Surgery: Phacoemulsification: Stop & Chop Technique

This video demonstrates the stop and chop method of phacoemulsification in a grade three cataract with some cortical element. I make my side port incisions at approximately three and nine o’clock, about three clock hours away from the main incision.

This helps me to access the entire three sixty degrees of the capsule during irony later, and it also helps me to identify the location of my side ports when they’re very clear corneal.

I inject a good viscoelastic for the capsulorhexis. I inject from the opposite side withdrawing as I inject to replace almost all the aqueous in the anterior chamber.

For the capsularexis, I use a needle cystotome. I start with the area away from the main port, fold the flap, and the fold of this flap will guide me to have the perfectly round capsularexis.

Every couple of clock hours, I will regrasp the flap and continue until we get a perfect central circle of approximately five point five millimeter.

I then proceed to do my main port incision, which I personally make after the rhexis so that the anterior chamber remains full and I do not lose any viscoelastic during my capsulorhexis. The main incision is made using a two point four millimeter blade. The two point four blade here is a bit blunt, which is where you see the struggle. It should be a nice three planar incision where you hitch the cornea, traverse into the stroma and then pierce the posterior stroma and desmeth by making the blade parallel to the iris. This ensures a three planar valvular and self sealing incision of a little less than two millimeter in length.

Hydrodissection is done by decompressing the anterior chamber slightly and then injecting balance all solution under the anterior capsule. I do this in at least two areas as you can see here. Look for the wave which you see and then decompress the nucleus to release the fluid from below the nucleus before injecting any more fluid. You can also do an hydrodelineation into the matter of the nucleus as seen here, and you can see that golden ring sign, which is a classic sign of a successful delineation, which is a separation between the endonuclease and the epinucleus.

Rotate the nucleus well to break all adhesions. As you can see here, the rotation is very challenging as the nucleus size is very large, so you should be a bit gentle, and as long as you have up to three clock hours of rotation, you’re good to proceed with the phacoemulsification.

Inject a good dispersive viscoelastic to protect the cornea before we start the nuclear management.

Here, I use the balance tip from Alcon’s and Turin. The first step is to clear off the central epinuclear matter.

After that, I begin to sculpt using higher power and low vacuum, creating a deep trench. This usually takes about two to three passes, but you must mimic the shape of the posterior lens like a boat, which means that in the central area, you’re going deeper, but in the peripheral area, you’re shallower to avoid any puncture into the posterior capsule. Once you have a good glue from this trench like you can see, you can separate the two heminuclei by using parallel forces to the iris and not compressing forces downwards.

You then align one of the heminuclei across from the tip, create a good hold with high vacuum in chop mode, and use the second instrument to create multiple pieces. You can proceed to create four to six pieces and then continue towards quadrant mode or nuclear management mode where you lift each piece using the tip and emulsify it.

For all phacoemulsification, it is important to stay in the safe central zone at the iris plane. Do not chase the pieces. And if machine followability is not bringing the nuclear fragments to the tip, use the second hand instrument like a Sinskey hook to bring the pieces towards the tip of the phaco.

The last fragment removal is the most crucial time as you may have a higher chance of developing posterior capsular tear or rent. You want to avoid surge at this point where the posterior capsule can suddenly get caught in the phaco tip. So at this point, it is better to switch to lower parameters to prevent the surge.

I prefer to go into epinuclear mode for the last piece, which really increases the safety and reduces the chance of any kind of posterior capsular rent.

The remnant epinucleus when thick and like a plate should be used in epinuclear mode with the phacoemulsification.

However, thinner epinucleus and the remaining cortex can be removed using irrigation and aspiration. In this case, we have used bimanual irrigation and aspiration.

The cortex here is very sticky, and one can use a side to side sweeping motion first to grasp the body of the cortical chunk, then pull this chunk to the safe zone and then aspirate it. This reduces the chance of catching the capsule and this is key to avoid a rent at this stage.

This is the most common stage at which surgeons do experience capsular tears and rents. So this is a very key point to learn.

IOL implantation here is done with a two point four cartridge. It is a monofocal Alcon intraocular lens.

You must stabilize the eye and watch the cornea to avoid depressing the cornea or pressing on the cornea with the cartridge.

The entry of the cartridge tip should be a gentle sliding motion and inject the lens directly into the capsular bag, which should be adequately inflated first with the dispersive viscoelastic.

Always ensure that the leading haptic is in the capsular bag before advancing the piston of the injector. As shown here, if one is able to pop the trailing haptic into the bag before it unfolds, it is ideal or else if the trailing haptic opens up outside of the bag or in the anterior chamber, it will have to be flopped into the bag gently or a gentle dialing can be attempted depending on the IOL rigidity and the material of the lens.

Viscoelastic removal is very important as any remnant viscoelastic can cause increase in intraocular pressure, fibrosis, and pain. Removal mode with high vacuum should be used. We do want to create a little bit of turbulence using the fluid so as to remove the viscoelastic that is stuck in the angles as well as on the cornea.

After which, you can go below the lens as shown here using only the irrigation. You can push the lens slightly away from you. Go below the IOL in the bag. Lift the lens up to remove all remaining viscoelastic that is trapped in the bag below the lens.

Seal the wounds using hydration. I hydrate the side pots first in one direction, followed by the main pot, especially the roof of the main incision. Once you hydrate the main wound and the roof, you will usually see that the entire eye is nice and rigid, after which you can continue to hydrate the other side of the side ports and check for the IOP.

The eye should be watertight but not too rigid.

Check the softness of the eye and ensure that it seems close to physiological before you close the case.