23 Phaco Chop Techniques

23
Phaco Chop Techniques

David F. Chang
CONTENTS
Introduction, 203 Removing the Chopped Fragments, 208
Advantages of Chopping, 203 Comparing Horizontal and Vertical Chop: Which Technique?, 210
Phaco Chop Variations, 205 Diagonal/Vertical Chop for Brunescent Nuclei, 211
Stop and Chop, 205 Comparison of Horizontal and Vertical Choppers, 211
Prechop Techniques, 205 Complications, 212
Horizontal Chop Technique, 206 Summary, 212
Initial Chop, 206 References, 212
KEY POINTS
• Phaco chop reduces ultrasound energy and zonular stress. • Vertical chop uses shearing force to fracture the nucleus.
• Chopping requires bimanual instrumentation, dexterity, and • A central pit or partial trench in the nucleus facilitates vertical
maneuvers. chopping of brunescent nuclei.
• Horizontal chop uses compressive force to fracture the nucleus.
INTRODUCTION ADVANTAGES OF CHOPPING (BOX 23.1)

Modern phaco methods employ lens disassembly to divide the firm Reduction in Ultrasound
nucleus into smaller maneuverable pieces. This strategy permits Pure chopping techniques eliminate lens sculpting as a means to divide
removal of the 10 mm–wide nucleus through a 5 mm diameter capsu- the nucleus into smaller pieces.1 Ultrasound energy is instead reserved
lorrhexis. In addition, most of the nuclear material is emulsified near for the phaco-assisted aspiration of the nuclear fragments. A number of
the center of the pupil and at a safe distance from the iris, posterior studies have documented a significant reduction in ultrasound power,
capsule, and corneal endothelium. time, and energy with chopping compared with divide-and-conquer.2–6
• A continuous curvilinear capsulotomy (CCC) is a prerequisite to This is especially important for brunescent nuclei where the risk of
preserving the bag-like anatomy of the lens capsule. In addition to endothelial cell loss and wound burn is much higher.
securely fixating and centering the intracapsular intraocular lens
(IOL), the continuous edge renders the entire capsular bag much Reduction in Zonular Stress
more resistant to tearing during nuclear disassembly and emulsifi- During sculpting, the capsular bag provides counterfixation and
cation (see Chapter 17). immobilizes the nucleus as the phaco tip cuts the groove. Sculpting
• The “hydro” steps are equally important. a bulky brunescent lens exerts greater stress on the zonules for this
■ Hydrodissection separates the epinucleus from the capsule so reason. Unlike a soft nucleus that absorbs pressure like a pillow, a
that it can spin within the capsular bag. It also loosens the cap- large firm nucleus directly transmits instrument forces, such as those
sular-cortical attachments, which facilitates subsequent cortical used for sculpting, rotation, and cracking directly to the capsular bag
cleanup.
■ The hydrodelineation wave cleaves a thin epinuclear shell apart
from the firm endonucleus. Because the epinucleus is soft, BOX 23.1 Five Advantages of Chopping
it is not divided by nuclear chopping or cracking maneuvers. 1. Reduction in ultrasound energy and time
Aspirating endonuclear fragments is much easier if they sepa- 2. Reduction in stress on the zonules and capsular bag
rate easily from the attached and surrounding epinucleus. The 3. Confining most ultrasound and vacuum-assisted aspiration to the supra-
mass of the epinuclear shell restrains the posterior capsule from capsular plane
trampolining toward the phaco tip as the final endonuclear frag- 4. Decreased reliance on the red reflex because of kinesthetic maneuvers
ments are emulsified (see Chapter 18). 5. Greater reliance on maneuvering the second instrument instead of the
• Nucleofractis methods include divide-and-conquer and the many phaco tip
variations of nuclear chopping, including prechopping.
203
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204 PART IV Nuclear Disassembly
A B
C D
Fig. 23.1 Horizontal chop. (A) Chopper passes beneath the continuous curvilineal capsulotomy
rim to hook the nuclear equator. The initial chop is in the horizontal plane. (B) The chopper moves
directly toward the impaled phaco tip causing compression of nuclear material until a fracture
occurs. (C) A sideways, manual separating motion by the two instrument tips propagates the
fracture through the remaining proximal nucleus. (D) After rotating the nucleus clockwise with
the chopper, the second chop is initiated by repeating these same maneuvers.
and zonules. Lateral displacement of a brunescent nucleus should be centripetally inward and away from the zonules, rather than outward
minimized during sculpting to reduce stress on the zonules. Excessive toward the capsule. This significant difference in zonular stress is read-
nuclear movement can occur if there is inadequate ultrasound power ily appreciated when both chopping and sculpting are compared from
or a sculpting stroke that is too fast or too deep. the Miyake-Apple viewpoint in cadaver eyes.
In contrast, with chopping, the phaco tip braces and immobilizes
the nucleus against the incoming mechanical force of the chopper2 Supracapsular Emulsification
(Figs. 23.1 and 23.2). The manual forces, generated by one instrument Chopping shares many of the same advantages of supracapsular phaco
pushing against the other, replace the need for ultrasound energy to techniques. Virtually all of the emulsification is reserved for phaco-
subdivide the nucleus. In addition, these manual forces are directed assisted aspiration of smaller fragments that have been elevated out of
CHAPTER 23 Phaco Chop Techniques 205
meeting and is a similar technique. Abhay Vasavada published his

