The Choo-Choo Chop and Flip Phacoemulsification Technique L. Howard Fine, MD {ine choo-chco chop and ip shacoomulscaton i a chopping technigue thal uses power modulations and high vacuum lens ‘win specie maneurars 19 maze the mount uvasoune ‘enoayin he eo andmaniize salety and conta, [Copyigt 1988.7 We, Saunders Company his technique i designed Wo take maenum advantage af argh ae technologies awsble Ubaugh the lean 20,000 Legacy (Aleon Surgical Ine, Fu Worth, TX) ae the ‘AMO Diploma? (Allergun Medical Optics, levine, CA) Phueo- Cmlefieation Systems, These technologes Inlude High- ‘rium eseetice an tubing, mull programe features fon both eysens, ae well asthe Nlackeol Mlezup (Alcon Sorgesl ine) withthe Legiy and burst mode and occlsion ‘mode capabiives withthe Diploasx Table 1. The result is tenhncedeflcieney,conra, alse The procedure is done follows A silepor incision is made to che left sith x tom slated diamond lie, aller which the antetiorehambor i Uergied with 0 mL preseratve-toe xglocaie. Using the softshell weehnlque descnbed by Steve Arshinol, Vscoat (Ales Suga! ne) placed ita the anterior chamber angle {ital oe ie pon, through the sie-por ison ils he sntrio chamber but allows the eye 16 remain relaivey sof. Prowse (Alcon Surgia nc) is inslled on top ofthe center of the ln eapsle undo the Visco Prove forees the Viscoat ‘ap against the come, cceating a soft skell which helps Snilze the anterior chamber and protect the endotheiem Addieonally Prove, which & s cohesive vscoelase, de ‘eases any tendency for irs prolapse during the hye steps [ter clear comes! ncsion, onal elenving hydracieecon ts perform inthe wo distal qadeans followed by hydode lineation, After the two hydro steps, the nucleus should oie ‘ally within the expla bag, The ackoolKelatan miroup fon the Legacy fs inioduced bevel down so aspirate the tplicleus tncovered by the capsulorheris, snd is then turned Bove up. With s Diplomx syster, a 30" standard bevel dow lip is sed throughout endonuclear removal. The Fine? ‘Nagahaei chopper (Rhein Medica, Tampa FL placed in the olden sing ane used vo sablze the cleus by ung and Paling town the inion alighly (Pig 1, after whieh the Dphaca tip lolipaps the micless i citer pulse mode at 2 Poleeseceond (Legacy) or Somsee burst made (Diplomas) ‘wich the mere etn this way we uinnize aleasoured energy Ivo the ys til inanimize ovr hold om the mceus a the Fron Organ Has Saas Unvary, Partand adite Orage Bye rte Eee 0%, ‘dee sp requeto Howard Pe, 1D, 1590 Cae 5 Ste 5, fagpan om 700 “Soprghte tendty We Saunco Company road eaves ovens 000 Coma Tacs Cataract and RebacBv Se: V3, Ne BG) 88: pe ETS acum builds beeen ples or burs, Because of the Aeeiesse in caviuional enegy around the up av thi ow pulse rate or in burst mvt, sh rane in the aces which the tipi embedded fie the needle very righily and gives ws an ‘exeelen hol! on the moceus, hus mizing enue of the hele as we coc and chop it Fig. 2 tn fot position 2 ‘The FineNagshars chop instrament is grooved on che borionia am close to the vercl “shop” clement withthe gr0nve parle ose direction af the sharp edge ofthe verse tlement im scoring the nueleus, the instrament is always moved to the direction the sharp edge ofthe wedge-shaped ‘ere elements facing (as tndested by the graove on the Insrument), thus faeiiatng scoring. The nucleus is scored by ringing the chop instrumentio the sid ofthe phaco need, I ‘chopped in hall by pulling the chopper tobe lt and slightly ddovn wile moving the phaco needle sil foot poston 2, 10 {he igh and slighty up. Then dhe mclear complex s route. ‘Thechop instruments gain brought nto the golden ing (Fg and the nuclews ie aesnllipopped, scored, and chopped ‘wih the resulting pe-haped segment now llipopped um the aco tip (Fig 4) The segment Is then evacuated, using high Yacuun and shoct bursts or ple snode phaco at 2 pulse! second (Fig 3). The nucleus is continually coated $0 that Peshsped segments cn be score, chopped, and removed ‘ssentally by the high vacoumn assed by shor bursts or ples of peo, The short burst or pulser of