beginning phaco surgeon: which technique?

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dyk33

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As a starting phaco surgeon, it seems like everyone starts out with divide and conquer technique. I've heard that you should master one technique before moving onto another but i was wondering, is there any reason for this? is chopping any harder to master (or start with)?

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I'm with you on this one. It seems that most people are switching to some form of chopping. Why shouldn't I just start learning to chop right now, and add the older methods later if I need them?

I understand that there may be a slightly increased risk(especially for a starting surgeon) to pop through the posterior capsule with a chopper, but if you know the typical depth of the lens, the phaco tip, and your chopper, I just think it would be easier to start with the newer technology/ideas. We don't make children today start with the old DOS system on computers, nor do we make them use the telegraph before graduating to a cell phone. The logic of starting with older techniques doesn't make sense to me. Can any attendings or upper level residents comment on this?
 
I'm with you on this one. It seems that most people are switching to some form of chopping. Why shouldn't I just start learning to chop right now, and add the older methods later if I need them?

I understand that there may be a slightly increased risk(especially for a starting surgeon) to pop through the posterior capsule with a chopper, but if you know the typical depth of the lens, the phaco tip, and your chopper, I just think it would be easier to start with the newer technology/ideas. We don't make children today start with the old DOS system on computers, nor do we make them use the telegraph before graduating to a cell phone. The logic of starting with older techniques doesn't make sense to me. Can any attendings or upper level residents comment on this?

While we don't start children with DOS, we do note they typically crawl before they can walk. First, you need a baby to go back to when everything goes to poopoo. I think that will universally be divide and conquer and or some kind of bowling out technique. Second, it's usually not the posterior capsule that hoses you, it is the anterior and posterior capsule. The chopper is placed over the anterior capsule, chopping ensues and now you have no anterior or posterior capsule, no sulcus and half of the lens is laying on the retina. Third with the newer generation phacos even with divide and conquer you are using only a fraction of the energy of a few years ago so the chance of wound burn etc... is greatly reduced. Fourth, the videos make chopping look real easy (see Chang), but unless you are comfortable inside the eye (esp using both hands) it isn't that easy. Those are some reasons just off the top of my head without putting alot of though into it, I'm sure there are more.
 
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At our program our chairman completely bypasses learing phaco first and makes us start with ECCE while at the VA. Even on patients that are perfectly good phaco candidates with vision of 20/50. Sucks for us and the patients
 
I'm with you on this one. It seems that most people are switching to some form of chopping. Why shouldn't I just start learning to chop right now, and add the older methods later if I need them?

I'm with Olddog on this one. You need to learn how to divide and conquer. While it's true that many are chopping (I would disagree with "most", and the ASCRS surveys would support me on that), if you talk to those surgeons who are really pushing it, they will most likely tell you that there are still situations where you have to be able to go back to divide and conquer. Several of them have actually now been going to pre-chopping, which, despite the name is actually closer to a divide and conquer approach (this is what I currently do most of the time).

It's not like divide and conquer is an outdated technique with inferior results and old equipment, so your analogy to DOS and the telegraph is not really appropriate. In the right hands, it can be just as fast as chopping (with less risk of losing that little chopped piece of nucleus in the angle to surprise you a few days later). You also have to consider that if you're using newer machines with either torsional or transverse motions, chopping is actually more difficult because the handpiece has a harder time grasping firmly onto the nucleus to pull it up unless you go to straight longitudinal phaco (which eliminates the benefit of using torsional).

As a starting surgeon, you're not at "slightly" greater odds of popping the capsule, you're at significantly greater risk. And, as Olddog mentioned, you have the opportunity to destroy both sides of the capsule.

And I completely agree with Olddog that you need to be very comfortable using both hands together before you start to chop. A lot of people think they have good control of that second hand from the beginning, but watch your early videos; you'll see that second instrument going all over the place, putting pressure on the paracentesis (making the chamber shallow), etc.

Certainly it's beneficial to know how to chop, especially if you do a lot of PXF and trauma cases. And it's good to know how to pre-chop, how to do stop-and-chop (which I think is a next good step in learning phaco), how to do a Brown's maneuver. The more possible good techniques you have at your disposal, the more likely you can face any situation, but divide and conquer should be the foundation from which you build up to everything else.
 
