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EW CATARACT 38 October 2016 by Liz Hillman EyeWorld Staff Writer easiest maneuvers first. "The chop- per is a lot larger than the typical second instrument, so using it as a second instrument for divide and conquer is a good way to get familiar with it," he recommended. "Then, after you've sculpted and cracked the nucleus into four quadrants, instead of immediately emulsifying a mobile quadrant or heminucleus, hold it centrally and slip the horizontal chopper around the equator," Dr. Chang said. "This lets you visualize, perform and understand the 3-D anatomy of chopping without having the iris or anterior capsule in the way." Anoth- er exercise is to slip the horizontal chopper around the equator of intra- capsular divided quadrants. "Use the chopper to tumble quadrants out of the bag, instead of aspirating them with the phaco tip, so that you have David F. Chang, MD, clinical professor, University of California, San Francisco, said that when transi- tioning from divide and conquer to chopping, it is helpful to isolate and learn some of the component skills one at a time. "When you eliminate all sculpt- ing with 'nonstop' intracapsular chopping, the most difficult step is that initial chop that bisects the unsculpted nucleus. And with hor- izontal chop, the most difficult pie- shaped fragment to remove is the first one. As more space is created within the capsular bag, it becomes progressively easier to chop, mo- bilize, and remove the remaining nucleus," he said. For this reason, Dr. Chang advocates learning the component steps of chopping in reverse while performing divide and conquer, so that you start with the ASCRS webinar offered pearls on this transition for young eye surgeons T he transition from divide and conquer to phaco chop has several considerations, and a recent ASCRS we- binar, specifically geared toward young eye surgeons (YES), had an expert panel to offer pearls on the topic. "Phaco FUN: How to Make Your Machine Work For You" continued the story of Theresa, a fictitious third-year resident who, as Zachary Zavodni, MD, The Eye Institute of Utah, Salt Lake City, put it, had already seen a "rather adventurous series of cases so far" that have been used as teaching moments in previ- ous YES webinars. Moving from divide and conquer to phaco chop Dr. Chang pointed out the "golden ring," the limit of the endonucleus, and said this is where the chopper should go. Dr. Chang said for those starting with phaco chop, it's easier to put the chopper in first, followed by the phaco tip, putting as much nucleus between the chopper and the phaco tip as possible. Source: David F. Chang, MD In this webinar, Theresa was em- barking on her seventh case and was ready to start the stepwise transition to phaco chop. These steps, accord- ing to the presentation, include: • Practice using the chopper as a second instrument • Practice getting pieces out of the bag with the chopper • Chop pieces in the pupillary/ anterior chamber plane • Chop the second heminucleus • Stop and chop • Trench and chop Thomas Oetting, MD, ophthal- mology residency program director, University of Iowa Carver College of Medicine, Iowa City, Iowa, said, "Going to chop after only seven cases seems fast. Our residents might spend upward of 100 cases going through this stepwise transition from divide and conquer to phaco chop." In the end, Dr. Miller said this cataract surgery was "a total life changer." The patient's visual acuity with correction was 20/80 in the right eye and 20/25 –2 in the left. Her manifest refraction produced 20/70 in her right eye and 20/25 +2 in her left. Even with a mild residual refractive error, Dr. Miller said, for this patient, "it was amazing." "Never argue with success— what a great result!" Dr. Koch said, it's big and floppy. Lens cells get behind the optic really fast." Finally, Dr. Miller said that patients with long eyes, like this woman, need to be counseled and prepared for their likely visual out- comes. "These patients have cataract surgery expecting they'll be like their friends—20/20 perfect vision with- out correction afterward—and that's not the way it is," Dr. Miller said. Cataract continued from page 37 reviewing Dr. Miller's case. "It appears as if he made an estimate of how much to increase the IOL power to avoid postoperative hyper- opia." Dr. Koch offered an example of the Wang-Koch adjustment for the Holladay 1 formula, which suggest- ed that the optimized axial length in this case was 37.91 mm. Plug- ging this figure into the LENSTAR calculation, selecting the IOL closest to plano on the minus side, would recommend –7.0 D—the same IOL Dr. Miller inserted with the excellent refractive outcome. EW Editors' note: Drs. Miller and Koch have no financial interests related to their comments. Contact information Koch: dkoch@bcm.edu Miller: kmiller@ucla.edu continued on page 40 Webinar reporter

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