Lavage of cortical material is greatly facilitated by the bimanual technique. The Duet® 20 G aspiration and irrigation canulas are introduced into the anterior chamber; the aspiration canula is used under the anterior capsulorhexis canopy to aspirate the cortical matter. Gradual step-by-step aspiration of individual fragments is performed progressing along adjacent zones after placing the aspiration probe in an occlusion position, moving the aspirated material towards the centre of the capsular bag.
After having performed lavage of the material on the opposite half to the entry point of the aspiration probe, the surgeon changes hands for manipulating the canulas in order to perform lavage of the material in the other half. Ablation of the material located under the corneal incisions thus no longer poses any onerous problems even with a narrow rhexis.
If the aspiration opening should become stopped up by an epinucleus fragment, the practitioner should use the irrigation probe to reduce the size of the fragment, thus facilitating continuation of the procedure.
The posterior capsule can then easily be polished with a rough-tipped aspiration probe with a low rate of aspiration.
Some practitioners advocate polishing the posterior face of the remaining anterior capsule in order to delay secondary posterior capsule opacification. In fact this manoeuvre appears not to bring about proven benefits, and can even lead to certain complications such as small zonular disinsertions in cases of excessive aspiration.
Following implantation within the bag, the irrigation aspiration of the viscoelastic agent is performed behind the implant while lifting the optics with the irrigation probe by sliding the aspiration probe opening upwards under it.
The procedure ends with the ablation of the intracameral viscous substance. Preserving the microincisions will enable effective ablation of the viscoelastic substance under the implant and in the anterior chamber while maintaining a closed eyeball through the end of the procedure. It should always be kept in mind that the aspiration probe should be withdrawn from the anterior chamber before the irrigation probe.
A collapse of the anterior chamber causes endothelial and posterior capsule rupture lesions. This can occur with incisions that are too wide and cause undesirable leaks, or because of an acute turn or kink in highly flexible tubing. It is therefore necessary to use instruments appropriate for the size of the incision from one end of the other of the procedure, relatively rigid anticollapse tubules, and the continuous infusion mode on the phacoemulsifier.
A hernia of the iris can occur with incisions that are too short or too wide, because of the significant irrigation pressure necessary to perform bimanual phaco. Reintegration often takes place at the end of the procedure, using viscoelastic agent, and only exceptionally requires peripheral iridectomy.
