10 Vacuum Hemi-Flip Phacoemulsification Over 30 years ago, surgeons like myself were excited about the evolution of the anterior capsulotomy from the can-opener capsulotomy to the continuous curvilinear capsulorrhexis (CCC) method of Thomas Neuhann and Howard Gimbel. At the advent of the CCC, existing methods of nuclear removal were fine for can-opener capsulotomies, but not for the CCC. At that time, I was fortunate to be a program participant at a cataract surgery session of the Contact Lens Association of Ophthalmologists (CLAO) meeting at which John Shepherd1 first described his divide-and-conquer phacoemulsification procedure. (Interesting that the most popular method for nuclear removal was introduced at a contact lens meeting.) Every phaco surgeon in the room knew this was a groundbreaking and important step for preserving the CCC. Four-quadrant divide and conquer appears to still be the preferred technique for phaco surgeons worldwide. Soon after this event, I became an investigator for the Staar foldable intraocular lens, the “Mazzaco Taco,” a welcome addition to small-incision cataract surgery. But what really inspired me to modify four-quadrant divide and conquer was the prediction in some circles that lens extraction and implantation of presbyopic intraocular lenses (IOLs) would become popular for precataract presbyopes as we became more familiar with multifocal IOLs and their benefit to cataract patients. Many of these younger, softer lens nuclei could be prolapsed through a standard 5.0-mm CCC, but there existed a subset in 50- to 60-year-old patients in whom the nuclei were firmer and full nuclear prolapse less predictable. The time period was the early 1990s, and phaco fluidics were continuing to be improved. I began trying to perform hemi-flip phaco on standard cataractous nuclei to feel proficient with hemi-flips for younger patients. At this time, Allergan (Parsippany, NJ) added the “Burst Mode” to its Sovereign phaco unit and I was finally able to consistently perform phacoemulsification of the hemi-nuclei.2–4 More recently, I have converted from peristaltic (flow based) phaco to venturi (vacuum) fluidics with the Bausch and Lomb (Rochester, NY) Stellaris and the AMO Signature (Abbott Medical Optics [AMO], Abbott Park, IL). Vacuum fluidics, more common for posterior segment surgeons, offer a welcome improvement for removing the hemi-nuclei.5 Now I routinely perform what I term vacuum hemi-flip procedures on most cataract and presbyopic lens cases. For standard nuclear removal without femtosecond CCC, I mark the centration and size of the CCC by placing a 6.0-mm optic zone marker on the central cornea.6 Cortical cleaving hydrodissection of the nucleus and cortex with balanced salt solution is performed through a 25-gauge cannula. A deep central nuclear groove is created with the 30-degree phaco tip (Fig. 10.1a). My second instrument, entered through the sideport incision, is a blunt “chopper,” not used for chopping but for nuclear manipulation and posterior capsular bag protection (Fig. 10.1b). It is called the Wallace Guardian (Storz, Bausch and Lomb) (Fig. 10.2). This instrument can be helpful when grooving the nucleus with a small pupil. Simply pulling the proximal edge of the groove toward the surgeon allows the distal groove to be visualized and phacoemulsified. Splitting the nucleus in half is more predictable with a deep groove that is near both nuclear equators (Fig. 10.1b). After separating the nuclear halves with the phaco tip and the Guardian, the halves are rotated 90 degrees. To avoid corneal endothelial trauma from streaming fluids and phaco energy, I adjust the irrigation ports in line with the phaco tip (Fig. 10.3). (I made this adjustment after learning about the significant phaco energy emanating from the phaco tip from a video presentation by William Fishkind.7) The first nuclear half is removed by using the Guardian to lift the left edge of the distal half and bringing it to the center of the pupil (Fig. 10.4). Modern vacuum fluidics enable the rapid nuclear removal of this first half. The second half is then rotated around in the capsular bag and the same method is employed for removal. The Wallace Guardian is placed posterior to the remaining nuclear material to protect the posterior capsule (Fig. 10.5). If significant phaco energy was needed to remove the first half, a dispersive viscoelastic (Viscoat, Alcon, Fort Worth, TX) is reinjected over the second nuclear half prior to phaco. Thanks to Howard Fine’s cortical cleaving hydrodissection, there are cases where the cortex and nucleus are now removed and IOL implantation is performed without additional cortical irrigation and aspiration.
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