“stop, chop, chop, and stuff ” technique in 1996,9 and Steve Arshinoff
published his “phaco slice and separate” method in 1999.10 For simpli-
fication, this author first proposed that all bimanual chopping meth-
ods be conceptually divided into two general categories: horizontal
and vertical chop.1 Both share the universal benefits of being able to
fragment the nucleus manually but accomplish this objective in differ-
ent ways. The classic Nagahara technique is an example of horizontal
chopping because, after the chopper hooks the endonucleus within the
capsular bag, it initially chops centrally toward the fixating phaco tip in
the horizontal plane (see Fig. 23.2). In vertical chopping, the phaco tip
Fig. 23.2 Horizontal chop. As much nucleus as possible is in the deeply impales the central nucleus and the sharp chopper tip presses
path of the horizontal chopper. The chopper tip must be kept downward in the vertical plane during the initial chop (Fig. 23.4).
deep during the chop, and the phaco tip must be impaled deeply
enough.
STOP AND CHOP
the capsular bag. Most of the emulsification is performed centrally in Paul Koch’s stop-and-chop method is a hybrid of divide-and-conquer
the pupillary plane at a safe distance from the posterior capsule and and horizontal chopping.7,12,13
endothelium. The phaco tip does not need to travel outside the cen- • His technique begins with sculpting a traditional deep, central
tral 2 to 3 mm zone of the pupil, which decreases the chance of cut- groove in order to crack the nucleus in half.
ting the iris or capsulorrhexis edge in small pupil cases. In contrast to • One then stops the divide-and-conquer method, and chops the
other supracapsular techniques, there is no need to prolapse and flip hemi-nuclei.1
the entire nucleus. The latter maneuver is riskier with a shallow ante- • Advantages:
rior chamber, zonulopathy, a small diameter CCC, or large brunescent ■ Nucleus is first bisected with sculpting and cracking, rather than
nucleus. with a single chop. In addition to avoiding the difficult first chop,
one chops only across the radius, rather than the full diameter of
Decreased Reliance on the Red Reflex the nucleus.
During sculpting, we judge the depth of the phaco tip by monitor- ■ Unlike with pure “nonstop” chop, the phaco tip can be posi-
ing the increasingly brighter red reflex at the base of the trough. With tioned within the trough up against the side of the hemi-nucleus
phaco chop the maneuvers performed with the chopper are more kin- that is to be cleaved.
esthetic and tactile, and there is no need to visualize the exact depth ■ The presence of the central trench facilitates removal of the
of the phaco tip. This is why chopping is advantageous with a poor first fragment because it is not tightly wedged inside the cap-
or absent red reflex, such as with small pupils and advanced mature sular bag. Although chopping the hemi-nuclei does partially
cataracts. reduce ultrasound energy, the majority of the sculpting required
by divide-and-conquer is used to create the first groove. Thus,
Greater Reliance on the Chopper than the Phaco Tip although stop and chop uses some chopping, it cannot deliver
Compared with the phaco tip, the chopper is much more maneuverable the full benefits that pure horizontal and vertical chopping tech-
and executes the most important movements with chopping. Using a niques can.14
slender and maneuverable chopper, instead of the phaco tip, to manip-
ulate the nucleus lessens the need to use ultrasound and vacuum near
PRECHOP TECHNIQUES
the posterior capsule or close to the edge of the pupil and capsulor-
rhexis. This is particularly advantageous if the nucleus fails to rotate for Among the many chopping variations, Takayuki Akahoshi and Jochen
any reason. Sequential chops can be made without rotating the nucleus Kammann (“Minimal energy chopping has advantages,” Ophthalmology
by simply repositioning the chopper in different equatorial locations Times, 1997) devised techniques for prechopping the nucleus before
and chopping toward the centrally impaled phaco tip. If aspirating an insertion and use of the phaco tip. Prechopping requires additional
intracapsular nuclear fragment with the phaco tip is ineffective, a hori- steps and instrumentation that incorporate the principles of horizontal
zontal chopper can be used to hook the equator and tumble the frag- chopping. In the case of a denser lens, one manual instrument must
ment out of the capsular fornix. generally hook the equator so that the penetrating and chopping forces
These five universal features make chopping an excellent technique are not transmitted directly to the capsular bag and zonules.
for complicated cases that entail greater risk of posterior capsule rup- One potential challenge with prechop techniques is that a certain
ture or corneal decompensation: brunescent nuclei, white cataracts, amount of debris is liberated after the initial chop. Without the phaco
weak zonules, posterior polar cataracts, crowded anterior chambers, tip to aspirate it, this may impair visibility for the subsequent steps.
capsulorrhexis tears, and small pupils. Chopping is also an excellent Another challenge is that most prechop techniques and instrumenta-
routine phaco technique for many of the same reasons. tion are designed to create four nuclear quadrants. Although adequate
for soft and medium nuclei, it is more difficult to create multiple,
smaller pieces with prechopping, as would be desirable for larger and
PHACO CHOP VARIATIONS denser nuclei. Another challenge with using the Akahoshi prechopper
Since Kunihiro Nagahara first introduced the concept of phaco chop is the ability to judge how deeply it has penetrated into a thicker, firm
at the 1993 ASCRS meeting, many different chopping variations have nucleus. Adequate depth is necessary before separation is commenced,
been introduced.7–11 Hideharu Fukasaku introduced his technique of but overpenetration can be risky for the capsular bag.
“phaco snap and split” at the 1995 ASCRS meeting. Vladimir Pfeifer’s The miLOOP (Carl Zeiss) is a retractable nitinol microfilament that
“Phaco Crack” method of chopping was introduced at the 1996 ASCRS functions as an intracapsular nuclear snare15 (Fig. 23.5) (Video 23.1).
A B
Fig. 23.3 Vertical chop. (A) After impaling the center of the nucleus with the phaco tip, the vertical
chopper incises downward into the nucleus just anterior to the phaco tip. (B) A sideways, manual
separating motion by the two instrument tips propagates the fracture through the remaining
nucleus.
needed to remove the nucleus. The denser the nucleus the greater the
potential reduction in ultrasound energy and time afforded by femto-
second laser nucleotomy will be.17 Chapter 26 describes this technology
and method in greater detail.
HORIZONTAL CHOP TECHNIQUE

