Flip and Chop early in the Learning Curve

Flip and Chop Tech title

Phaco Chop is my preferred technique of nucleus removal during cataract surgery because it is safe, efficient, and uses much less ultrasonic energy than older techniques like Divide and Conquer or even Stop and Chop. When I teach Phaco Chop to my residents, it is a relatively steep learning curve. Most residents can get quite comfortable with Stop and Chop, but they often ask for an intermediate step instead of jumping all the way to Phaco Chop. This is when I teach them Flip and Chop.

The order of learning is typically:

  1. Divide and Conquer
  2. Stop and Chop
  3. Flip and Chop
  4. Phaco Chop (in the bag, either horizontal or vertical)

In the Flip and Chop technique, the lens nucleus is partially prolapsed out of the capsular bag and then chopped. I’ve shown this technique before since I often use it for smaller pupils to avoid having to use iris hooks or pupil expansion devices. By bringing the nucleus away from the posterior capsule, it gives more room for placement of the chopper and a higher margin of safety. While the nucleus is in closer proximity to the corneal endothelial surface, the use of phaco power modulations and good dispersive viscoelastics ensure that there is no damage to these delicate cells. Clear corneas on the first post-op day are expected and these patients will achieve excellent vision.

As an experienced Phaco Chop surgeon, I tend to use Flip and Chop in these cases:

  • smaller pupil where the nucleus can be brought out of the capsular bag
  • very soft lens with primarily PSC cataract and mild nuclear sclerosis
  • prior vitrectomy eyes to bring the nucleus out of the bag
  • high degree of axial myopia to bring the nucleus out of the bag

It is a valuable technique to learn and should be in your toolbox of nucleo-fractis maneuvers.

click below to watch the video and learn this technique:

5 Comments

  1. Such a wonderful video…
    I use to keep vacuum at 340 only
    For flip n chop do we still need to raise to 400 for all grades of cataract??

  2. Love your flip-and-chop videos. I really like this technique (and it’s other supracapsular incantations eg ‘pop and chop’). The key step is prolapsing the nucleus, and I’m not always successful doing that even when I think the rhexis is sufficiently large (5-5.50mm). Any tips or pointers? I do make sure I have a sufficiently large rhexis, and I even burp out a bit of OVD to make room for the lens to come forward. I routinely use a Chang cannula (27g right angled cannula) for hydrodissection — do you recommend a straight cannula for this technique? Do you depress or angle down a bit on the nucleus to pop it up? Or do you tent the cannula up a bit when you inject so the fluid wave hugs the capsule? Does it make a difference how far place the cannula past the rhexis edge? Just under it or the further into the capsular fornix? When do you worry about capsular block (at 1:32 in the above video how did you know the BSS wasn’t trapped behind the lens?) Lots of hydrodissection questions for an often overlooked but critical part of the case! Any tips would be appreciated!

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