I was a prelaunch evaluator of the INTREPID Transformer I/A Handpiece (Alcon). As a surgeon who prefers coaxial technique, I was concerned that this new handpiece would not perform as well as a traditional coaxial I/A handpiece and that combining coaxial and bimanual modes in one handpiece would somehow affect its functionality. I was pleasantly surprised.
From my first case, I found that I did not have to compromise my maneuverability and effectiveness in coaxial mode. Furthermore, switching from coaxial to bimanual technique is seamless (Figure 1). By simply twisting the proximal and distal portions of the handpiece in opposite directions, I can separate the aspirating portion from the irrigating portion to allow transformation to a traditional bimanual I/A system. There is no need to open an additional I/A pack or change cassette tubing. In addition, you may not need to change machine parameters.
Figure 1. Lawrence Woodard, MD, holds the Transformer I/A Handpiece in coaxial mode (A), then twists to remove the aspirator from the handpiece (B) to use in bimanual mode (C).
Since those initial cases, I have used the Transformer I/A Handpiece for about 300 cataract surgeries, employing bimanual technique in approximately one-third of them. In my hands, the Transformer I/A Handpiece functions identically to a traditional coaxial I/A handpiece. Being able to switch from coaxial to bimanual mode and back again during a single surgery is a great function of this handpiece, particularly for difficult subincisional cortex removal. The polymer tip is capsule-friendly and the conical design allows for easy access under the anterior capsule.
In this article, I describe some specific scenarios that underscore the benefits of using the Transformer I/A Handpiece.
Minimize Corneal Distortion
One of the reasons I have rarely performed bimanual surgery over the years is because my primary cataract incision is too large for a traditional bimanual handpiece. Consequently, I have to create another sideport incision for the bimanual handpiece or place a suture in the main incision and enter through that, a maneuver I would rather avoid.
What I love about the Transformer I/A Handpiece is that I can use my primary incision for irrigation, while my secondary incision accommodates the aspirating portion of the handpiece without the need for an additional incision. This technique obviates the need for a suture in the primary incision to ensure proper sealing. Additionally, not creating a third incision minimizes the opportunity for corneal distortion. The more incisions we create, the more likely we are to induce astigmatism, which will affect the accuracy of the measurements we obtain with intraoperative aberrometry. Minimizing the need for additional incisions and the resultant increase in surgically induced astigmatism helps us achieve more predictable outcomes.
Capsule- and IOL-friendly Polymer Tip
In my experience, the single-use polymer tip of the Transformer I/A Handpiece is definitely more capsule-friendly compared with traditional metal I/A tips, which may develop tiny burs or irregularities after frequent use and sterilization.
I find that the Transformer I/A Handpiece polymer tip is also more IOL friendly. For example, when a surgeon attempts to remove ophthalmic viscosurgical device from beneath a lens, the lens may be drawn toward the aspirating port, and a metal I/A tip may scratch it. Any imperfections on a lens affect how light passes through it. A multifocal IOL already disperses light more than a traditional IOL, and imperfections will adversely affect the quality of the patient’s vision. Depending on the size and location of the scratch, the surgeon may need to replace the lens, which is a delicate maneuver that prolongs the surgery and increases the chances for complications. On the other hand, the polymer tip of the Transformer I/A Handpiece protects the IOL and prevents scratches.
Avoid Posterior Capsule Opacification and Capsule Contraction
As patients increasingly choose advanced technology IOLs, surgeons must take every precaution to meet their expectations. For example, I remove anterior lens epithelial cells before IOL implantation on every case to help minimize the risk of anterior capsular contraction and posterior capsule opacification, which necessitates a posterior capsulotomy with an Nd:YAG laser after surgery.
Although not a common occurrence, anterior capsule phimosis due to excessive overgrowth of lens epithelial cells may cause a lens to decenter, which will degrade vision through a toric or a multifocal IOL. In my experience, thoroughly removing as many cells as possible decreases the likelihood of this complication. Because the tip of the aspirating port on the Transformer I/A Handpiece is much smaller and easier to maneuver under the anterior capsule than a traditional coaxial port, lens epithelial removal may be performed more completely in bimanual cases.
Femtosecond Conundrum
Cortex removal is more challenging in a femtosecond laser case compared to a manual phacoemulsification case. During a standard phacoemulsification procedure, after the nucleus has been extracted, the small stringy fragments of cortex that remain are floating inside or central to the capsule, so they are easily purchased by the Transformer I/A Handpiece tip and removed.
On the other hand, the femtosecond laser cuts many of those little fingers or projections, so that the surgeon must use the Transformer I/A Handpiece tip to go under the anterior capsule and purchase the cortex. This makes cortical removal more challenging, particularly when attempting to remove subincisional cortex. In these cases, bimanual technique facilitates cortex removal, because the aspirating portion of the bimanual tip is much smaller than a standard coaxial I/A tip and easier to maneuver under the capsule to remove the remaining cortical material.
Summary
The INTREPID Transformer I/A Handpiece is an excellent addition to our armamentarium of handpieces for cataract surgery. It allows for a seamless transition between coaxial and bimanual irrigation and aspiration without any loss in functionality of either. In addition, I feel it enables easier removal of subincisional cortical material and anterior capsule lens epithelial cells, which facilitate a better overall procedure.
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