At our program our chairman completely bypasses learing phaco first and makes us start with ECCE while at the VA. Even on patients that are perfectly good phaco candidates with vision of 20/50. Sucks for us and the patients

That's been a big debate; I can understand the argument for doing it that way, but I don't agree with it. Unlike the D&C vs. chop, here is a situation where you're talking about using an older technique that takes longer to do for most surgeons on the US, has a longer healing time, and gets a slightly worse final outcome (not as bad as some expected from a big study last year).

I do think that it's beneficial to learn how to do it. Where I disagree is in the patient selection. In my case, I had done around 80 phacos before I did my first ECCE. I had a carefully selected patient who had a rock-hard, dens lens and relatively low visual potential (we were expecting 20/200-20/400 at best, starting at LP). The others that I did after that were similar situations. It's nice to know how to do an ECCE if you suddenly find that you've broken the capsule and you still have a whole lot of lens left; and don't think you'll get to the point where you'll never break capsules; if you think that, I'd recommend spending some time in Osher's video symposium at AAO, where he and his crew of well-known surgeons go through and show some of their disasters and how they dealt with them. It's also nice to know how to do them if you plan on spending some time in Africa doing surgery. If you're with a well-supported group like Harvest Africa, you'll have access to what we have here. But in most cases, you'll be taking them out with whatever is handed to you.
 
As a resident who has begun to learn cataract surgery this year I agree that divide and conquer is the way to go when you start out. Plus, when you become decent, it really doesn't take that much time or use a lot of phaco time.

You will also need to go back to this technique when things go bad.

I also agree that when you start out you are not good with your second hand and chopping would be difficult. I started chopping at the end of my first cataract rotation and definitely think you should get a good feel for the inside of the eye and how to move your instruments around before you try chopping.

That being said, cataract surgery using any technique is AWESOME! So much fun.
 
I'm with Olddog on this one. You need to learn how to divide and conquer. While it's true that many are chopping (I would disagree with "most", and the ASCRS surveys would support me on that), if you talk to those surgeons who are really pushing it, they will most likely tell you that there are still situations where you have to be able to go back to divide and conquer. Several of them have actually now been going to pre-chopping, which, despite the name is actually closer to a divide and conquer approach (this is what I currently do most of the time).

Exactly, you can't chop every lens. If you can't fall back on divide and conquer then you're going to be pretty screwed. Since divide and conquer is much easier than chop, it makes sense to learn it first. I don't agree with learning non-phaco ECCE before phaco (b/c it should only be done in a select few patients), but you should still definitley know how to do an non-phaco ECCE too.
 
Here's an interesting study: http://shortlinks.net/vyo740 It shows phaco time and phaco power of phaco-chop vs. divide & conquer techniques. The conclusions are pro-phaco-chop, but have nothing to say about resident training.
 
Exactly, you can't chop every lens. If you can't fall back on divide and conquer then you're going to be pretty screwed. Since divide and conquer is much easier than chop, it makes sense to learn it first. I don't agree with learning non-phaco ECCE before phaco (b/c it should only be done in a select few patients), but you should still definitley know how to do an non-phaco ECCE too.


Agree. And it might be worth your time to learn small-incision phacosection technique with the Kansas (and similar) trisector instruments. That is the other non-phaco ECCE technique (the one that can be done without sutures.)
 
It seems that most people are switching to some form of chopping.

I was thinking of this thread the other day. There was an article in this month's Review of Ophthalmology that gave the results of one of the national surveys on cataract surgery. For primary technique, here's what was reported:
Quadrant division: 48%
Phaco chop: 17%
Divide in two: 13%
Phaco flip: 11%
 
Here's an interesting study: http://shortlinks.net/vyo740 It shows phaco time and phaco power of phaco-chop vs. divide & conquer techniques. The conclusions are pro-phaco-chop, but have nothing to say about resident training.

The problem with this type of study is that the skeptics will say that much of the phaco energy used during D&C is during sculpting, and that energy is predominately absorbed by the lens. It's the energy used during the quadrant removal part that is much more damaging to the cornea (in theory).
 
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