7/7/13 Chopping techniques beneficial for nucleus removal | Ocular Surgery News

Ophthalmology

Chopping techniques beneficial for nucleus removal

This  preferred  method  for  cataract  surgery  requires  technical  skills  but  is  safer  and  more  efficient  than  a  divide-­and-­conquer
approach.
Ocular  Surgery  News  U.S.  Edition,  February  25,  2008
Uday  Devgan,  MD,  FACS

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The  most  efficient  technique  of  nucleus  disassembly  is  a  purely  mechanical  one  in  which  the  nucleus  can  be  chopped  into  segments
within  a  few  seconds.  These  smaller  segments  can  then  be  easily  removed  with  relatively  little  phaco  energy.  Compare  this  with  the
divide-­and-­conquer  technique  in  which  a  tremendous  amount  of  ultrasonic  energy  is  required  to  create  the  grooves  that  are  used  to
create  the  quadrants.  A  simple  analogy  is  splitting  firewood:  A  grooving  technique  is  similar  to  using  a  saw  to  cut  through  the  piece  of
wood,  whereas  a  chop  technique  is  like  using  an  axe  to  chop  and  split  the  firewood  along  the  grain.

The  basic  concept  of  chopping  is  holding  the  nucleus  with  the  phaco  probe  while  the  chopping  instrument  splits  it  into
pieces.  The  most  common  difficulty  that  beginning  surgeons  have  in  chopping  techniques  is  failure  in  adequately  fixating
the  nucleus  so  that  it  can  be  chopped.  If  you  are  going  to  use  a  fork  and  knife  to  cut  a  piece  of  meat,  you  must  first  hold
and  immobilize  the  meat  with  the  fork  so  that  the  knife  can  do  the  cutting.  Similarly,  the  phaco  probe  must  achieve  a  high
enough  vacuum  level  to  firmly  fixate  the  nucleus  so  that  the  chopper  can  do  the  mechanical  splitting  of  the  cataract.

Uday A  high  vacuum  level  is  required  to  achieve  the  holding  power  that  we  desire  for  chopping.  Depending  on  the  phaco  needle
Devgan size  that  you  are  using,  the  vacuum  level  should  be  between  250  mm  Hg  and  400  mm  Hg,  and  if  you  are  using  a
peristaltic  fluid  pump,  remember  that  total  occlusion  of  the  phaco  tip  is  required  to  achieve  the  maximum  preset  vacuum  level.  With
the  vacuum  setting  high,  bury  the  phaco  tip  into  the  nucleus  using  phaco  power  (foot  pedal  position  3),  then  once  you  have  full
occlusion  of  the  tip,  back  off  the  pedal  into  position  2  so  that  the  nucleus  is  being  held  by  the  high  vacuum  level.  Now  the  cataract  is
well-­fixated  and  we  are  ready  to  employ  a  chop  technique.

Horizontal chopping

The  original  technique  of  chopping  described  by  Nagahara  is  a  horizontal  chop  (Figures  1a,  1b  and  1c).  The  phaco  probe  is
embedded  into  the  nucleus  and  the  chopper  is  passed  under  the  capsulorrhexis  and  toward  the  lens  equator.  Once  at  the  lens
equator,  the  chopper  is  brought  toward  the  phaco  tip.  It  is  this  action  of  moving  the  chopper  and  the  phaco  tip  together  that  does  the
chopping.  When  this  is  accomplished,  the  pieces  need  to  be  separated  by  pulling  the  two  instruments  apart.  For  most  surgeons,  this
means  bringing  the  chopper  toward  the  left,  while  the  phaco  probe  is  pushed  toward  the  right.  A  complete  separation  of  the  two
pieces  is  required  for  complete  mobilization  of  the  halves  and  for  further  chopping  into  segments.

