EyeWorld Asia-Pacific June 2016 Issue

June 2016 EWAP FEATURE 21 prefers the carousel method with its virtue of speed and applicability to cataracts of any density. “I use the phaco handpiece in quadrant removal mode to begin chewing at the nucleus from its equator, causing it to spin into the port.” Steven Safran, MD , Lawrenceville, NJ, thinks that horizontal chop has the advantage of safety: “Horizontal chop can be done in a very controlled manner supporting the nucleus as you do it so there’s minimal or no stress on the zonules. It can be done in the bag away from the endothelium with low phaco energy using a mechanical crossing motion.” Two out of three surgeons use a different method depending on cataract density. There is a trend toward preferring one of the “carousel” methods for softer cataracts, a chop method for medium cataracts, and divide and conquer for dense cataracts. My own methods are carousel for soft cataracts, stop and chop for medium cataracts, and divide and conquer for dense cataracts. Why do we use the method we do? No doubt it relates to what works best for our own dexterity, neurologic makeup, and personality, but some of it may be due to bias. • Status quo bias . We human beings tend to stick with what we learn and accept change reluctantly when problems occur, new methods come along that seem irresistible, or evidence of superiority becomes irrefutable. As the saying goes, “If it isn’t broken, don’t fix it.” This is not to say that what we learned in training is not necessarily completely satisfactory, but there is the hazard of missing out on a better method. • Clustering bias . When mishaps or challenges occur during surgery, especially when they occur in clusters, we tend to question our methods and even our very skills, grasping at straws, trying new things that may or may not be superior or are in fact worse in our hands. • Argumentum ad populum . Everyone’s doing it, so it must be better. • Fallacy of novelty . If it’s new, it must be better. • Appeal to fea r. If you don’t adopt new methods, you risk being left behind. I hope this will provide food for thought for those who are considering other methods, validation for those who continue to use certain methods after trying others and seeing no reason to change, and to help us overcome our biases. EWAP Editors’ note: Dr. Gossman is in private clinical practice at Eye Surgeons & Physicians, St. Cloud, Minn. He has no financial interests related to this article. Contact information Gossman: n1149x@gmail.com Views from Asia-Paci c Hadi Prakoso, MD Klinik Mata Nusantara Jakarta, Indonesia Tel. no. +62811970992 hadi.eyesurgeon@gmail.com I t is very interesting that the question “what is your preferred chopping technique and why do you choose it” is always attracting a long debate in the last decade. Every surgeon has their own reason to justify their “method of choice” and have proved their good results with it. Many surgeons choose a hybrid technique to overcome various densities of cataract. When I started doing phaco around 20 years ago I chose “divide and conquer” as my phaco technique since it was the most popular and “easy to do” technique at that time. After a couple of years, I learned the “stop-and-chop” technique due to its popularity and because it looked more ef cient than the rst one. Because of my curiosity, I then changed and tried to master other techniques such as horizontal and vertical chop and pre-chop. Year after year, changing and mastering one technique to another, I came to the conclusion that there is no one technique that is really perfect and can be employed in all the different densities of cataract. That is why I apply different techniques on different situations, depending on the density of the cataract. For soft cataracts, I use high vacuum with minimum to zero power to dissolve the nucleus and the pre-chop technique is the method I choose for grade 3. When dealing with grade 4, I use vertical and sometimes horizontal chop. And for brunescent and black cataracts that almost always appear in my daily surgery I prefer stop-and-chop, which in my experience is the best, safest, and most ef cient technique for such challenging case. By applying speci c techniques on different cataract densities, I obtain great results in terms of speed/surgical time, ef ciency (using much lower phaco energy), and safety (much lower incident of endothelial cell violation, wound burn, zonular loss, and posterior capsule rupture). But anyway, I have seen many great surgeons who stick to one technique and are able to apply it successfully on different kinds of cataract densities. Therefore, in my opinion, it’s not a matter of what is your preferred technique for nucleus division but what is the safest technique for yourself and for the sake of your patients. Editors’ note: Dr. Hadi Prakoso declared no relevant financial interests.