• Users Online: 217
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 9

Flower petal chop: Technique for nuclear cataract phacoemulsification


Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission10-Dec-2021
Date of Acceptance25-Dec-2021
Date of Web Publication09-Feb-2022

Correspondence Address:
Dr. Rajesh Subhash Joshi
Department of Ophthalmology, Government Medical College, Nagpur - 440 012, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_130_21

Rights and Permissions
  Abstract 


Objective: To describe a phacoemulsification technique to face chalenging situations such as hard and leathery nucleus.
Methods: The present technique was successfully performed in 52 eyes of 48 patients, over a period of 3 months.
Results: None of the patients had zonular dehiscence or posterior capsular rupture. In 40 eyes, the cornea was clear on the 1st postoperative day, while in 12 eyes, the cornea cleared on the 4th postoperative day. Visual acuity improved to 20/20 (corrected distance visual acuity) at the end of the 3-week follow-up.
Conclusion: The flower petal chop technique is an effective and safe technique for phacoemulsification of hard and leathery cataracts.

Keywords: Nucleus fragmentation techniques, Phacoemulsification, chopping techniques


How to cite this article:
Joshi RS. Flower petal chop: Technique for nuclear cataract phacoemulsification. Pan Am J Ophthalmol 2022;4:9

How to cite this URL:
Joshi RS. Flower petal chop: Technique for nuclear cataract phacoemulsification. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 May 25];4:9. Available from: https://www.thepajo.org/text.asp?2022/4/1/9/337478




  Introduction Top


Phacoemulsification has become the technique of choice in cataract extraction. Nagahara K, “Phaco Chop,” film presented at the ASCRS 3rd American–International Congress on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, May 1993. Since the introduction of the phaco-chop technique by Nagahara in 1993, there have been many modifications of this technique, including the stop-and-chop,[1] nucleofractis,[2] cross-chop,[3] drill-chop,[4] pocket-chop,[5] crater-and-split,[6] crater-and-chop,[7] multilevel chop,[8] lift and crack,[9] and retrochop[10] techniques.

However, performing phacoemulsification remains challenging in certain situations, especially in hard and leathery nuclei. Division of the nucleus puts more stress on the zonules. As the lens fibers are laid over time, the nucleus becomes hard, and complete nuclear division may not be possible.

The flower petal chop technique can be safely and effectively used to remove all grades of nuclear cataracts. In this technique, through and through division of the nucleus is not required, thus preventing stress on the zonular fibers. The thick epinuclear plate is emulsified in the end, which safeguards the posterior capsule.


  Surgical Technique Top


Surgery begins with the creation of a side port incision with 0.5% topical proparacaine hydrochloride drops used as a local anesthetic, following which 0.06% trypan blue dye is injected under air to stain the anterior capsule. An ocular viscoelastic agent (2% hydroxypropyl methylcellulose, Appavisc, Appasamy Ocular Devices, Puducherry, India) is injected into the anterior chamber (AC) through the side port with a 23-gauge (G) blunt-tip cannula. A 2.8 mm, self-sealing, clear corneal temporal incision is made. The capsulorhexis is completed using capsulorhexis forceps under the viscoelastic agent. The size of the rhexis is kept at approximately between 5.5 and 6 mm. A cortical cleavage hydrodissection is performed with a balanced salt solution (BSS), the AC is filled with a viscoelastic agent, and the nucleus is not rotated.

The settings for the nucleus chop were power 80%, vacuum 350 mmHg, and aspiration flow rate 34cc/min (Oertli Swisstech, Switzerland). The phaco tip is introduced into the AC and the superficial cortex and epinuclear plate are removed. The phaco tip is then embedded in the paracentral portion of the nucleus, and the phaco chopper is introduced underneath the rhexis margin as far as the equatorial area of the lens [Figure 1]. The chopper firmly holds the nucleus while the phaco tip advances toward the splitter with the use of ultrasonic energy [Figure 2]. As cleavage occurs, the phaco tip and the chopper laterally spread apart, separating the epinucleus from the central hard nucleus. The chopper is then introduced into the cleavage and the nucleus–epinucleus complex is rotated [Figure 3] and [Figure 4]. Separation of the rest of the epinucleus and nucleus is continued until the central hard nucleus is separated from the rest of the epinucleus [Figure 5]. First, the endonucleus is emulsified followed by the epinucleus after bringing it into the central capsular bag area. The parameters are not changed until the last fragment is emulsified, as they are in the linear mode. After emulsification of the nuclear fragments, irrigation and aspiration of the remaining cortex is performed using the irrigation and aspiration probe. An intraocular lens is implanted in the capsular bag, and stromal hydration of the side port and main incision is completed with BSS [Videos 1-3].
Figure 1: Phaco tip and chopper is introduced with chopper near the equatorial area of the lens

