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For Now, I'll Keep My Phaco Sleeve

I have been vexed and perplexed by my failure to understand a trend that seems to be catching some steam. The gist of my confusion is this: Why, oh why, do so many of my friends tell me that they prefer bimanual microincision phacoemulsification? In this issue, in fact, we have an article about the virtues of the technique. It is good that we present reliable information on all emerging surgical approaches, but I'm still perplexed.

One argument given to me is that "The chamber is maintained better," over which I ponder "Better that what?" Right now I use a tight incision around a flexible sleeve, raise my bottle up as high as it will go, and I have a rock steady anterior chamber. They operate without the sleeve, have some leakage around the tip, and claim a better chamber. "Curious," I think.

"Be sure to use lower vacuum settings because the inflow is reduced," I am advised. That doesn't seem like progress. I thought we were trying to increase our vacuum settings. Puzzled I remain.

"Smaller incisions," I am told. Bimanual phaco only requires two 1.4-mm incisions, and then a 2.8-mm incision for the implant for a total of 5.6 mm of corneal cutting. I use a single 0.8-mm incision and the 2.8-mm incision, for a total of 3.6 mm, less than two-thirds what they use. "What the ... ?" I mumble.

"Better control," they say, because the manipulator also irrigates. Maybe they're right, but I don't see how it should make much of a difference. I do remember to keep the irrigator in the eye at all times when I try bimanual, but it is not natural to me. I can do it, though. I'm not completely inflexible.

"Bimanual is a bit slower," my friends tell me, but it is worth the extra time. I wonder how that worth is measured. How do you calculate value when the surgeon is less productive and the patient has a longer operation?

What's the Rush to Bimanual?

We've spent so many years developing efficient and effective techniques for removing cataracts that I wonder why suddenly we have a pressing need to shift to an operation that cannot improve over my stable anterior chamber, requires lower vacuum settings, uses more and longer incisions, is uncomfortable, and slows me down. Am I missing something? Has progress passed me by, or am I witnessing novelty born of boredom? Perhaps one day I will discover that I have missed the train and need to catch up. Until then, I'll keep my silicone sleeve.