Horizontal chopping uses compressive force to bisect the nucleus along
the natural fracture plane created by the lamellar orientation of the lens
fibers (see Fig. 23.1) (Video 23.2). The key initial step is to use the chop-
per tip to hook the nuclear equator within the epinuclear space of the
peripheral capsular bag before initiating the horizontally directed chop
Fig. 23.4 Vertical chop. The phaco tip lollipops into the central
(see Fig. 23.2). Whether to first position the chopper or the phaco tip
nucleus and lifts slightly as the vertical chopper tip impales
downward. This shearing action fractures the nucleus. is a matter of personal preference. Because chopper placement is the
most difficult and intimidating step, many transitioning surgeons find
it easier to first position the chopper before impaling the nucleus with
• It is gradually opened beneath the capsulorrhexis rim in the coronal the phaco tip (Fig. 23.6).
plane (see Fig. 23.5A).
• Once fully opened, the nitinol loop is rotated around the nuclear
INITIAL CHOP
equator until it encircles the nucleus along the sagittal plane
(see Fig. 23.5B). • Hydrodelineation is particularly important for horizontal chopping
• Retracting the microfilament into the barrel of the injector shaft because it decreases the diameter of the endonucleus that must be
bisects the nucleus in half. For denser nuclei, a second instru- peripherally hooked and divided by the chopper.2 In addition, the
ment presses against the nasal nuclear pole during loop retrac- separated soft epinucleus provides anatomic working space within
tion to prevent it from rotating anteriorly out of the capsular bag which the horizontal chopper can be placed and maneuvered
(see Fig. 23.5C). peripheral to the endonuclear equator without overly distending or
• Rotating the nucleus 90 degrees and repeating this set of maneu- perforating the peripheral capsular bag. After the endonucleus has
vers creates four quadrants that are then emulsified with the been evacuated, the epinuclear shell can be flipped and aspirated as
phaco tip. Like other methods of manually fragmenting the the final step.11
nucleus, ultrasound power and time are reduced compared with • First aspirate the central anterior cortex and epinucleus with the
divide-and-conquer.16 phaco tip in order to better visualize and estimate the size of the
By precutting and softening the nucleus the femtosecond laser can endonucleus and the amount of separation between the endonu-
also reduce the amount of ultrasound or manual instrument energy cleus and the surrounding capsular bag.
A B
C D
Fig. 23.5 Prechop with miLOOP. (A) Nitinol loop is opened in the coronal plane and beneath
the anterior capsule. (B) The opened loop is swept along the posterior capsule to encircle the
nucleus in the sagittal plane. The posterior-most portion of the loop can be visualized at the right
(arrow). (C) A second instrument provides counter pressure against the nasal nuclear pole as the
nitinol loop is retracted back into the tubular instrument shaft. (D) The linear fracture through the
bisected dense nucleus can be visualized after injected dispersive optical variable device.
• The chopper tip touches the central endonucleus, and maintains vertically downward and positioned as proximally as possible to
contact as it passes peripherally beneath the opposing capsulor- maximize the amount of nucleus located in the path of the chopper2
rhexis edge (see Fig. 23.6B–C). This ensures that the tip stays inside (see Fig. 23.2). If the depth of the phaco tip is too shallow, sufficient
the bag as it descends and hooks the endonucleus peripherally. compression of the central nucleus cannot occur. Once impaled, the
Although some surgeons tilt the chopper tip sideways to reduce phaco tip holds and stabilizes the nucleus with vacuum in foot pedal
its profile as it passes underneath the capsulorrhexis edge, this is position 2. Although not quite as essential for horizontal chopping as
generally not necessary unless the CCC diameter is small or the with vertical chop, high vacuum improves the holding power, which
endonucleus is very large. During this series of maneuvers, the keeps the nucleus from wobbling or spinning during the chop.
elongated horizontal chopper tip can be kept in an upright and • The chopper tip is pulled directly toward the phaco tip; upon
vertical orientation because the capsulorrhexis will stretch like an contact, the two tips move directly apart from each other (see
elastic w
aistband without tearing (see Fig. 23.6B). Fig. 23.6D). This sideways separating motion occurs perpen-