Click here to view
Figure 2: Phaco tip (Arrow) moving toward the chopper with the ultrasonic energy

Click here to view
Figure 3: Creation of chop in the epinucleus

Click here to view
Figure 4: Creation of chop in the epinucleus

Click here to view
Figure 5: Multiple chops in the epinucleus with the separation of the hard central core of the nucleus from the epinucleus

Click here to view







The present technique was successfully performed in 52 eyes of 48 patients, over a period of 3 months. None of the patients had zonular dehiscence or posterior capsular rupture. In 40 eyes, the cornea was clear on the 1st postoperative day, while in 12 eyes, the cornea cleared on the 4th postoperative day. Visual acuity improved to 20/20 (corrected distance visual acuity) at the end of the 3-week follow-up.


  Discussion Top


Chop techniques are useful for fast and safe phacoemulsification of the nucleus in the capsular bag. Various techniques described for chopping of the nucleus involve separation of the nucleus with a chopper and phaco tip, which causes stress on the capsular bag and zonules. Furthermore, chopping maneuvers that separate nuclear pieces in the bag increase the stress factor on the zonules and may lead to zonular dehiscence. This particularly occurs in hard cataracts with a brown or black nucleus. These nuclei have leathery fibers that are difficult to separate, and the posterior plate of such nuclei is difficult to crack. Due to the absence of a posterior capsular cushion, any attempt to crack the posterior plate near the posterior capsule could cause posterior capsular rupture.

The flower petal chop technique of separation of the epinucleus from the central hard core of the nucleus was followed per the “woodcutter” technique described by Dr. Mahatme. (Mahatme VH. “Woodcutter technique splits hard nuclei effectively,” Ocular Surgery News, September 1, 2001). Whenever a woodcutter wants to divide a wooden log into two vertical pieces, he nails a chisel at a point and then starts hammering the log with an axe some distance away from the chisel. He continues to hammer in the direction of the chisel, and when he is about to approach it, the log suddenly breaks into two vertical pieces. The same principle is followed in this technique, wherein the epinucleus is divided in the flower petal form, leading to the separation of epinucleus from the central hard core of the lens.

The woodcutter technique was proven to be helpful in the through and through division of all grades of nuclei. In the flower petal chop, complete division of the nucleus was not performed. We aimed to separate the nucleus from the epinucleus.

The present technique is a modification of the “decrease and conquer” technique described by Kim et al. for hard cataracts.[11] Kim advocated rotation of the nucleus after hydrodissection. The phaco tip was embedded in the central part of the nucleus to stabilize it, and the nucleus chopper was advanced toward the phaco tip and pulled toward and downward to the left of the phaco tip for the separation of the epinucleus. In our technique, rotation of the nucleus was not required. We believe that the firmness of the nucleus is essential during chopping. Moreover, it is not possible to see the posterior pole of the nucleus in dense brown, black, or white cataract. This proves advantageous in posterior polar cataract, wherein rotation of the nucleus was not advocated. We recommended placing the phaco tip in the paracentral portion of the nucleus, slightly toward the incision side, and stabilizing the nucleus with a chopper. This helped in the long path toward the chopper after adequately burying the phaco tip in the epinucleus portion of the lens to avoid the edge of the rhexis margin.

“Stop and chop” and “divide and conquer” techniques have been described for nuclear cracking. However, these techniques need sculpting of the nucleus for the creation of a center groove, carried out using ultrasonic power. As the phaco tip faces upward while creating the crater, the energy may get delivered to the endothelium, leading to endothelial cell loss. In hard cataracts, the phaco-chop technique has been shown to cause less dissipation of ultrasonic energy than the “stop chop” and “divide and conquer “techniques.[1] Our technique did not need sculpting of the nucleus; the ultrasonic power was used inside the nucleus after burying the phaco tip in the endonucleus. Vanathi et al. described the crater-and-chop technique for phacoemulsification of hard leathery cataracts, but this technique required initial sculpting of the nucleus with adequate depth for the emulsification of the nuclear pieces;[7] they also suggested power modulation near the equatorial and posterior capsular regions. In our technique, no power adjustment was required as the parameters were in the linear mode. Cracking and emulsification of nuclear fragments took place in the iris plane, away from the posterior capsule.

