EyeWorld Asia-Pacific December 2016 Issue

33 EWAP CATARACT/IOL December 2016 Dr. Chang pointed out the “golden ring”, the limit of the endonucleus, and said this is where the chopper should go. Dr. Chang said for those starting with phaco chop, it’s easier to put the chopper in first, followed by the phaco tip, putting as much nucleus between the chopper and the phaco tip as possible. Source (both): David F. Chang, MD by Liz Hillman EyeWorld Staff Writer Moving from divide and conquer to phaco ASCRS webinar offered pearls on this transition for young eye surgeons T he transition from divide and conquer to phaco chop has several considerations, and a recent ASCRS webinar, specifically geared toward young eye surgeons (YES), had an expert panel to offer pearls on the topic. “Phaco FUN: How to Make Your Machine Work For You” continued the story of Theresa, a fictitious third-year resident who, as Zachary Zavodni, MD , The Eye Institute of Utah, Salt Lake City, put it, had already seen a “rather adventurous series of cases so far” that have been used as teaching moments in previous YES webinars. In this webinar, Theresa was embarking on her seventh case and was ready to start the stepwise transition to phaco chop. These steps, according to the presentation, include: • Practice using the chopper as a second instrument • Practice getting pieces out of the bag with the chopper • Chop pieces in the pupillary/ anterior chamber plane • Chop the second heminucleus • Stop and chop • Trench and chop. Thomas Oetting, MD , ophthalmology residency program director, University of Iowa Carver College of Medicine, Iowa City, Iowa, said, “Going to chop after only seven cases seems fast. Our residents might spend upward of 100 cases going through this stepwise transition from divide and conquer to phaco chop.” David F. Chang, MD , clinical professor, University of California, San Francisco, said that when transitioning from divide and conquer to chopping, it is helpful to isolate and learn some of the component skills one at a time. “When you eliminate all sculpting with ‘nonstop’ intracapsular chopping, the most difficult step is that initial chop that bisects the unsculpted nucleus. And with horizontal chop, the most difficult pieshaped fragment to remove is the first one. As more space is created within the capsular bag, it becomes progressively easier to chop, mobilize, and remove the remaining nucleus,” he said. For this reason, Dr. Chang advocates learning the component steps of chopping in reverse while performing divide and conquer, so that you start with the easiest maneuvers first. “The chopper is a lot larger than the typical second instrument, so using it as a second instrument for divide and conquer is a good way to get familiar with it,” he recommended. “Then, after you’ve sculpted and cracked the nucleus into four quadrants, instead of immediately emulsifying a mobile quadrant or heminucleus, hold it centrally and slip the horizontal chopper around the equator,” Dr. Chang said. “This lets you visualize, perform and understand the 3-D anatomy of chopping without having the iris or anterior capsule in the way.” Another exercise is to slip the horizontal chopper around the equator of intracapsular divided quadrants. “Use the chopper to tumble quadrants out of the bag, instead of aspirating them with the phaco tip, so that you have the feeling of hooking and cradling the nuclear equator with the horizontal chopper tip while it is in the capsular bag.” “Next, use stop and chop to transition to intracapsular chopping … you’ve already cracked the trenched nucleus in half so you only have to chop the radius of the nucleus rather than the full diameter. Because you’ve sculpted that little trench, it automatically gets you to position your phaco tip at a much deeper level than with an unsculpted, untrenched nucleus,” Dr. Chang said. “Finally, stop and chop is the first time that you’re actually placing the horizontal chopper peripherally under the anterior capsular rim, hooking the equator of the nucleus, turning the chopper tip so that it’s vertically oriented, and then chopping directly toward the phaco tip, which is your chopping board,” he continued. “The key is keeping both your chopper and your phaco tip deep, and to have as much nucleus in the path of the horizontal chopper as possible.” Once adept with this, the surgeon can transition to “non- stop” chopping by eliminating the sculpting and initial trench. continued on page 37