• Once it reaches the epi/endonuclear junction, the chopper tip must dicular to the path of the initial chop, and propagates the fracture
be vertically oriented as it descends into the epinuclear space along- through the remaining nucleus located behind the phaco tip (see
side the edge of the endonucleus (see Fig. 23.6C). If it has not trav- Fig. 23.1C). The denser and bulkier the endonucleus, the further the
eled peripherally enough, lowering the chopper will depress, rather hemi-sections must be separated in order to cleave the posterior-
than hook the nucleus equator. The smaller the endonucleus, the most nuclear attachments. Thanks to the elasticity of the CCC, even
larger the epinucleus, and the easier this step will be. Once in posi- a momentary wide separation of large hemi-nuclei will not tear the
tion, slightly nudging the nucleus with the chopper confirms that capsular bag.
it is alongside the equator and that it is within, rather than out- The ergonomics and tactile feel of the horizontal chop will vary
side the capsular bag. Injecting dispersive OVD beneath the distal significantly as one advances along the nuclear density scale. A soft
CCC edge will improve visualization and expand the space through nucleus has the consistency of soft ice cream. Simply depressing the
which the chopper must pass (see Fig. 23.6A). phaco tip into the nucleus, without either vacuum or ultrasound,
• Next, the phaco tip deeply impales the nucleus just within the tem- can embed it deeply enough. In addition, no resistance is felt as the
poral CCC edge (see Fig. 23.6C). The phaco tip should be directed chopper is moved. With a medium density nucleus, the chopper
A B
C D
Fig. 23.6 Horizontal chop. (A) Dispersive OVD (Viscoat) is injected beneath the nasal anterior cap-
sular rim and into the equator of the capsular bag. (B) The horizontal chopper tip maintains contact
with the anterior endonuclear surface as it passes beneath the anterior capsular rim. (C) After the
chopper tip descends within the epinuclear shell to hook the nasal equator of the endonucleus,
the phaco tip impales the proximal nucleus just within the temporal continuous curvilinear cap-
sulotomy edge. (D) The chopper moves in the horizontal plane toward the phaco tip; sideways
separation of the two instrument tips propagates the fracture until the nucleus has been bisected.
encounters slight resistance as the chopping motion is initiated, which opposite heminucleus is impaled with the phaco tip in a central
indicates that the desired compression is taking place. This resistance location. If there is difficulty in occluding the phaco tip, the bevel
becomes much greater when chopping denser brunescent nuclei. As may need to be aligned parallel to and facing the surface it is about
the chopper drives toward the phaco tip, it feels as though the nucleus to impale. Repeating the same steps of hooking the equator and
is being squeezed in between the two instrument tips (see Fig. 23.2). chopping toward the phaco tip will now create a small, pie-shaped
This is followed by an abrupt snap as the full-thickness split occurs. fragment.
Correspondingly more ultrasound power must be used in order for • The strong holding force afforded by high vacuum facilitates levita-
the phaco tip to be able to impale denser nuclei. Deeper penetration tion of this first piece out of the bag. Insufficient holding force may
can be achieved by retracting the irrigation sleeve further to expose be the result of inadequate vacuum settings or failure to completely
more of the metal tip, and using single burst or pulse mode rather than occlude the phaco tip.
continuous phaco.11 • Each subsequent chop is a repetition of these same steps. Because
of the need to hook the equator during every horizontal chop, it is
advisable to remove each wedge-shaped piece as soon as it is cre-
REMOVING THE CHOPPED FRAGMENTS ated. Once half of the capsular bag is vacated, the phaco tip can
• Upon completion of the initial chop, the nucleus should be com- impale and pull the remaining hemi-nucleus toward the center of
pletely bisected. If not, it can be rotated so that that a second the pupil. This allows the horizontal chopper tip to be positioned
attempt can be made in a new area. The chopper tip rotates the alongside the outer endonuclear edge under direct visualization,
bisected nucleus 30 to 45 degrees in a clockwise direction, and the and without having to pass it beneath the anterior capsule.
• Larger nuclear pieces can be further chopped into smaller frag-

