In this anonymous video, a resident surgeon struggles with phaco chop. It is not an easy technique to learn, which is why it has not been adopted by more surgeons. Nagahara described the technique 25 years ago and it makes cataract surgery more efficient and safer. We recently hosted a video of a resident surgeon who learned the phaco chop technique and it would be helpful for novice surgeons to compare these two videos.
The key technique that is missing from this video is sufficient holding power of the nucleus. The nucleus should be held still by the phaco probe while the chopper splits it. This requires a few steps:
- Machine settings should be for high vacuum (at least 400 mmHg) with a moderate flow rate and sufficient inflow to balance the fluidics
- The phaco tip should be exposed enough to be embedded into the nucleus. Using a bevel down approach is recommended as well.
- Bury the phaco tip into the dense endonucleus just inside the sub-incisional capsulorhexis edge, not in the center of the nucleus.
- Hold the nucleus still using the high vacuum achieved by occluding the phaco tip. If the high vacuum level is not achieved it is because the tip is not sufficiently occluded.
- Place the chopper around the nucleus a sufficient distance away from the phaco tip. You want a large chop, not a tiny one.
- Bring the chopper toward the phaco tip and then pull apart. The nucleus should now be split into two halves.
In this video, the surgeon struggles throughout the case which is more difficult due to the soft nature of the nucleus and the pupillary miosis. This is a good surgeon with great potential, who will blossom into an accomplished surgeon. This video review is meant to be helpful and instructive with the goal of improving surgical skill. All beginning surgeons should do the same: record video of surgeries and then ask for expert analysis and criticism.
Click below to learn why phaco chop was so difficult in this case: