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Small-Incision
Bimanual
Phaco Chop
Specialized instruments help to perform the chopping BY JÉRÔME C. VRYGHEM, MD
Most cataract surgeons obtain excellent means of ultrasound and, thanks to its holding proper- ties, helps to dislodge the nuclear fragments. Higher flow and vacuum levels and the mechanical action of sion. In these cases, a conventional fold- the chopper compensate for the lower ultrasound set- able IOL is easily implanted and the procedure is safe tings. In a bimanual procedure, the instruments can and effective. Patients are in the habit of demanding a easily be switched, making access to all parts of the safe, high-quality, and effective procedure. The way I deliver these results is to offer microincision cataract When the incision size is reduced, the sleeve of the phaco tip must be removed. Modern phaco technolo- An experienced cataract surgeon loves to push his limits because it provides excitement in the routine ofdaily surgery. Once a surgeon manages to try MICS,conquer the learning curve, and improve upon his sur-gical parameters, he develops a system that is difficultto abandon for his old, broader incision technique.
In an attempt to decrease ultrasound distribution in the anterior chamber and shorten my procedure times,I first moved from the divide and conquer to stop andchop technique. I then transitioned to phaco chop.
Using the Sovereign phaco system (Advanced MedicalOptics, Inc., Santa Ana, California; Figure 1), I was ableto reduce my effective phaco time to an average of 1.43seconds.
Once I started phaco chop, my procedure immedi- ately became bimanual. The chopper helps me to crackthe nucleus as well as manipulate or stabilize the frag-ments. The phaco probe fragments the nucleus by Figure 1. Dr. Vryghem at the operating microscope.
APRIL 2008 I CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 57
GmbH, Nuemberg, Germany; Figure 2) provides a flowof 80 mL/minute and makes sure that the bottle heightof the balanced salt solution does not need to beincreased.
The actual size of my sideport incision is 1.2 mm for the 20-gauge slightly bent phaco tip. The main incisionis 1.4 mm during phacoemulsification; it is enlarged to1.9 mm for IOL insertion.
Appropriate instruments are needed when using smaller incisions for MICS. The MST DuetCapsulorrhexis (MicroSurgical Technology, Redmond,Washington; Figure 3) forceps provide perfect control Figure 2. The Vryghem Chopper
Figure 3. The Duet
of the rhexis even when performed through a small has an ultrathin wall, a bigger
Capsulorrhexis forceps
incision. IOLs for MICS must have a suitable design for lumen, and a Nagahara tip.
provide control of the
stability in the capsular bag and a normal-sized optic (6 rhexis through a
mm). To avoid damaging the IOL during MICS, I prefer microincision.
injection using a Medicel 1.8 mm cartridge (MedicelAG, Wolfhalden, Switzerland). The cartridge is docked gy, such as that of the WhiteStar software (AdvancedMedical Optics, Inc.) developed for the Sovereignphaco machine, makes sure that thermal burns at the site of the incision are avoided. Only a perfect match between the size of the sideport and the phaco tip inone hand and the main incision and the irrigating phaco chopper in the other hand can ensure anterior chamber stability. In the beginning, this can be a chal-lenge to achieve, as fluctuations in the anterior cham-ber cause the patient discomfort. into the incision; the tip does not penetrate into the Therefore, under a Healon5 (Advanced Medical anterior chamber. I prefer hydrophilic acrylic IOLs, such Optics, Inc.) dome, I inject intracameral lidocaine as the Acri.Tec Acri.Smart 36A (Carl Zeiss Meditec AG, before creating the capsulorrhexis (ie, Arshinoff tech- Jena, Germany) or the PhysIOL MicroSlim (Liége, nique) and while performing hydrodissection and Belgium). Both lenses give excellent visual results and To ensure a good anterior chamber depth and a high I believe that the differences in induced astigmatism flow rate, I developed a titanium irrigating chopper between a broader, 2.5-mm incision and a MICS inci- with an ultrathin wall (50 µm), a bigger lumen, and a sion are nonsignificant. Since first performing my small Nagahara tip. The Vryghem Chopper (A.R.C Laser incision bimanual phaco technique, I have been ableto analyze and fine-tune my phaco parameters so TAKE-HOME MESSAGE
much that I feel more in control of these parametersnow than when I used a broader incision. For me, since • Incisions of 1.2 and 1.4 mm can be used for nucleus transitioning to MICS as my routine procedure, there removal with a MICS chopping technique; the main incision is no way to return to a broader incision again. is widened to 1.9 mm for IOL insertion.
I am completely comfortable performing MICS in allcases. ■ • Dr. Vryghem’s effective phaco time with MICS is 1.43 sec- Jérôme C. Vryghem, MD, practices at • Intracameral lidocane is injected under a Healon5 dome Brussels Eye Doctors, in Brussels, Belgium. Dr. Vryghem states that he has no financial inter-est in the products or companies mentioned. • The differences in induced astigmatism between a 2.5- He is a member of the CRST Europe Editorial mm and a microincision are nonsignificant.
Board. Dr. Vryghem may be reached at +32 2 741 6999;info@vryghem.be. 58 I CATARACT & REFRACTIVE SURGERY TODAY EUROPE I APRIL 2008

Source: http://www.vryghem.eu/frontend/files/profiles/publications/39/small-incision-bimanual-phaco-chop.pdf