Eyeworld

EW CATARACT 73 The next step is to use the second instrument, in my case the Seibel chopper, to displace the opposite heminucleus and create a small amount of space between the nuclei, 0.5 mm in width. Next is the part that is tricky to conceptu- alize but not particularly difficult to perform. The embedded corner of the 0.5 mm is depressed toward the optic nerve and retracted toward the main wound so that the edge of the nucleus clears the edge of the capsu- lorhexis. This sounds more difficult than it is to perform. The accompa- nying video shows this technique with a quite dense nucleus with an average-sized capsulorhexis. Step 3: Tilt and "unscrew" the heminucleus The next step is to tilt the retracted corner of the lens up toward the cor- nea. The heminucleus is not flipped, only the corner is tilted up. The heminucleus is then "unscrewed" anteriorly in a clockwise fashion if the left heminucleus is engaged or in a counterclockwise fashion if the right heminucleus is engaged with the phaco tip. The heminucleus is unscrewed a total of 90 degrees so that a quarter of the nucleus sits atop the opposite heminucleus. This is best seen in the video and in Figures 2–4. Particularly in dense nuclei, this means reacquiring the nucleus with the phaco tip to com- plete the 90-degree turn. Step 4: Chopping without aspiration It would not be in the cornea's best interest to perform phacoemulsi- fication of the lens nucleus this far anteriorly in the eye, and I do not do so. Rather, the heminucle- us is split in half and this is done without phacoemulsification or even aspiration. Since the phaco tip is still engaged in the anterior heminucleus, the Seidel chopper is employed to hook the periphery of the lens nucleus, and with irrigation only and no aspiration running, a chop is performed. The phaco tip and the crux of the Seibel constitute two-point fixation of the heminu- cleus and aspiration therefore does not contribute to surgeon control of the lens. Indeed, aspiration is not desirable because of the fluidic surge that may accompany the comple- tion of the chop. The portion of the heminucleus that is not anteriorized remains in the capsular bag and usually falls back into its original anatomical position. At this point, we have a quarter of the nucleus that has already been separated and is above the capsulor- hexis. This quarter is repositioned a bit more posteriorly to protect the cornea and phacoemulsification of this quarter and the quarter to which it had been attached is per- formed according to the surgeon's favored technique. The identical procedure is performed with the other heminucleus, and this is very simple to anteriorize because there is a great deal of space now in the capsular bag. Thus, the entire lens nucleus is removed without a single rotation. The technique is very zonule friendly, and in the event that the surgeon is unable to perform all of the steps, nothing is wasted aside from a bit of time. Surgeons wishing to give this no-turn technique a try should incorporate the different parts of this method in a stepwise fashion. The surgeon should select a moderately dense 3 + nuclear scle- rotic lens and first attempt the short 3 mm groove with same-side crack- ing. Keep in mind that difficulties cracking the lens nucleus are often not because the lens is too dense but because there is insufficient purchase to achieve the leverage for a good crack. Certainly there will be plenty of purchase available with a groove this short. Next, surgeons should practice the technique of creating a gap be- tween the two heminuclei with the second instrument while engaging the contralateral heminucleus with the phaco. The most difficult part of the technique is the retraction and tilt of the lens, but once this is achieved, the unscrewing of the heminucleus is easy work. EW Editors' note: Dr. Young is clinical professor of ophthalmology, New York University School of Medicine. Contact information Young: jyoungmd@gmail.com save $ 4440 on a 440 Mobile Stretcher Bed & save even more at ASCRS Booth#1746 877-708-2421 | mti.net | sales@mti.net Watch a video of this technique on EWAR

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