Pop and Pre-ChopA Safe Supracapsular

Phacoemulsification Technique Jayati S. Sarkar, MD

Christopher E. Starr, MD, FACS

Department of Ophthalmology

Weill Cornell Medical College

New York-Presbyterian Hospital

New York, NY 10021

The authors have no direct financial interests in any of the topics/products mentioned

Purpose

• To describe Pop and Pre-Chop, a novel safe technique of supracapsular nuclear disassembly during phacoemulsification.

• We report the results of 50 consecutive surgeries performed by a trainee with a cumulative surgical experience of fewer than 100 cases.

Methods/Technique

Surgical technique:

• 2 corneal paracenteses are made 180 degrees apart followed by a clear corneal wound 90 degrees away.

• A soft-shell technique (dispersive + cohesive viscoelastic) is utilized to protect the corneal endothelium.

Methods/Technique

• After creating a 5.0 to 6.0 mm capsulorhexis, hydrodissection is performed tangentially via the main wound. Pushing gently down on the peripheral nucleus with the cannula enables the lens to tilt or prolapse (‘Pop’) out of the bag.

• Viscoelastic is then injected behind the nucleus to protect

the posterior capsule and keep the prolapsed nucleus upright.

• A cyclodialysis spatula is then introduced through one paracentesis and is placed behind the lens and a sinsky hook is introduced through the opposite paracentesis and placed in front of the lens.

Sinsky in front

Cyclodialysis spatula behind

Methods/Technique

• Via a scissoring pre-chop maneuver at the iris plane, the nucleus is easily cracked into two halves

• The nucleus can be further broken down into quadrants or smaller pieces using this pre-chopping maneuver

• Supracapsular phacoemulsification is then performed. Since the nucleus is already divided, less phaco energy is needed for disassembly.

Scissoring pre-chop maneuver divides the nucleus into 2 hemispheres

Results

• N=50 consecutive surgeries performed with the Pop and Pre-chop technique by a trainee

• Mean Preop BCVA was 20/70 (range 20/40-20/800)

• Mean Postop day UCVA was 20/40 (range 20/20-20/200)

• Mean Postop week one UCVA was 20/30 (range 20/15 to 20/60)

• Mean Postop month one BCVA was 20/25 (range 20/15 to 20/60)

– Limited visual recovery in 3 pts with POM#1 BCVA of 20/50-20/60 range was due to preexisting epiretinal membrane in 2 pts and advanced glaucoma in 1 pt

Results• Mean phaco time during surgery was 20 secs

(range 0 to 1.58min)

• Mean corneal edema POD#1: 1+ ( range 0-4+)

• Mean corneal edema POW#1: 1+ ( range 0-2+)

• Mean corneal edema POM#1: 0

• Posterior capsular breaks: 0

• Other surgical complications: 0

Advantages and DisadvantagesPotential Advantages:• Less total phaco energy and time than other supracapsular and in-the-bag techniques because

the lens is pre-chopped and divided manually.

• Less corneal endothelial cell loss and postoperative corneal edema than other supracapsular techniques

• Since the pre-chop maneuver occurs at the iris plane, it is simpler and carries less risk to the bag and zonules when compared to in-the-bag pre-chopping techniques

• Ideal for novice surgeons and trainees as there is less phaco time and phaco-manipulation required and the entire procedure is performed away from the posterior capsule and zonules

– It is recommended that a dispersive viscoelastic be repeatedly applied to the corneal endothelium throughout these procedures

• In challenging cases of floppy iris or miotic pupils, the prolapsed lens can act as an iris retractor

• The ‘Pop’ can be performed through an average sized capsulorhexis (5.0-6mm) and does not need to be larger as commonly believed.

Potential Disadvantages:• Supracapsular techniques carry the potential for greater damage to the corneal endothelium.

• Caution should be taken in short eyes with shallow anterior chambers

Conclusion • The novel Pop and Pre-Chop phacoemulsification

technique incorporates the traditional advantages of established supracapsular techniques (posterior capsular protection) and minimizes the known disadvantages (corneal endothelial cell loss).

• Because of its increased safety and simplicity it may be a useful technique for the beginning surgeon.