How ironic that 2 articles evaluating tips and bevel-down phaco appeared in the same issue of the journal and arrived at exactly opposite conclusions.1,2 Faramarzi et al.1 compared bevel-up and bevel-down phaco and concluded, “… we do not recommend emulsifying a cataractous lens with the phaco tip in the bevel-down position.” Unfortunately, this study did not select a tip specifically designed for bevel-down phaco.
Kim et al.2 compared 3 tips including the reverse miniflared 30-degree Kelman tip and confirmed the “relative safety of the bevel-down technique” and the advantages of using this tip. I would, however, like to politely correct Kim et al., who state that “the reverse miniflared 30-degree Kelman configuration tip was designed to aid surgeons in positioning their wrist during the bevel-down technique.” Actually, the tip was developed for other reasons as I co-designed this tip with Alcon Laboratories, Inc. (Figure 1).
My original thinking was that reducing the curve on the tip to 12 degrees would combine efficient torsional cutting with better phaco aspiration than the 45-degree tip because the curve of the needle would be 50% less extreme. I also reasoned that a bevel-down tip could be easily buried in the central cortex at the beginning of the phaco procedure when I prefer to use higher power and vacuum. The cornea is better protected when ultrasound energy is directed away from the endothelium and when the ophthalmic viscosurgical device (OVD) cannot find its way into the tip, remaining undisturbed in the anterior chamber.
After a divot or partial-depth groove is made, the bevel is rotated upward, providing an excellent angle for deeper sculpting. The lower vacuum prevents the OVD from being aspirated. The nucleus is divided into hemispheres and chopped, followed by safe removal of the quadrants in the posterior chamber. The bevel faces upward since the slashing motion of the tip should never be perpendicular to the anterior capsule edge.A
In conclusion, the authors of both articles are to be congratulated for bringing attention to tip design. The surgeon should strive to adopt a specific tip and a surgical technique that ensure safe, gentle, and efficient phacoemulsification.
1. Faramarzi A, Javadi MA, Karimian F, Jafarinasab MR, Baradaran-Rafii A, Jafari F, Yaseri M. Corneal endothelial cell loss during phacoemulsification: bevel-up versus bevel-down phaco tip. J Cataract Refract Surg. 2011;37:1971-1976.
2. Kim EK, Jo KJ, Joo C-K. Comparison of tips in coaxial microincision cataract surgery with the bevel-down technique. J Cataract Refract Surg. 2011;37:2028-2033.
OTHER CITED MATERIAL
A. Osher RH, “Evaluating Clinical Benefits of the New Torsional Software in Mini-Flared 12° Reverse Bevel Phaco Tip,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2010