ments. The size of the pieces should be kept proportional to the size Pearls for the Initial Horizontal Chop
of the phaco tip opening. For example, just as one cuts a steak into • Remove the anterior epinucleus centrally before initiating chopping.
smaller portions for a child’s mouth, the nucleus should be chopped • Impale deeply with the phaco tip just within the temporal CCC edge.
into smaller pieces for a smaller diameter 20-G phaco tip. Poor fol- • Keep the chopper tip deep as it moves toward the phaco tip.
lowability and excessive chatter of firm fragments engaged by the • Pull the chopper tip directly toward the phaco tip to maximize c ompressive
phaco tip may indicate that they are too large. force.
A B
C D
E F
G H
Fig. 23.7 (Continued)
I J
Fig. 23.7 Vertical/diagonal chop of a brunescent nucleus. (A) Sculpting nasally creates a half-
trench. (B, C) The nucleus is rotated 180 degrees until the trench beneath the phaco tip. (D) The
phaco tip impales the nasal unsculpted nucleus at the base of the half-trench. (E) The vertical
chopper tip is positioned beneath the trypan blue–stained anterior capsular rim and initiates a
diagonal/vertical chop toward the impaled phaco tip. (F) Sideways separation of the two instru-
ment tips propagates the fracture through the leathery posterior plate peripherally. (G) After the
two instrument tips are repositioned more centrally, repeating the sideways separating motions
extends the fracture through the central posterior plate until the nucleus has been bisected. (H)
After rotating the nucleus slightly counterclockwise, the phaco tip impales one heminucleus; the
second diagonal/vertical chop is initiated. (I) Progressive sideways separation of the two instru-
ment tips propagates the fracture through the leathery posterior plate starting peripherally until
it intersects centrally with the prior fracture. (J) The horizontal chopper abuts the equator of the
large mobile fragment to “subchop” it in half.
• The phaco tip secures its purchase by penetrating deeply into the
Potential Pitfalls During the Initial Horizontal Chop core of the brunescent mass and using high vacuum for holding
• If the phaco tip is too central and shallow, insufficient compressive force power so that the nucleus doesn’t become dislodged. In a brunescent
will be generated. lens, using single bursts of phaco avoids the coring away of material
• Elevating the chopper tip during the initial chop will only score the nuclear around the tip that occurs with continuous ultrasound. The result is
surface. improved purchase and a much better seal around the tip, which is a
• Veering the chopper to the side to avoid contacting the phaco tip reduces prerequisite for attaining and maintaining high vacuum.
compressive force and causes the nucleus to swivel. • In horizontal chop, sequentially removing each newly created frag-
• Make sure the chopper tip remains underneath the edge of the CCC. ment provides the chopper and phaco tip with greater working
• Try to keep the nuclear complex centered during the initial chop to avoid space within the capsular bag. In contrast, vertically chopped pieces
transmission of forces to the zonules. need not be removed until the entire nucleus is fragmented (see
• If a nucleus is too dense, consider converting to an alternate technique Fig. 23.7). This is because the presence of the adjacent interlocking
such as stop and chop. pieces better stabilizes and immobilizes the section being chopped.
In addition, because the vertical chopper is never placed peripheral
to the nucleus equator, vacating space within the capsular bag early
on provides no real advantage. Much like a chisel would be used
Vertical Chop Technique with a block of ice or granite, the vertical chopper tip can be used to
• Whereas the horizontal chopper moves inward from the periphery cleave the nucleus into multiple pieces of variable size.
toward the phaco tip, the vertical chopper is used like a spike or
blade from above to incise downward into the nucleus just anterior
to the centrally impaled phaco tip (see Fig. 23.3A). The sharp verti- COMPARING HORIZONTAL AND VERTICAL CHOP:
cal chopper tip generally stays central to the capsulorrhexis margin.
WHICH TECHNIQUE?
Thus, in contrast to horizontal chopping, it is always visualized and
usually does not pass underneath the anterior capsule or behind It is worth learning and using both variations because the different
the iris. fracturing mechanisms offer complimentary advantages and disadvan-
• The most important step in vertical chop is to bury the phaco tip tages. Vertical chopping requires a nucleus that is brittle enough to be
