Almost all cases of phacoemulsification can be performed by means of a bimanual microincision approach. The major advantage ofbimanual microincisions has been an improvement in control over most of the steps involved in endocapsular surgery. The anterior chamber is more stable during capsulorhexis construction, hydrodelineation and hydrodissection can be performed more efficiently, and separation of irrigation from aspiration allows for improved followability by avoiding competing currents at the tip of the phaco needle.
In addition, by switching infusion and aspiration handpieces between the two microincisions, 360° of the capsular fornices are easily reached and cortical clean-up can be performed quickly and safely. Increased utilization of this technique has revealed many preoperative conditions that are perhaps better approached using a bimanual rather than a coaxial technique.
This was demonstrated recently by a 58-year-old male who had undergone a 16-cut RK followed by a hexagonal keratotomy (Hex-K) and multiple astigmatic keratotomies OD. The patient required a penetrating keratoplasty (PK) for disabling glare and several years later developed a dense posterior subcapsular cataract. Although the PK had removed all of the Hex-K and the bulk of the RK, the remnants of the RK incisions that extended to the limbus were still present and at risk for splaying open during phacoemulsification.
Irrigation and aspiration of residual cortical material was accomplished with the MST Duet handpieces, alternating instruments between the two incisions in order to access all of the cortical material with minimal wound stress (Figure 3).