Transcript Pop and Pre-Chop Safe Supracapsular Phacoemulsification

Pop and Pre-Chop
A 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.
Cyclodialysis spatula behind
Sinsky in front
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)
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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 Disadvantages
Potential Advantages:
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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
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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:
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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.