Eyeworld

EW CATARACT 46 March 2016 by Mitchell Gossman, MD 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, C ontinuing the discussion of the methods ophthal- mologists use for cata- ract 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 main- tain 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 meth- ods, 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?" How are we performing nucleus division during cataract surgery? Yes 13% No 87% Divide and conquer 38% Horizontal chop 15% Vertical chop 8% "Extracapsular carousel" (prolapse nucleus to iris plane or AC and phaco/ aspirate around the periphery as it spins) 1% "Intracapsular carousel" (phaco/ aspirate around the periphery as it spins in the capsular bag) 0% Phaco flip (similar to "carousel" but performed with nucleus inverted) 2% "Stop and chop" (single groove splitting in two followed by horizontal chop) 26% Pre-chop (separate nucleus into segments with pre-chopper instrument) 8% No disassembly, express nucleus via large or small incision 0% Other: Create a half-bowl and chop 1% Divide and conquer 22% Horizontal chop 14% Vertical chop 2% "Extracapsular carousel" (prolapse nucleus to iris plane or AC and phaco/ aspirate around the periphery as it spins) 13% "Intracapsular carousel" (phaco/ aspirate around the periphery as it spins in the capsular bag) 19% Phaco flip (similar to "carousel" but performed with nucleus inverted) 10% "Stop and chop" (single groove splitting in two followed by horizontal chop) 8% Pre-chop (separate nucleus into segments with pre-chopper instrument) 7% No disassembly, express nucleus via large or small incision 0% Other: Venturi aspiration from center out 1% Divide and conquer 42% Horizontal chop 7% Vertical chop 13% "Extracapsular carousel" (prolapse nucleus to iris plane or AC and phaco/ aspirate around the periphery as it spins) 0% "Intracapsular carousel" (phaco/ aspirate around the periphery as it spins in the capsular bag) 0% Phaco flip (similar to "carousel" but performed with nucleus inverted) 3% "Stop and chop" (single groove splitting in two followed by horizontal chop) 34% Pre-chop (separate nucleus into segments with pre-chopper instrument) 1% No disassembly, express nucleus via large or small incision 0% Other: Mixture of techniques depending on what works best 1% 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 pro- cedure makes separation of frag- ments somewhat easier, one still has to divide and conquer or chop 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 cata- racts 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) cata- racts? If you use a hybrid method, select the one that fits best." Mitchell Gossman, MD Pulse of ophthalmology: Survey of clinical practices and opinion

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