Sometimes new does not mean safer

1.

Masuda Y, Oki K, Iwaki H, Okamoto T, Tsuneoka H. Use of the phaco tip technique for lens cleavage and removal during cataract surgery. Clinical Ophthalmology. 2016;10:1925–1929.

2.

Bordeianu CD. A new phacoemulsification technique meant to protect the relatively more fragile diathermic capsulorhexis rim. Abstract in: The 22nd ESCRS Congress, Paris, 2004. Dublin: ESCRS; 2004:122.

3.

Sourdille P, Poirer C. Immobile movement concept enhances safety of bimanual microincision surgery. Ocular Surg News. 2007;25(20):46–47.

Q:

A second instrument is used to split the grooved nucleus, to chop the quarters, and to manipulate the fragments. In all, the authors used more than three instruments: cannula for saline or for ophthalmic viscoelastic device, phaco tip, chopper, and irrigation/aspiration cannula.

R:

Our surgical technique focuses on three parts of the cataract surgical process. These include 1) hydrodissection using a syringe and cannula, 2) nucleus phacoemulsification using the phaco tip, and 3) aspiration of cortex using the irrigation/aspiration tip (I/A tip). In all of these stages, we only use the phaco tip with support from the Shinkawabashi hook, which is used to divide the nucleus.

Q:

The wound leakage around the chopper is obvious. Given these conditions, how could the intraocular pressure be considered stable?

R:

Wound leakage at the paracentesis site is a normal part of any phacoemulsification surgical procedure, and thus, the leakage seen in the video is not considered to be a special event when using this technique. Our statement that the intraocular pressure (IOP) was considered to be stable is based on comparisons with the IOPs that are observed during conventional surgical methods, which usually require the insertion and removal into the anterior chamber of three different instruments.

Q:

Then, cortex aspiration continues with the phaco tip inserted under the anterior capsule at 6 o'clock. This might be a novelty, but again, in my opinion, risks are involved; the aspiration mouth is large and wide bites of the attached cortex are aspirated.

R:

Once again, we would like to emphasize that at this particular stage of the procedure, with the whole-lens in place and keeping the entire capsule stretched, aspirating under the capsulorhexis edge does not vacuum or engage the capsule. The aspiration port never becomes fully occluded, and the Dewey phaco tip provides additional safety because of its smoothly polished edge.

Q:

In the video, sometimes, the tissue did not come off easily, and forced tractions were evident; in case of small disinsertion of the inferior zonule, unobservable before surgery because usually it is not accompanied by irido-phacodonesis, these tractions could enlarge the disinsertion.

R:

When using the phaco tip for the cortical removal prior to the nucleus removal, we believe that the traction did not exceed that which occurs during the original cortical removal when using IA.

Q:

Nothing in the video presentation attached to the article proves that this theory works; at no time was a hydrodissection wave observed. I rather believe that the repeated manipulations of the nucleus with the belly of the phaco tip during the anterior cortex aspiration loosened the adhesions of the soft cortex to the posterior capsule.

R:

Observation of the hydro-wave is not important during irrigation dynamic pressure hydrodissection (iH) because, in contrast to the conventional manual hydrodissection that requires the use of a cannula and syringe, the iH technique is able to achieve the hydrodissection effect through the use of a mild irrigation pressure at multiple capsulorhexis edges. However, I do agree with the latter point made by Dr Bordeianu, as aspiration of the anterior cortex does help to loosen the cortical-capsular adhesion, thereby facilitating the irrigation flow throughout the entire cortical-capsular space.

Q:

However, these forced movements of pushing/rotating the still adherent nucleus are far from the ideal phacoemulsification technique, in which the lens should not change its position in relation to the other components of the anterior pole; this is of particular importance, especially in cases with frail zonulae.

R:

Please note that the rotation of the nucleus, which is free from the cortical-capsular connection, only occurs after the iH has been completed. Since we never rotate the nucleus if any adherence is present, this ensures that we are preventing excessive force on the capsule and zonulae.

Q:

Overall, I believe that my technique is safer, after performing the “one drop staining technique” for the anterior capsule (an original approach) …

R:

Since we have not been able to find and read your cited manuscript or to watch any videos that document your surgical technique, we cannot compare the safety of the two different methods. Once we are able to access this information, we look forward to a discussion on the comparisons between these two techniques.

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