as deeply into the center of the endonucleus as possible (Fig. 23.7). snapped in half. A lack of firmness explains the difficulty of performing
Depressing the sharp vertical chopper tip downward, while simul- vertical chop or divide-and-conquer techniques in soft nuclei. The abil-
taneously lifting the nucleus slightly upward imparts a shearing ity of the horizontal chopper tip to easily slice through a soft nucleus
force that fractures the nucleus (see Fig. 23.4). This is in contrast to instead of fracturing it makes horizontal chopping an excellent method
the compressive force produced by horizontal chopping. for these cases.
• After initiating a partial thickness split, the embedded instrument Horizontal chop is this author’s preference for weak zonule cases,
tips are used to pry the two hemi-sections apart. Just as with hori- such as with pseudoexfoliation or traumatic zonular dialysis. Because
zontal chopping, this sideways separation of the instrument tips of the inwardly directed, compressive instrument forces, horizontal
extends the fracture deeper and deeper until the remainder of the chop minimizes nuclear movement or tilt. This is invaluable when any
nucleus is cleaved in half (see Fig. 23.3B). nuclear tipping or displacement could shear and dehisce weakened
zonules. Finally, horizontal chop is more effective for subdividing • Rotate the nucleus before repeating the same peripherally initiated
smaller, mobile nuclear fragments, particularly if they are brunescent. diagonal chop (see Fig. 23.7H and I). The nucleus will be completely
Small mobile pieces are hard to fixate adequately for vertical chop- fragmented once the sequential fractures intersect in the center.
ping because there is insufficient mass for the phaco tip to impale. • Partially segmented fragments often remain apically connected by
Attempting to vertically shear such fragments with a chopper will often a central leathery posterior plate. Try to inject a dispersive OVD
dislodge the small piece instead. Trapping and then crushing the frag- through one of the incomplete cracks in the posterior plate to dis-
ment between the horizontal chopper and the phaco tip will immobi- tance it from the posterior capsule. Because a dispersive OVD resists
lize and divide it most effectively. aspiration, the surgeon can attempt to carefully phaco through the
The limitation of horizontal chopping is in its relative inability to remaining connecting bridges that have been viscoelevated away
transect thicker, brunescent nuclei. First, horizontal chopping should from the posterior capsule.
never be used in the absence of an epinuclear shell because there will be • After being elevated out of the capsular bag the brunescent fragments
insufficient space in the peripheral bag to accommodate the chopper. are often still quite sizable. Switch to a horizontal chopper to subdi-
In this situation, forcing the chopper tip into a tightly packed capsular vide mobile brunescent fragments into smaller pieces (see Fig. 23.7J).
bag risks tearing the CCC. Second, the horizontally directed path of the
chopper may not be deep enough to sever the leathery posterior plate
of a rock hard nucleus. Pearls for the Initial Vertical Chop
Because vertical chop is more consistently able to fracture the leathery • Lollipop deeply into the central nucleus with the phaco tip.
posterior plate, it is generally preferable for denser nuclei2 (see Fig. 23.7). • High vacuum provides the stronger grip needed for brunescent nuclei.
After an axe blade is swung into an upright log, it can only penetrate part • Avoid phaco needle motion that will create a cavity (i.e., torsional or
way. Prying the two hemi-sections apart is necessary in order to extend ellipse).
the split through the remainder of the log. The same is true for a brunes- • Lift the nucleus slightly as the vertical chopper incises into it directly in
cent nucleus after an initial horizontal or vertical phaco chop. Once the front of the phaco tip.
partial split is made by the chopper, it is the sideways separation of the • Sculpt a half-trench or central pit to allow the phaco tip to impale more
instrument tips that extends the fracture along the natural lamellar cleav- deeply with a rock hard lens.
age plane through the remainder of the nucleus (see Fig. 23.7E–G). In
horizontal chop, this propagating fracture continues horizontally toward
the surgeon, but it will not tend to advance further and further poste-
riorly. In contrast, with vertical chop, as the two halves are pried apart,
the advancing fracture propagates downward in the vertical plane until it
