I have been using co-axial since residency. I find it to be quick and efficient. I have heard of the benefits of bimanual, but I don’t think it would make much of a difference in my results, as my astigmatism now is close to 0.25 anyway. Perhaps in cases like very shallow chambers or vitreous loss, bimanual may have a slight edge- fortunately, those situations don’t come up too often. I guess high volume surgeons who do see more challenging cases may see the benefit.

The debate over bimanual vs. coaxial has played itself out in journals and presentations.

As per the Ophthalmology Times, at a presentation last September, Dr. Jorge Alio told delegates that “[b]imanual microincision cataract surgery (MICS) and microaxial phacolemulsification provide optically better incisions but bimanual MICS respects more corneal prolateness than microaxial phaco . . . MICS is associated with less corneal oedema in the short term and less inducation of corneal aberrations in the long term.”

Dr Graham Barrett, defending coaxial phaco, disagreed, stating that equipment he developed enabled a technique he called coaxial MICS, which he termed C-MICS. He said that bimanual phaco suffered from compromised fluidics. Moreover, he said that astigmatism didn’t differ significantly between bimanual MICS and his C-MICS technique. Read more ^[1] on the pros and cons of coaxial versus bimanual phaco identified by Drs. Alio and Barrett.

There was also a September 2007 article in Ophthalmology Times Europe on the subject entitled “Head-to-head: bimanual vs microincision coaxial phaco.”  The article reported that

“Many researchers have reported the advantages of bimanual phaco to include less surgically-induced astigmatism, increased followability of nuclear fragments and the added flexibility of using two incisions, allowing differing angles for the surgical approach, whilst disadvantages include anterior chamber instability, potential wound trauma and lower vacuum levels. With regards to microcoaxial phaco, less endothelial cell loss and less Descemet’s membrane trauma have been reported, however, the disadvantages of the technique have been found to be similar to those encountered in standard coaxial phaco, such as, difficulty in removing the sub-incisional cortex and decreased followability, as irrigation may push nuclear fragments away from the phaco tip.”

See further details here ^[2].

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