Bimanual irrigation / aspiration can be helpful to access a full 360 degrees of cortex, keep the anterior chamber maintained, and allow separation of the inflow and outflow in cases where the posterior capsule is open.
This brief video shows how we use two different set-ups for bimanual I/A during a complicated case. In this surgery, the posterior capsule has been ruptured and we want to avoid vitreous prolapse. The key is to keep the anterior chamber deep and pressurized and the bimanual I/A system facilitates this.
For cortex removal, we use the transformer I/A tip which permits infusion via the traditional phaco incision (of 2.2, 2.4, or 2.8 mm) while the small gauge aspiration tip is placed via the paracentesis. A second paracentesis can be made, as shown in this case, to allow more complete access to the undersurface of the anterior capsule.
At the end of the case, with a sulcus IOL securely placed, we need to remove the viscoelastic from the anterior chamber while keeping it inflated and pressurized. In this situation, we suture the main incision closed with 10-0 nylon, then we prepare for bimanual I/A via the two smaller paracentesis ports. Many surgeons use dedicated instruments for bimanual I/A, having both a 23 gauge infusion instrument and a 23 gauge aspiration instrument. But we don’t have that readily available in this case, so what should we do?
We asked the anesthesiologist for a sterile IV set-up which is used for giving intra-venous medications. We remove the needle from this and discard it because all we want is the plastic tip. This is connected directly to the infusion line of the phaco tubing and we can now proceed with bimanual I/A to remove the viscoelastic.
Click below to learn about these two methods of bimanual irrigation / aspiration: