Eyeworld

EW CATARACT 72 March 2018 Tips and techniques by Joshua Young, MD crack is performed same-side rather than cross-action and is not difficult to perform even in the densest of lenses. Step 2: Embed, depress, retract Once the nucleus is completely cracked, the fun begins. Traditional- ly, in a chopping technique, the lens would now be rotated, but I have al- ready stated that no rotation will be required in this technique. The tip of the phaco is embedded at a very acute angle approximately 0.5 mm from the fracture into the heminu- cleus of choice. As a right-handed surgeon, it is often easiest for me to embed the phacoemulsification tip into the left heminucleus, but I have many times embedded in the right heminucleus without difficulty. A lthough we may imagine the zonules to be like the spokes of a bicycle wheel, our surgical expe- rience often contradicts this. Pseudoexfoliative eyes do not do well with lens rotation as the zonules tend to release from the lens. Perhaps a more apt analo- gy would be to visualize the lens zonules as strands of spaghetti. Spa- ghetti, when uncooked, has substan- tial tensile strength. One can hang a fairly sizable weight from a strand of uncooked spaghetti without the spaghetti breaking. However, if one exerts even a modest lateral force onto the strand of spaghetti, it will snap. This is a better way to visu- alize the fragility of the zonules in cases of pseudoexfoliation in which lens rotation can prove disastrous. I gave this mechanical issue a great deal of thought and devel- oped a technique to extract the lens without rotating the nucleus at all. I have been so pleased with this technique that it is now the method I initially attempt for the majority of my cataract surgeries. Step 1: Creation of a short deep groove I am not an advocate of divide and conquer, not only because it requires a great many steps but also because it necessitates the rotation of the lens several times. However, divide and conquer does demon- strate that it is possible to crack a lens with a very short groove. If the width of the groove is approximate- ly 1 mm and the length of each of the grooves does not exceed 7 mm, then each of the arms of the cruciate pattern is no more than 3 mm. This means that it is possible to crack a lens with a groove as short as 3 mm in length. The initial step of this technique involves making a 3 mm groove in the center of the lens. The groove should be quite deep and the sides of the groove sheer, but the groove need not be very long, as in Figure 1. Cracking such a short groove necessitates an orientation to the second instrument that may be different from the orientation to which the surgeon is accustomed. I use a Seibel chopper (Katena, Denville, New Jersey) as my second instrument and orient it with the ball of the chopper pointed toward my navel as I insert the chopper to the bottom of the groove. The Bicycle spokes, spaghetti, and a no-spin technique Figure 1: The short sheer groove Figure 2: Embedding the phaco tip ½ mm from crack Figure 3: Distal corner of heminucleus is tilted anteriorly and "unscrewed" above contralateral heminucleus Figure 4: Unscrewing to 90 degrees Source: Joshua Young, MD

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