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EW CATARACT 37 October 2017 plane, thereby minimizing potential compromise of the posterior capsule. Applications With traditional chopping methods, stabilization of the posterior nucleus and visualization of the peripheral nucleus can render both soft and dense nuclei difficult to fragment. With AC/NE, however, nuclear stabilization is achieved simply by placing the phaco tip on the anterior lens surface, while the chopper is readily placed beneath the lens nu- cleus under direct visualization near the pupillary center—a maneuver easily executed even in small pupil cases. ized machine settings for fluidics and power modulation are unneces- sary, lending a degree of confidence and relative efficiency to the proce- dure. In the absence of ultrasound, corneal edema and inflammation are minimized, and because the direc- tional component of the chopping maneuver is anterior toward the capsular opening, zonular stress is reduced. With traditional methods of nuclear disassembly, includ- ing divide and conquer, and both horizontal and vertical chopping, the phaco needle must work deep in the capsular bag to either sculpt or stabilize the posterior nucleus and remove lens material. With AC/NE, the phaco tip remains near the iris tip resting on the anterior lens surface. Slight downward pressure with the phaco tip may be applied for dense nuclei, but burrowing is unnecessary. Although I use a 30-de- gree phaco tip with the bevel facing up or sideways, pressure may be applied with any part of any phaco tip. The resultant lens fragment is then elevated out of the capsular bag by the chopper from the underside of the fragment, with some lens fragments appearing to rotate or "tumble" into the supracapsular space. Advantages Because AC/NE relies solely on man- ual and compressive forces, special- Figure 2. The chopper is advanced under the heminucleus, while the phaco tip is positioned on the anterior surface of the lens without ultrasound or vacuum. Figure 4. The resultant nuclear fragment is elevated by the chopper out of the capsular bag for phacoemulsification. Figure 5. The chopper is advanced under a remaining nuclear piece, and the process is repeated. continued on page 38 compromise of the posterior capsule. However, this space is easily accessi- ble due to the downward mobility of the posterior capsule, the compress- ibility of the anterior vitreous, and the relative protection afforded by the adjacent epinuclear and cortical layers. Most heminuclei allow ample access. For dense heminuclei, access may be improved by using the pha- co tip to gently rock the nucleus and elevate the posterior lens surface. To perform an anterior chop, nuclear hemisection by traditional methods must first be performed. A Seibel olive-tip chopper is then placed blunt side down underneath the opposing heminucleus and drawn anteriorly toward a stationary phaco Figure 3. The chopper is drawn toward the phaco tip in an anterior chopping motion. Because the entire thickness of the nucleus is sandwiched between the instruments, a complete chop is guaranteed by manual compression. Special machine settings are unnecessary. Steve Elieff, MD, discusses anterior chop/nuclear elevation.

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