Aslan et al. described a modification of the crater-and-chop technique (originally described by Vanathi et al.). In this technique, they recommended creating a small central crater, 3 mm in diameter, at the geometric center of the endonucleus. The nucleus was divided as per the horizontal chop technique as seen in a routine chop technique. However, the initial crater needed to be formed by the sculpting method with continuous use of linear ultrasonic energy. To create a crater, one should be careful not to push the nucleus as it may cause undue stress on the zonular apparatus. Some authors advocate measurement of the lens thickness preoperatively so as to predict the depth of the crater and the nucleus intraoperatively.[6] In our technique, there was no need to form the crater; hence, the chances of causing zonular weakness did not arise. Evaluation of the depth of the central crater and the nucleus was not required.

Cakir et al. described the “lift and crack” technique for the phacoemulsification of dense cataracts in patients with incomplete capsulorhexis, a small pupil, and zonular weakness. This technique required a rhexis, 6–7 mm in size.[9] This compromised the implantation of multifocal and toric lenses because the stability of these lenses could not be guaranteed in large-sized rhexis, and beginners needed to learn to hold the nucleus in a high vacuum and be able to bring the nucleus edge out of the rhexis margin. In our technique, the rhexis need not have been large; a 5.5–6 mm rhexis was sufficient to perform nucleus-cracking maneuvers in the bag. If needed, multifocal and toric lenses could be implanted and remained stable. Learning the technique would not be difficult as it was just the modification of the routine chop technique.

Hawang et al. described the technique of nuclear disassembly in hard cataracts, wherein the bevel-down phaco tip was embedded in the nucleus to create a deep and narrow hole. The Akahoshi prechopper was inserted into the hole and cracked the nucleus into two hemispheres. The chopper rotated the hemispheres, divided them into quadrants, and emulsified within the capsular bag.[12] Pushing too hard while creating a deep crater may cause zonular weakness; hence, prechopping needs experience. The AC may become shallow during the procedure, leading to endothelial damage. Inadvertent placement of the prechopper in the supracapsular region may lead to damage to the zonular complex. The need to form the AC repeatedly leads to an increase in the surgical time. In our technique, we maintained the AC form throughout the procedure and needed to form it only while pulling the phaco probe and chopper out of it.

Vasavada et al. described a multilevel chopping technique in hard, brunescent, or black cataracts, in which occlusion was maintained at the single site, and the chopper was repositioned at different sites from the anterior to posterior of the nucleus.[8] In the learning phase, a surgeon may need to make changes in the vacuum and flow rate as one is near the posterior capsule. In the present technique, the epinucleus was divided like a flower petal and the central hard core was emulsified after its separation from the epinucleus. Therefore, the surgeon would always be away from the posterior capsule and need not change the phaco parameters. Due to thick epinuclear plate associated with hard cataracts, we recommend not to change phaco parameters.

The retrochop technique, described by Flabella et al., has been shown to be helpful for brunescent and black cataract phacoemulsification.[10] However, the technique needed an oval capsulorhexis (size = 7 mm × 5.5 mm) with the wider axis pointing toward the paracentesis incision and a special chopper (retrochopper) for chopping the nucleus. The technique did have a few cases as its learning curve. In the flower petal chop, no special instruments were required, and the chopping could be done using Sinskey hook. However, we recommend a sharp chopper for better cutting of the nucleus.

Recently, the femtosecond cataract surgery has become popular due to its safety in hard-grade nuclear cataracts.[13],[14] It has been shown to reduce corneal endothelial cell loss and central corneal thickness and helps to achieve better postoperative visual outcomes compared to conventional phacoemulsification.[15],[16] Chen et al., in their study on phacoemulsification of hard cataracts by femto laser, have shown a reduction in ultrasonic power and early visual outcome as compared with those with conventional phacoemulsification.[16] However, it was a nonrandomized cohort study, and the sample size was small. The present study is based on the Indian rural population, and the setup lacked femtosecond laser cataract removal machine. Therefore, comparison with the femto-laser cataract technique was beyond the scope of this study. We recommend comparison with routine chop technique with larger sample size with different surgeon expertise.

