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Small-sleeve phaco technique allows 6-mm IOL through sub-2-mm incision
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CHICAGO — A phaco technique using a small coaxial irrigation sleeve, torsional ultrasound and a new IOL inserter allows the implantation of a standard 6-mm IOL through a sub-2-mm incision, according to a presentation here
Takayuki Akahoshi, MD, described his technique at a symposium sponsored by ASICO held here during the American Academy of Ophthalmology meeting.
Dr. Akahoshi said his coaxial phaco technique employs the Alcon Nano Sleeve, a small-diameter sleeve that provides sufficient irrigation and appropriate wound protection, and the new ASICO Royale II injector.
He said he prefers a coaxial approach to ultrasmall-incision surgery, rather than a bimanual technique, for several reasons.
"We can use conventional tools and conventional technique," with a coaxial approach, he said. "With bimanual incision you have to make the third incision just for implanting the lens if the incision was damaged. This is not reasonable."
Dr. Akahoshi uses the Akahoshi Ultra diamond knife to make the sub-2-mm main incision, and he makes the side-port incision as small as possible using the Akahoshi Sideport diamond knife. Both knives are made by ASICO.
To allow more irrigation fluid into the anterior chamber, he makes an additional hole himself on the Nano Sleeve, he said.
“The additional hole in the posterior side of the tip pushes away the capsule and reduces the chance of capsule rupture,” Dr. Akahoshi said in an interview with Ocular Surgery News.
“I try to remove the cataract with minimum damage to the incision. This is critical” to protecting the structure of the incision," he said during the interview.
Dr. Akahoshi said he uses the ASICO Hybrid Combo Prechopper to prechop grade 1 and 2 nuclei prior to phacoemulsification. He uses a karate-prechop technique to slice the nucleus in half, rotates the lens and divides it in half again to create four quadrants that are easy to remove.
"The divide-and-conquer method is not suggested because it can damage the incision opening," he said.
If the nucleus is a grade 3 or higher, Dr. Akahoshi supports the nucleus with a Nucleus Sustainer through the side port to protect the ciliary zonules and capsular bag.
Dr. Akahoshi uses the Alcon OZil torsional utrasound handpiece for phacoemulsification in custom burst mode on the Alcon Infiniti Vision System. Dr. Akahoshi explained that with a conventional handpiece the tip moves in and out, but with torsional ultrasound it swings back and forth. The OZil handpiece is capable of both movements, he said.
It is important to use a bent tip when using torsional ultrasound, Dr. Akahoshi said during the symposium. The 1.1 mm standard Akahoshi tip is commercially available from Alcon, but a straight tip can also be altered, he said.
"You can make your own Akahoshi tipby bending it with needle-nose pliers," he said. "If you bend too much, the tip may be broken. This is a small modification on the torsional handpiece."
Dr. Akahoshi said he has implanted more than 4,000 of the 6 mm AcrySof IOL through sub-2-mm incisions using his counter-traction technique.
He uses the new ASICO Royale II injector, placing the lens into an Alcon Monarch C-cartridge manually, making sure he inserts the IOL so that the leading haptic bends and creates an elbow.
"The elbow is key," he said.
He inserts only the tip of the cartirdge into the sub-2-mm incision and allows the sharply bent haptic elbow to enter into the incision. It is also necessary to have a firm eye, or the IOL will not inject into the chamber, he said.
The IOL unfolds in a controlled fashion, and the wound is self-sealing, Dr. Akahoshi said.