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7/7/13 Chopping techniques beneficial for nucleus removal | Ocular Surgery News

Stop  and  chop  technique

(Figures  1a-­1c).  The  phaco
probe  is  embedded  into  the
nucleus  and  the  chopper  is
passed  under  the  capsulorrhexis
and  toward  the  lens  equator.
Once  at  the  lens  equator,  the
chopper  is  brought  toward  the
phaco  tip.  It  is  this  action  of
moving  the  chopper  and  the
phaco  tip  together  that  does  the
chopping.

Images:  Devgan  U

In  a  nucleus  with  more  density, To  minimize  the  stress  on  the

vertical  chopping  is  an  effective capsular  bag,  the  nucleus  can  be
and  safe  technique. tilted  out  of  the  capsular  bag.

Vertical chopping

In  a  nucleus  with  more  density,  vertical  chopping  is  an  effective  and  safe  technique  (Figure  2).  The  phaco  tip  is  embedded  into  the
nucleus  and  a  high  vacuum  level  is  used  to  fixate  it.  The  chopper  is  then  placed  vertically,  into  the  center  of  the  nucleus,  well  within
the  confines  of  the  capsulorrhexis.  Once  the  chopper  and  phaco  tip  are  fully  buried  in  the  center  of  the  nucleus,  the  two  instruments
are  pulled  apart:  the  chopper  to  the  left  and  the  phaco  probe  to  the  right,  thereby  separating  the  two  nuclear  halves.  These  nuclear
halves  can  then  be  further  chopped  into  smaller  segments  and  emulsified.

Tilt and chop

To  minimize  the  stress  on  the  capsular  bag,  which  is  particularly  helpful  in  cases  of  pseudoexfoliation  or  trauma  in  which  there  is
zonular  weakness,  the  nucleus  can  be  tilted  out  of  the  capsular  bag  (Figure  3).  A  relatively  large  capsulorrhexis  of  5  mm  or  more,
combined  with  hydrodissection  or  viscodissection,  will  aid  in  partially  prolapsing  the  nucleus  out  of  the  capsular  bag.  With  the
nucleus  tilted  out  of  the  capsular  bag,  it  is  easy  to  place  the  chopper  around  the  lens  equator  or  even  behind  the  nucleus.  The
chopper  is  brought  toward  the  phaco  tip  and  the  two  instruments  are  pulled  apart  to  create  the  two  nuclear  halves.  The  tilt-­and-­chop
technique  is  my  preferred  technique  for  dense  cataracts  in  which  a  significant  amount  of  force  is  required  to  propagate  the  chop
through  the  nucleus.  By  placing  the  chopper  behind  the  nucleus,  with  the  phaco  probe  in  front  of  it,  I  am  able  to  exert  a  high  degree  of

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7/7/13 Chopping techniques beneficial for nucleus removal | Ocular Surgery News
chopping  force  while  being  gentle  to  the  zonules  and  other  intraocular  structures.

Chopping  techniques  are  quickly  becoming  the  preferred  method  for  cataract  surgery  because  of  the  efficiency  and  safety  that  they
provide.  Although  the  technical  skill  required  for  chopping  is  higher,  the  great  majority  of  ophthalmologists  can  master  it  with
practice.

For more information:

Uday  Devgan,  MD,  FACS,  is  in  private  practice  at  Devgan  Eye  Surgery  in  Los  Angeles,  Beverly  Hills,  and  Newport  Beach,
California.  Dr.  Devgan  is  Chief  of  Ophthalmology  at  Olive  View  UCLA  Medical  Center  and  an  Associate  Clinical  Professor  at  the
Jules  Stein  Eye  Institute  at  the  UCLA  School  of  Medicine.  Dr.  Devgan  can  be  reached  at  11600  Wilshire  Blvd.,  Suite  200,  Los
Angeles,  CA  90025;;  800-­337-­1969;;  fax:  310-­388-­3028;;  e-­mail:  devgan@gmail.com;;  Web  site:  www.DevganEye.com.  Dr.Devgan
is  a  consultant  to  Abbott  Medical  Optics  and  Bausch  &  Lomb,  and  is  a  stockholder  in  Alcon  Laboratories  and  formerly  in
Advanced  Medical  Optics.

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