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We appreciate the commendable work by Kageyama et al, which was published in the BJO.1 We have also studied the results of left handed non-dominant hand phacoemulsification prospectively, performed in left eyes of 29 patients with an immature senile cataract and against the rule astigmatism. Phacoemulsification was performed by an experienced surgeon (RBV) under peribulbar anaesthesia. The surgeon sat at the head end of the patient while performing these operations (on left eyes). In all the cases, a 3.2 mm clear corneal temporal incision was made with a diamond knife held in the left hand of the surgeon. Following a continuous curvilinear capsulorhexis and hydroprocedures a phaco chop nucleotomy technique was done using Storz Protégé phaco machine. The chopper was held in the right hand of the surgeon and inserted from the 12 o’clock side port and the phaco probe was held in the left hand of the surgeon and introduced from the main incision on the temporal side. This was followed by automated irrigation aspiration and implantation of an Acrysof foldable intraocular lens (Alcon MA 60 BA) in the capsular bag.
In our study of 29 patients the mean age of the patients was slightly younger, 63.50 (SD 9.61) years (range 43–80 years), than patients of Kageyama et al. Out of 29 eyes, nucleus hardness was grade 3 or more in 17 eyes in our series. It would be worthwhile to know the nuclear hardness in the series reported by Kageyama et al as the manoeuvres in hard cataract may be more difficult to perform with the non-dominant hand.
The mean ultrasound power used in our cases was 25.7% (9.5%) and the mean effective phacoemulsification time was 18 (11) seconds. No posterior capsular tear or vitreous loss was present in our cases and this could be attributed to the fact that an experienced surgeon performed the surgery. However, were there any anterior capsular tears noted by Kageyama et al, which occurred in two eyes in our series during the chopping procedure? Nevertheless, none of these cases had a posterior extension of the tear with vitreous loss. Twenty seven eyes (93.1%) achieved a best corrected visual acuity of 20/20 at 4 weeks after the surgery, while two eyes had a best corrected visual acuity of 20/40 because of the presence of age related macular degeneration. It would be also worthwhile to know the amount of astigmatism preoperatively and postoperatively reported by Kageyama et al, as one of the advantages of a temporal incision phaco is less surgically induced astigmatism.2 The mean preoperative keratometric ATR astigmatism was 0.54 (0.44) D (range 0.25 to 2 D) and the mean postoperative ATR astigmatism was 0.25 (0.64) D (range −0.75 to 1.75D) (Wilcoxon signed rank test, p = 0.0267) in our series. We had a similar mean endothelial loss of 6.02% at the end of 12 weeks.
Clear corneal non-dominant hand phacoemulsification is indeed a safe and efficacious method. This obviates the need for a surgeon to change position between cases. In addition, the dominant hand is utilised for chopping, which makes the chopper the most active instrument, while the non-dominant hand holds the ultrasound hand piece as a passive instrument in the centre of the capsular bag. This helps to reduce the use of ultrasound energy for nuclear management, as the chopper is the primary instrument used for mechanical disintegration of the nucleus.