Potential Pitfalls During the Initial Vertical Chop
• A phaco tip that is too superficial generates insufficient leverage and shear-
eventually transects the posterior-most layer (see Fig. 23.3B).
ing force.
• Creating a cavity surrounding the phaco needle precludes full tip occlusion,
adequate vacuum generation, and “hold.”
DIAGONAL/VERTICAL CHOP FOR
• The sharp chopper tip must be underneath or just within the CCC edge
BRUNESCENT NUCLEI before incising vertically downward into the nucleus.
• Failure to intersect sequential chops through the posterior plate results in
• With an ultrabrunescent lens, slightly alter the angle of the vertical
partially separated fragments that remain connected at their apex, like the
chop. Instead of incising straight down like a karate chop striking a
petals of a flower.
board, the vertical chopper should approach the embedded phaco tip
more diagonally (see Fig. 23.7E). This provides more of a horizontal
vector that pushes the nucleus against the phaco tip, while the vertical
vector initiates the downward fracture. This diagonal chop therefore
combines the mechanical advantages of both strategies. COMPARISON OF HORIZONTAL AND
• Start by sculpting a central deep pit or half of a traditional groove VERTICAL CHOPPERS
before rotating the nucleus 180 degrees18 (see Fig. 23.7A–C). By
starting at the bottom of the pit or groove, the phaco tip can be The wide range of different chopper designs often confuses the tran-
impaled more deeply than would have been possible without this sitioning surgeon. The many variations can be categorized as either
preliminary debulking step (see Fig. 23.7D). Retracting the irriga- horizontal or vertical choppers. Because each works in dissimilar ways,
tion sleeve and using single burst mode further maximizes penetra- their design principles are quite different.
tion of the phaco tip. Horizontal choppers usually feature an elongated, but blunt-ended
• Because of the steep angle of the phaco tip, maximal penetration tip (see Fig. 23.2). A tip length of 1.5 to 2.0 mm is necessary to transect
advances the tip into the peripheral nucleus. Initiating the vertical thicker nuclei, and the inner cutting surface of the tip may sometimes
chop in this thinner region better enables it to transect the pos- be sharpened for this purpose of incising denser lens material. The very
terior-most layer of an ultrabrunescent lens. However, this means end of the tip is always dull to diminish the risk of posterior capsule
that the vertical chopper tip must pass peripherally beneath the perforation. Many horizontal choppers have a simple right-angle tip
capsulorrhexis rim before incising diagonally toward the phaco tip design. However, this shape does not conform as well to the natural,
(see Fig. 23.7E). Because of the poor red reflex, capsular dye aids curved contour of the lens equator and peripheral capsular bag. The
anterior capsule visualization for this purpose. author prefers the curved shape of an elongated microfinger or claw
• After initiating the diagonal chop, the hemi-sections are manually because it can wrap snuggly around the lens equator without distend-
pried apart until the propagating fracture breaks through the leath- ing or stretching the peripheral fornices of the capsular bag.2 The
ery posterior plate in the periphery (see Fig. 23.7F). Each time the microfinger design also allows one to cup the nucleus equator so that it
separating motion is repeated, the chopper tip is repositioned more cannot slip away as the compression begins.
and more centrally. The posterior fissure will steadily unzip toward Vertical choppers feature a shorter tip that has a sharpened point
and across the central pole of the posterior plate (see Fig. 23.7G). or edge in order to penetrate denser nuclei (see Fig. 23.4). If the tip is
too dull, it will tend to displace the nucleus off of the phaco tip rather complimentary advantage of horizontal chop to subchop larger nuclear
than incising into it. In contrast to horizontal choppers, the length of fragments can be combined in the same case.
the vertical chopper tip is shorter because it never encompasses the
nuclear periphery.
REFERENCES
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3. DeBry P, Olson RJ, Crandall AS. Comparison of energy required for
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The side-port incision should always serve as the motionless ful- requirements in phaco chop and divide and conquer nucleofractis
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port incision, somewhat counterintuitive movements must be made 5. Storr-Paulsen A, Norregaard JC, Ahmed S, Storr-Paulsen T, Pedersen TH.