For every case, we recommend to stain the anterior capsule with trypan blue. Staining helps in the visualization of the capsulorhexis margin during chopping maneuvers. As the phaco probe moves toward chopper, it should be buried inside the epinucleus to avoid catch of the rhexis margin. Beginners should be observant to avoid chopper inadvertently chopping the rhexis margin.


  Conclusion Top


The flower petal chop technique is an effective and safe technique for phacoemulsification of hard and leathery cataracts. Separation of the hard core of the nucleus from the epinucleus obviates the need for a through and through crack of the nucleus, making it an easy technique for the beginners as well as experienced surgeons to learn.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Koch PS, Katzen LE. Stop and chop phacoemulsification. J Cataract Refract Surg 1994;20:566-70.  Back to cited text no. 1
    
2.
Gimbel HV. Divide and conquer nucleofractis phacoemulsification: Development and variations. J Cataract Refract Surg 1991;17:281-91.  Back to cited text no. 2
    
3.
Kim DB. Cross chop: Modified rotationless horizonal chop technique for weak zonules. J Cataract Refract Surg 2009;35:1335-7.  Back to cited text no. 3
    
4.
Kim DY, Jang JH. Drill and chop: Modified vertical chop technique for hard cataract. Ophthalmic Surg Lasers Imaging 2012;43:169-72.  Back to cited text no. 4
    
5.
Braga-Mele R, Mednick Z. Pocket-chop technique for phacoemulsification. J Cataract Refract Surg 2016;42:1531-2.  Back to cited text no. 5
    
6.
Aslan B, Müftüoglu O, Gayretli D. Crater-and-split technique for phacoemulsification. J Cataract Refract Surg 2012;38:1526-30.  Back to cited text no. 6
    
7.
Vanathi M, Vajpayee RB, Tandon R, Titiyal JS, Gupta V. Crater-and-chop technique for phacoemulsification of hard cataracts. J Cataract Refract Surg 2001;27:659-61.  Back to cited text no. 7
    
8.
Vasavada AR, Raj SM. Multilevel chop technique. J Cataract Refract Surg 2011;37:2092-4.  Back to cited text no. 8
    
9.
Cakir H, Utine CA. Lift and crack technique for risky cataract cases. J Cataract Refract Surg 2010;36:539-41.  Back to cited text no. 9
    
10.
Falabella P, Yogi MS, Teixeira A, Jopetibe F, Sartori J, Schor P. Retrochop technique for rock-hard cataracts. J Cataract Refract Surg 2013;39:826-9.  Back to cited text no. 10
    
11.
Kim HK. Decrease and conquer: Phacoemulsification technique for hard nucleus cataracts. J Cataract Refract Surg 2009;35:1665-70.  Back to cited text no. 11
    
12.
Hwang HS, Kim EC, Kim MS. Drill-and-crack technique for nuclear disassembly of hard nucleus. J Cataract Refract Surg 2010;36:1627-30.  Back to cited text no. 12
    
13.
Chen X, Yu Y, Song X, Zhu Y, Wang W, Yao K. Clinical outcomes of femtosecond laser–assisted cataract surgery versus conventional phacoemulsification surgery for hard nuclear cataracts. Journal of Cataract & Refractive Surgery. 2017 Apr 1;43(4):486-91.  Back to cited text no. 13
    
14.
Hatch KM, Schultz T, Talamo JH, Dick HB. Femtosecond laser–assisted compared with standard cataract surgery for removal of advanced cataracts. Journal of Cataract & Refractive Surgery. 2015 Sep 1;41(9):1833-8.  Back to cited text no. 14
    
15.
Chen X, Xiao W, Ye S, Chen W, Liu Y. Efficacy and safety of femtosecond laser-assisted cataract surgery versus conventional phacoemulsification for cataract: A meta-analysis of randomized controlled trials. Sci Rep 2015;5:13123.  Back to cited text no. 15
    
16.
Chen X, Chen K, He J, Yao K. Comparing the curative effects between femtosecond laser-assisted cataract surgery and conventional phacoemulsification surgery: A meta-analysis. PLoS One 2016;11:e0152088.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Surgical Technique
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed941    
    Printed28    
    Emailed0    
    PDF Downloaded59    
    Comments [Add]    

Recommend this journal