7.18 Intraocular Cautery (Fig. 7.27)

It has been found that biaxial microincision instruments allow intraocular cautery by using an irrigating cannula in one of the microincisions and a microincision bipolar cautery in the other. Pinching of the irrigation tubing leads to bleeding, clearly identifying the point source because the eye softens and the bleeding points start to ooze. They are precisely cauterized with the bipolar cautery, and therefore trauma to intraocular structures is minimized by avoiding more cautery than is necessary [15].

7.19Biaxial Microincision Instruments

(Figs. 7.28 and 7.29)

There are a number of other instruments that have been developed for use through 1.1 mm microincisions. Iris reconstruction is very much easier utilizing intraocular forceps that stabilize the iris for suturing. New intraocular needle holders are also usable through a 1.0-mm incision. In this way, very fragile and atrophic irides can be sutured without putting excessive stress on the iris tissue. The knots are tied with a Seipser external tying mechanism [16] and the knots are cut with an intraocular microincision scissors, that is also admissible through a 1.0-mm incision.

Fig. 7.28 Suturing of atrophic iris using microincision intraocular forceps

Fig. 7.29 Nicking the capsulorhexis with microincision scissors prior to enlarging the capsulorhexis

Fig. 7.27 Bipolar intraocular microcauterization with easy identification of the bleeding point by pinching the infusion tubing

For late reopening of capsular bags to recenter IOLs, a capsulorhexis is enlarged in the late postoperative period by nicking the rhexis with a microincision intraocular scissors, and then tearing a larger opening with a microincision capsulorhexis forceps. Viscodissection of the lens [17] within the capsular bag, can be accomplished through microincisions which also allow for repositioning of IOLs without the need to make larger incisions to manipulate them intraocularly. There are currently additional microincision instruments under a state of development, including microincision Collibri forceps, microincision iris graspers, and microincision IOL holders and cutters.

Take Home Pearls

ßBiaxial microincision phacoemulsification is believed to be a technique that has a very short

learning curve, is highly atraumatic, and is unquestionably the technique of the future. For those who are willing to go through the short learning curve now, it represents the best and the safest technique at present, for the management of certain difficult and challenging cases.

ßThe separation of infusion from aspiration and ultrasound energy allows the use ofincoming

fluid wave as a unique instrument to hold back floppy irides.

ßThe anterior segment can be sequestered from the posterior segment in cases of ruptured cap-

sules and zonular dialyses.

ßIt is especially useful in situations in which the smaller instrumentation of biaxial phacoemulsi-

fication are required, such as in high hyperopia, small eyes, and crowded anterior chambers.

ßIt has unique advantages in high myopia and posterior polar cataracts.

ßNew instrumentation facilitates:

ßRepositioning decentered lenses in fibrosed capsules

ßControl of bleeding pre-, intraand postoperatively

ßIntraocular suturing, especially following iris trauma

References

1.Fine IH, Hoffman RS, Packer M (2008) Use of bimanual microincision phacoemulsification for difficult and challenging cases. In: Garg A, Fine IH, Alió JL, Chang DF, Weinstock RJ, Mehta KR, Bovet JJ, Tsuneoka H, Malyugin B, Pinelli R, Pajic B, Mehta CK (eds) Mastering the techniques of advanced phaco surgery. Jaypee Brothers, New Delhi, India

2.Girard LJ (1978) Ultrasonic fragmentation for cataract extraction and cataract complications. Adv Ophthalmol 37:127–135

3.Shearing SP, Relyea RL, Loaiza A, Shearing RL (1985) Routine phacoemulsification through a one-millimeter nonsutured incision. Cataract 2:6–10

4.Hara T, Hara T (1989) Endocapsular phacoemulsification and aspiration (ECPEA) – recent surgical technique and clinical results. Ophthalmic Surg 20(7):469–475

5.Tsuneoka H, Shiba T, Takahashi Y (2001) Feasibility of ultrasound cataract surgery with a 1.4 mm incision. J Cataract Refract Surg 27:934–940

6.Agarwal A, Agarwal A, Agarwal S, Narang P, Narang S (2001) Phakonit: phacoemulsification through a 0.9 mm corneal incision. J Cataract Refract Surg 27(10): 1548–1552

7.Tsuneoka H, Shiba T, Takahashi Y (2002) Ultrasonic pha-

coemulsification using a 1.4 mm incision: clinical results. J Cataract Refract Surg 28:81–86

8.Tsuneoka H, Hayama A, Takahama M (2003) Ultrasmallincision bimanual phacoemulsification and AcrySof SA30AL implantation through a 2.2 mm incision. J Cataract Refract Surg 29(6):1070–1076

9.Fine IH, Packer M, Hoffman RS (2004) Power modulations in new technology: improved outcomes. J Cataract Refract Surg 30:1014–1019

10.Fine IH, Hoffman RS, Packer M (2004) Optimizing refractive lens exchange with bimanual microincision phacoemulsification. J Cataract Refract Surg 30:550–554

11.Osher RH, Yu BC-Y, Koch, DD (1990) Posterior polar cataracts: a predisposition to intraoperative posterior capsule rupture. J Cataract Refract Surg 16:157–162

12.Vasavada AR, Sing R (1999)Phacoemulsification in posterior polar developmental cataracts. In: Lu LW, Fine IH (eds) Phacoemulsification in difficult and challenging cases. Thieme, New York, NY, pp 121–128

13.Aravind H, Aravind S, Vadi K, Natchair G (2006) Bimanual microphaco for posterior polar cataracts. J Cataract Refract

Surg 32(6):914–917

14. Vasavada AR, Raj SM (2004) Inside-out delineation. J Cataract Refract Surg 30(6):1167–1169

15.Fine IH, Hoffman RS, Packer M (2004) Bimanual bipolar diathermy for recurrent hyphema following anterior segment intraocular surgery. J Cataract Refract Surg 30(9): 2017–2020

16.Seipser SB (1994) The closed chamber slipping suture technique for iris repair. Ann Ophththal 26(3):71–72

17.Fine IH, Hoffman RS (1997) Late reopening of fibrosed cap-

sular bags to reposition decentered intraocular lenses. J Cataract Refract Surg 23:990–994