EyeWorld Asia-Pacific December 2018 Issue

Views from Asia-Paci c proach breaks up the nucleus with as little use of power and greatest use of mechanical disas- sembly and fluidics as possible. However, soft cataracts present certain problems. I think the phaco prechop is a good way to approach soft nuclei. You need to fill the anterior chamber with viscoelastic, do your 5 mm rhexis and full nuclear mobilization, and refill the anterior chamber with viscoelastic to provide a firm base to push the prechopper against. Push the prechopper toward the center of the nucleus and separate the blades several times until the nucleus splits. Then, turn the nucleus to repeat and remove seg- ments with minimal power. The ‘soft slice’ technique is a different approach and is effective for up to 2+ nuclei.” Here, the nucleus is sliced from the periphery to the center using a device like the Mackool iris repositor, which is blunt and has a short shaft. After each slice is completed, the segments can be separated until the nucleus is in four pieces, at which point it can be removed with minimal use of ultrasound power. Phaco chop allows for fast and safe surgery, especially for hard cataracts, that need far lower energy levels in the eye due to the greater use of mechanical division, producing clearer day 1 corneas because of the lower energy use. There are two ba- sic techniques, horizontal and vertical chopping, which can be mixed and matched. “Horizontal choppers tend to be longer with a blunt end and often with a blade on the inside edge. Vertical choppers have shorter tips, often with a point. I use my own, which has a blade on the inside also. These differences reflect the way in which the two techniques are used,” Dr. Packard explained. “Horizontal chopping is very much a two-dimensional maneuver. You embed the phaco tip, then take the chopper out to the periphery of the nucleus and slide it over the nucleus, bring- ing the two instruments together and separating into segments. You can chop up the nucleus as many times as you like, but this is especially important with a hard cataract, which will enable you to use less power. Vertical chopping is a three-dimensional maneu- ver because you are lifting at the same time as you are chopping and separating.” The sharp verti- cal chopper is embedded in the nucleus near the end of the phaco Mohan RAJAN, MD Chairman and medical director, Rajan Eye Care Hospital Pvt. Ltd. #5 Vidyodaya 2nd Street, T. Nagar, Chennai, India 600017 Tel. no. +91-044-28340500 Fax no. +91-044-28343711 drmohanrajan@gmail.com I would like to classify the cataracts into the following groups 1. Very soft 2. Neither soft nor hard (neither here nor there) NHNT cataracts or in-between cataracts 3. Hard 4. Suprahard In a country like India we encounter hard and suprahard cataracts quite commonly. NHNT cataracts are in my opinion the toughest cataract to deal with as these cataracts don’t suck or crack and are difficult to chop as well. I recommend a deep narrow trench for these cataracts using moderate phaco power and low vacuum. Then try to crack into two halves using two rods. Then use pulse phaco with low phaco power and high vacuum and flow rate to remove each half. For hard and suprahard cataracts, I use a technique I have described and call “Quick Chop Express”. In this technique, I use a sharp and long chopper (Mohan Rajan Chopper, 1.75- to 2-mm tip) and perform vertical chop or karate chop wherein the chopper is directed towards the optic nerve in front of the rhexis margin. My phaco tip is directed vertically with the bevel down and buried into the body of the nucleus. The sharp and long chopper opens up the posterior nuclear plate with great ease with very minimal vector forces. The first objective is to divide the nucleus into two halves. We have to make sure that we see the posterior capsule through and through across the nucleus. Once this is done, I attack each half and chop them into multiple, small pieces and emulsify using hyper pulse on the Stellaris machine (90 pps/vacuum 450–600 mmHg/phaco power 40%/duty cycle 40%). The dual linear feature of the Stellaris Phaco Machine (Venturi System) enables me to control the phaco power and vacuum simultaneously. The whole process of nucleus removal takes only 1–2 minutes irrespective of the density of the cataract. I make sure that viscoat is injected regularly into the AC to prevent corneal endothelial damage during the nucleus removal. The plane of emulsification is also maintained posteriorly away from the corneal endothelium to ensure clear corneas postop. Quick Chop Express is a safe and effective method to remove any grade of nucleus. The advantages of Quick Chop Express are that it reduces phaco time, phaco energy, and surgical time, and ensures a clear cornea postoperatively. Quick Chop Express is a combination of technology and technique. The technology is available in the form of phaco machines such as the Stellaris, Centurion, SignaturePro, Turbovit, etc. The technique is vertical chop using the sharp chopper. Editors’ note: Dr. Rajan declared no relevant nancial interests. Breaking down – from page 41 42 EWAP CATARACT/IOL December 2018