with the horizontal chopper in particular. Assuming a right-handed Endothelial cell damage after cataract surgery: divide-and-conquer versus
surgeon, the chopper should be introduced through a paracentesis phaco-chop technique. J Cataract Refract Surg. 2008;34:996–1000.
6. Park J1, Yum HR, Kim MS, Harrison AR, Kim EC. Comparison of
located 45 degrees to the left of the phaco tip (see Fig. 23.6B).
phaco-chop, divide-and-conquer, and stop-and-chop phaco techniques
in microincision coaxial cataract surgery. J Cataract Refract Surg.
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7. Koch PS, Katzen LE. Stop and chop phacoemulsification. J Cataract
Improper technique can lead to complications with either chopping Refract Surg. 1994;20:566–570.
method. If a firm nucleus is not well supported by the phaco tip, down- 8. Vasavada AR, Desai JP. Stop, chop, chop, and stuff. J Cataract Refract Surg.
ward force from a vertical chopper can push the nucleus against the 1996;22:526–529.
posterior capsule. This can displace the bag enough to rupture the 9. Vasavada AR, Singh R. Step-by-step chop in situ and separation of very
zonules. If one loses track of the CCC location, one could perforate dense cataracts. J Cataract Refract Surg. 1998;24:156–159.
the peripheral anterior capsular rim with the vertical chopper. Finally, 10. Arshinoff SA. Phaco slice and separate. J Cataract Refract Surg.
1999;25:474–478.
excessive surge during removal of the final nuclear fragment or epi-
11. Fine IH, Packer M, Hoffman RS. Use of power modulations in
nucleus could cause forward trampolining of the posterior capsule into
phacoemulsification. Choo-choo chop and flip phacoemulsification. J
the sharp vertical chopper tip. Cataract Refract Surg. 2001;27:188–197.
Likewise, because the horizontal chopper tip is not visualized once 12. Vajpayee RB, Kumar A, Dada T, Titiyal JS, Sharma N, Dada VK. Phaco-
it passes behind the iris, erroneous placement outside of the bag could chop versus stop-and-chop nucleotomy for phacoemulsification. J
occur. If the chop is initiated with the horizontal chopper placed outside Cataract Refract Surg. 2000;26:1638–1641.Can I, Takmaz T, Cakici F,
the capsular bag, a large zonular dialysis will result. Finally, the absence Ozgül M. Comparison of Nagahara phaco-chop and stop-and-chop
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to placing a horizontal chopper tip in the peripheral capsular space. 2004;30:663–668.
Too small of a CCC diameter increases the risk of tearing the con- 13. Pereira AC, Porfírio Jr F, Freitas LL, Belfort Jr. R. Ultrasound energy
and endothelial cell loss with stop-and-chop and nuclear preslice
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14. Park JH, Lee SM, Kwon J-W, et al. Ultrasound energy in phacoemulsification:
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All chopping techniques use manual instrument forces to segment the Surg. 2018;44:932–934.
nucleus, thereby replacing the ultrasound power otherwise needed to 16. Ianchulev T, Chang DF, Koo E. Micro-interventional endocapsular
nucleus disassembly: novel technique and results of first-in-human
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randomized controlled study. Br J Ophthalmol. 2019;103:176–180.
orientation of the lens fibers creates natural fracture planes within the
17. Chen X, Yu Y, Song X, Zhu Y, Wang W, Yao K. Clinical outcomes
hardened nucleus that the chopping maneuver takes advantage of. In of femtosecond laser–assisted cataract surgery versus conventional
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For soft nuclei, horizontal chopping is easier and more effective. For for phacoemsulsification of hard cataracts. J Cataract Refract Surg.
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mentation and fracturing the leathery posterior plate. However, the
CHAPTER 23 Phaco Chop Techniques 212.e1
Video 23.1: Pre-chop using the miLOOP.

This video demonstrates the use of the miLOOP (Carl Zeiss) to pre-
chop the nucleus.
Video 23.2: Phaco Chop Techniques.
This video demonstrates and compares the horizontal, vertical, and
diagonal variations of phaco chop.

23 Phaco Chop Techniques

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Phaco Chop Techniques

INTRODUCTION ADVANTAGES OF CHOPPING (BOX 23.1)

meeting and is a similar technique. Abhay Vasavada published his

HORIZONTAL CHOP TECHNIQUE

• Larger nuclear pieces can be further chopped into smaller frag-

Video 23.1: Pre-chop using the miLOOP.

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