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Area of Additional Attention Comparison between Chop & Woodcutter's technique

DEALING WITH NUCLEUS & ITS FRAGMENTS USING WOODCUTTERS TECHNIQUE (Presented at AIOS,R !e & Ger!an", P#$%&s'ed &n OSN (Se)t *++,Phacoemulsification procedure basically involves removing nucleus by dividing it in small fragments. For grade & ! nuclei" chopping technique is considered as best amongst e#isting techniques. Author wants to highlight a new approach to divide such nuclei & has named this new technique as W$$%C&''()'* '(C+, -&(. When a woodcutter wants to divide a wooden log into two pieces" he first nails a chisel in the log. *ome distance away from the chisel" he hammers on the log with an a#e goes on hammering" slowly approaching chisel. As soon as he is very close to the chisel" the wooden log automatically gets divided into two vertical fragments . .as shown in fig./0. Woodcutter's technique is based on same principle.

n 1arate chop technique" we normally hold the nucleus with phacotip & then move chopper towards the phaco tip. As against this" in Woodcutter's" chopper is placed at same place & not moved. nstead" the phaco tip" which is holding the nucleus" is moved towards the chopper .with phaco on0. 'his automatically divides the nucleus in two fragments" when phaco tip approaches near the chopper. 'hus chopper acts li1e a chisel & phaco tip li1e an a#e .as shown in fig.20. )emember that" phaco sleeve should be /.3 mm behind the outermost point of phaco tip & you have to move phaco tip towards chopper with phaco on.

C+$P '(C+, -&(

W$$%C&''() '(C+, -&(

f you 1eep distance very small" depth of phaco tip entering inside nucleus is less & division becomes slightly difficult. For a harder nucleus this distance should be more f the distance is more" the irrigation may stop even if you withdraw phaco probe slightly. ,o sculpting or grooving in nucleus is required. t is easier to master woodcutter's technique with clear corneal incision. 'he advantages of Woodcutter's technique are that ' it is fast to perform" you are away from posterior capsule as well as 4onules" simple & easy even for phaco beginners and a boon especially for nuclei which are not so soft.

H . t Learn / F r 0e1&nner 2 After you have mastered sculpting & ma1ing partial thic1ness groove you can directly start learning woodcutters technique. 'his can be better learnt by replacing nucleus in goat's eye by nucleus from stored eye ban1 eyes" which are not useful for 1eratoplasty. 5y this you get e#act feeling of having operated on patient's eye. 6a1e main Phaco and side port incision on goats eye. 'hen do capsulorhe#is. 6a1e a larger self sealing incision of about 7mm on goats eye from opposite side. 'hen push the nucleus ta1en out from the eye ban1 eye through the large incision. (mbed this nucleus in soft corte# of goats eye by passing through capsulorhe#is. 'hen suture the large incision. ,ow learn woodcutter technique on this nucleus. For that matter you can learn any technique of dividing nucleus in this way.

F r P'a3 !aster2 Follow the steps .see above0 in grade three or four cataract. %o not get disheartened even if you are unable to do it in first case. 'he technique shall not do any harm to the patient's eye even if it fails. 8radually you shall be master en9oying the fruits of learning this technique. 'his technique is the best way to deal with harder nuclei li1e grade " " and !.

Ste)s 4 .

d3#tters te3'n&5#e

Phaco sleeve should be /.3 to 2 mm behind the outermost point of Phaco needle. 'he e#posed tip .portion of the Phaco needle" which is not covered by sleeve0 should be slightly more as compared to that required for routine chop technique. f you 1eep distance very small" depth:part of Phaco tip entering inside the nucleus is less & division becomes slightly difficult. For a harder nucleus tip e#posed should be more. f the distance is more than required" the disadvantage is that irrigation may stop even if you withdraw Phaco hand piece slightly. .'his is because the irrigation ports come near the incision and get covered by incision0For this technique there is no need of sculpting. *imilarly no need to ma1e a groove in nucleus. 'his technique can be directly applied to divide nucleus Ste)s ( Part of the Phaco needle" which is not covered by sleeve" should be slightly more as discussed earlier. 5oth the instruments i.e. Phaco needle and chopper are introduced inside in the anterior chamber. Push the nucleus slightly .by one millimeter0 to opposite cloc1 position .opposite to the incision site0 with the help of a chopper. (mbed the Phaco tip into the nucleus. ;ou should enter 1eeping hand piece <= to >= degrees vertical. 'he advantage of this is that the tip gets fully embedded inside before you reach the center of nucleus or center of capsulorhe#is. When the preset vacuum is reached" pull the nucleus towards incision site by one mm. (mbed the chopper at capsulorhe#is margin into the nucleus. 'his is possible only when you are holding the nucleus firmly with Phaco tip. Push the Phaco tip with Phaco on towards the chopper. 'his will brea1 the nucleus into two vertical fragments in nearly all the cases. f not" then introduce the chopper into the depth of the crac1 that you have made and try to separate two fragments from each other. t is necessary to go to the base of the crac1 with chopper because it is easier to displace fragments without stretch on 4onules. f still you cannot divide the nucleus" which may happen in the beginning then rotate the nucleus by />= degrees. f rotation is not possible" repeat hydro dissection. 'ry to rotate again. $nce rotation is complete through />= degree" again perform the

same procedure as mentioned earlier. For second crac1 or cleavage rotate the nucleus. 'he previous groove .which is created by movement of Phaco tip towards the chopper0 gives you space. .;ou get more space as hard central part is ta1en out0. 'his space can be utili4ed for inserting Phaco needle in the center and again dividing the nucleus in above? mentioned manner. 'he procedure is repeated till small fragments of nucleus are made. n most of the cases you will be able to achieve fragmentation of nucleus into two pieces@ e#cept in very soft nuclei. d3#tters te3'n&5#e

Ad6anta1es 4 .

While ma1ing division of nucleus you are always away from posterior capsule. +ence there is no danger of rupturing it. 'he chopper stabili4es the nucleus. 5ecause of this" stretch on 4onules is less. 'his is why am using Phaco power to divide nucleus rather than chopper. Chopper only stabili4es nucleus" & gives direction for crac1 to develop. As told earlier" chopper can be compared to the chisel stapled in the log of wood & Phaco to the a#e. As you are in the nucleus & then using Phaco power" even if power is more" it will not get dissipated towards" corneal endothelium" which minimi4es endothelial damage ;ou get more space in the center as hard part is ta1en out when we move the Phaco tip towards the chopper with Phaco on. ;ou can increase vacuum to a great e#tent. (ven if there is a slight surge" it wonAt cause much harm as posterior capsule is far away & there is nucleus in between Phaco tip & posterior capsule. Bess power is required as Phaco is done after stabili4ing nucleus with chopper as if you are feeding the nucleus in the Phaco tip. %ivision is in one stro1e most of times especially in hard nucleus. Bess Phaco time is required as division is in one stro1e. 'he procedure is fast to perform. *econdly hard part of nucleus is ta1en out easily as if you feed it to the needle while moving Phaco needle towards chopper. Cleavage e#tends beyond and deep in the substance of nucleus because of strain created by chopper. We may feel that Phaco needle will touch the chopper. 5ut this will not happen because nucleus gets fragmented into two even before you reach up to the chopper. 'hatAs why you will never go up to equator i.e. peripheral soft part of nucleus. 'he needle can become hot as Phaco is on with tip occluded. n small pupil or small capsulorhe#is it is possible to divide the nucleus as you do not have to go to the periphery and still you get the division of nucleus