage per case of balanced salt solution has decreased, reflecting both improved surgical control and shorter case times. Coaxial or single-handpiece phacoemulsification carries all of the advantages of a tried and true technique: peer acceptance; industry support; and the comfort of familiarity. With continually smaller coaxial phaco probes (Alcon Laboratories, Inc., Fort Worth, TX) that permit the lens’ emulsification through incisions as short as 2.2mm, coaxial cataract surgery is becoming truly astigmatically neutral, and incisions are far less prone to postoperative leakage. Bimanual phacoemulsification involves the use of one probe that emulsifies while aspirating and another that solely irrigates. These probes are placed through two watertight limbal incisions of 1.2 to 1.4mm. The creation of a larger incision is necessary until the FDA approves a rollable IOL that can be inserted through one of the original incisions. So, why should surgeons consider adding the bimanual technique to their surgical armamentarium? Aren’t two incisions preferable to the enlargement or addition of a third one? Are there specific patient groups or clinical scenarios for which bimanual surgery is advantageous?