altasouod ‘ergy ontinuously reshape the pieshaped seginent that te hep at the tip allowing for occlusion and exiracion by tbe vast. The sae ofthe pieshapod segments customized re the density of he nucleus, wih smaller segments for denser ‘nce. Phacy in rst made ora this Yow pulse rate sounds like “choo-ehoc-dheo-choo" ergo che name of his ecnigue ‘With bars mode or the Ibs pulse rat, the woclest mate tends to stay a1 the Up rather than chatter as vacuum holds between pees. The chop insrumenc is wsed 10 stall the seinen into the ipo Keep it doe in the nucle shel ‘Alter evacuation of the Mist heml-ueleus, the second bem-ucles coated othe dal prion ofthe bag. andthe chop insrumentsabilzes ic while Is llipepped Ts then Scored (Fig 6) snd chopped. The ple-shaped sepments can be chopped a second tne to reduce thei size (Fig 7) a they pete to large to ely evacuate These Is litle tendency for niclear materi to come up ite the anterior chamber with thle echruque- Usually a siays Gown within the eptnclar shell, but the postion of the tendonuciear material can be coatolled by che chop instru: tment. After evacaton ofl cadonudene uteri the Diple- tna ip i trmed bevel yp) (Fg 8), the epinelear ry ts immed Ay each of dhe thee quadrans, nobly cortex a ‘tell nthe fllowing wey. s exch quadrant of the epaalear ‘inte the cortex theadce eapsulr Fors flows ‘er ehe Maer ofthe eples and ito dhe placa tip. Then 61RSL, Fos Pca I ana RST a Power Gi) oo s ‘Sug as aoe Be Se z a = 7 E. = Fame Heme orm Bin Bi Eoten x 7 e z Hetinc!Ghap are Flip Bee T&A Central SER oe 3 % See Re, a = zs 3 eas = et, 2 7 = Bion eine, Emon : g = & rules fof the four quadrants of rim and orniceal cortex hve been evaciaed. 11 important Bot to allow the epi nucleus to flip too esr thus avoiding 2 lege amount of ‘sido ones remaining alter evacuation of heepinoceus The epinuckar cm of the Forth quadean is then weed 95 banal tn Mp the epics (ig) Ashe remaining portion ‘le epnuelesr no arin evacuated fom the eye, 80% {0008 othe ine allot cortex in eracaated witht (Fg 10 ‘Gonuuing withthe softshell vechague, the eapsular bagi filled wth Prove and West since ini he centr ofthe tipsilarbog wo help stabilize the anesor chambered to Blut the movement ofthe foldable 1OL a5 uw implanted ito he ye Il the contex wis meampleely mablized during ept ow of he nutes ing Lolipopplng for Figure 1. Stabil the inal chp. to viseodisest the corte into the eapaular fornix and drape ome of ton top ofthe capsulobests (ig and 12)-Provis {Shen Injected ino the Bio ofthe bg, forcing the Visca snerirly. The foldable iteaaula Tense UOL} Is then i phate. vid conex evacuated with residual viscoelastic, che posterior capsule being protected by the opuc of the 1OL. Mobilzvion of Viecom is grealy factated becsuse ie feneased within the much inove highly cohesive Provise ad less ime is necessary to evacuate reside) viscoelastic “The chow-choo chop an lip technique uses te se hyo(CH0-CHOO GHOR AND FLIP PHACOEMULSIFCATION 63 Figure3. Stabieaion of the nucleus Before commencing the second chop. Figure. Mobilization of the ist ple-shape segment. r ciara \ \ yA \ ceguent adherent to she peo ip afer ond chop,Figure 7. Mobilizing the final quadant pty eapoular bog afer Ripping of the «ptFigure 11, Viscodissecion of residual cortex before 1OL, ‘implantation forces ry dleaserble the nucleus but subssntes mechanical vf energy (gooving) to further sum is sed a am extractive tesnique to remove niles than sing ele sound ensigy to convert the neous to emulate thet Is ‘evacuated by aspirin, This ochnique manmizes safety and ‘ont aswell asefcencyinall cases, andallon for phsco of hander cle! in the presence ola compromised endothllun, This technique facies the acevement of evo goals: 65 Figure 12, Viscodiscection of residual cortex before 101, srapaneaion, nally jovasive catatact surgery ane maximally capi visu rehabilitation References 1 Free Chae oo ang tacoma. Pa 12 Mowat 'S, Thetikaon A: Tha OMB Ciplomax ia endoentclar ‘harsernstran inne ads Presoemcsen Naw Tex ‘zy Gieal sociation Tore Ni Since 1998, S720