For the past few years, the lure of ever smaller incisions has enticed cataract surgeons who perform temporal, clear corneal phacoemulsification with topical anesthesia. With a variety of shooters, we have been placing IOLs through 2.5- to 2.8-mm incisions and we feel comfortable with our self-sealing wounds and good results. Still, as many of us recall with previous transitions in our cataract surgery development, taking on a new skill requires stepping out of one's comfort zone to take advantage of even better technology. Such has been the situation with bimanual phacoemulsification.
As proposed by those who taught the transition to phacoemulsification in the 1980s, it is imperative to have a plan that allows many opportunities to revert back to a more familiar technique when one feels uncomfortable. The original "Three Steps to Phaco," pioneered by William Maloney, MD, David Dilman, MD, and I. Howard Fine, MD, allowed an entire generation of surgeons performing extracapsular cataract extraction to take on a different set of surgical skills in a predictable manner. A similar approach can be taken as bimanual phacoemulsification is adopted.
1. In the transition, plan on performing bimanual irrigation/aspiration (I/A) only after removal of nucleus with a standard sleeved phaco-tip technique. Get used to the two-handed feel of the instruments.