EyeWorld Asia-Pacific June 2016 Issue

June 2016 20 EWAP FEATURE How are we performing nucleus division during cataract surgery? by Mitchell Gossman, MD C ontinuing the discussion of the methods ophthalmologists use for cataract surgery, how are we performing division of the nucleus for phacoemulsification? We have many goals for this process, some of them contradictory: • Lower phaco energy to help maintain a clear postoperative cornea • Phaco energy dissipated farther from the corneal endothelium • Phaco performed far from the posterior capsule in order to avoid capsule rupture during phaco • Speed • Rapid learning curve • Inexpensive • Usable on all densities of cataracts Hundreds of articles and book chapters exist on the many methods, but what are we actually doing? A survey was performed of 97 practicing ophthalmologists who volunteered to participate from the ranks of participants of the eyeCONNECTIONS online community and volunteers around the U.S. Responses are anonymous in order to encourage candor. The first question was, “Is the femtosecond laser your preferred method to disassemble the nucleus during cataract surgery?” Yes 13% No 87% Reasons given for preferring femto were safety, efficiency, and less phaco power required. One respondent pointed out that while most of the time the femto procedure makes separation of fragments somewhat easier, one still has to divide and conquer or chop to some extent. For virtually all insurance-covered cataracts in the U.S., the nuclear division/softening part of femtosecond laser-assisted cataract surgery cannot be billed to the patient unless done incidental to other billable treatments such as astigmatism and presbyopia. The second question was, “For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for average density cataracts? If you use a hybrid method, select the one that fits best.” The third question was, “For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for soft cataracts or clear lens extraction? If you use a hybrid method, select the one that fits best.” The fourth question was, “For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for very dense (but still phacoemulsifiable) cataracts? If you use a hybrid method, select the one that fits best.” The totals may not equal 100% due to rounding. The fifth question was, “Please explain why you use the method you do for average density cases.” There were 60 responses and are discussed below. The sixth question was, “Please explain why you use a different technique for different density cataracts, if this is the case.” There were 44 responses and are discussed below. As you can see, as with other parts of cataract surgery, there is great diversity in what methods are employed to divide the nucleus for phacoemulsification, and surgeons no doubt achieve excellent results or they would explore other methods. Jay Erie, MD , Mayo Clinic, Rochester, Minn., prefers divide and conquer for most cases: “The biggest advantage to me is that most of the phaco energy is expended in the bag; therefore, it is ‘free’ phaco power with respect to potential endothelial trauma.” Ravi Krishnan, MD , Eye Institute of Corpus Christi, Texas, Mitchell Gossman Divide and conquer 38% 22% 42% Horizontal chop 15% 14% 7% Vertical chop 8% 2% 13% “Extracapsular caroused” (prolapse nucleus to iris plane or AC and phaco/aspirate around the periphery as it spins) 1% 13% 0% “Intracapsular carousel” (phaco/aspirate around the periphery as it spins in the capsular bag) 0% 19% 0% Phaco flip (similar to “carousel” but performed with nucleus inverted) 2% 10% 3% “Stop and chop” (single groove splitting in two followed by horizontal chop) 26% 8% 34% Pre-chop (separate nucleus into segments with pre-chopper instrument) 8% 7% 1% No dissassembly express nucleus via large or small incision 0% 0% 0% Other: Create a half-bowl and chop 1% - - Other: Venturi aspiration from center out - 1% - Other: Mixture of techniques depending on what works best - - 1%