O@PoC

Ophthalmology @ Point of Care 2017; 1(1): e2-e7

DOI: 10.5301/oapoc.0000001

eISSN 2399-3685 Technology @ POINT OF CARE

Ultrachopper assisted prechopping for small-incision

cataract surgery
Rubén D. Berrospi1,2, Alejandro Tello1-3, Virgilio Galvis1-3
1
 Centro Oftalmológico Virgilio Galvis, Floridablanca - Colombia
2
 Fundación Oftalmológica de Santander- FOSCAL, Floridablanca - Colombia
3
 Universidad Autónoma de Bucaramanga, Bucaramanga - Colombia

ABSTRACT
Purpose: To describe a new technique to split rock-hard nuclei using an ultrasonic chopper (Ultrachopper) and a
prechopper, in order to perform a modified small incision manual cataract extraction.
Methods: The Ultrachopper device, which is compatible with modern phacoemulsification systems, is used to
facilitate the division of very hard nuclei in a straightforward manner using a manual prechopper, and the two
fragments are extracted using Kansas forceps.
Results: In rock-hard nuclei, this technique is very effective to divide and extract the fragments. The risk of com-
plications related to phacoemulsification on these very challenging cases is avoided.
Conclusions: This modified small incision manual cataract extraction technique, assisted with an ultrasonic chop-
per (Ultrachopper) and a prechopper, is a very good alternative in rock-hard nuclei.
Keywords: Cataract, Phacoemulsification, Prechopping, Small incision manual cataract extraction, Ultrachopper

Introduction A device consisting of a blade vibrating at ultrasonic speed

Phacoemulsification has progressively become the stan-
dard for cataract surgery worldwide, but in cases of rock-hard
nuclei, the incidence of complications, like posterior capsule
rupture and corneal edema are still higher than in standard
cases (1-4). Modifications of the phacoemulsification original
techniques have been proposed to overcome the challenge
of dividing very hard nucleus. Akahoshi described in 1992
his phaco prechop technique, using a mechanical manual
device to separate the nucleus before emulsifying the frag-
ments. That author has shown in many scientific meetings
that his technique can be performed in hard cataracts, and
many cataract services use it (5-9). On the other hand, sev-
eral authors have found that this technique is very difficult
to master (9, 10).
Some studies and researchers have suggested in the last
20 years that other alternatives, like standard extracapsu-
lar extraction or small incision manual extraction, might
be superior to phacoemulsification in those very advanced
cases (11, 12).
Accepted: November 12, 2016
Published online: December 19, 2016
Corresponding author:
Alejandro Tello
Centro Oftalmológico Virgilio Galvis
Centro Médico Ardila Lulle
3rd Floor, Module 7
Floridablanca, Colombia
alejandrotello@gmail.com
(Ultrachopper, Alcon, Fort Worth, USA) has been described
as an option to divide these rock-hard nuclei (9, 13, 14). This
ultrasonic chopper is effective in cutting rock-hard cataracts.
However, when performing phacoemulsification in such
advanced cases, dividing the nucleus is not the only challeng-
ing step, because emulsifying the very dense nuclear frag-
ments also poses additional risks to the corneal endothelium
and posterior capsule. Therefore, we looked for an alterna-
tive, and herein we describe a technique that combines the
cutting capabilities of Ultrachopper, completing the division
of the nucleus with an Akahoshi prechopper, followed by a
manual removal of the fragments, in order to perform a safer
cataract extraction in very advanced cases.
Surgical technique
Using topical or peribulbar anesthesia, initially a 6.5 mm
biplanar sclerocorneal tunnel is constructed, beginning
around 1.5-2.0 mm posterior to the limbus and with a depth
of around 70% of the scleral thickness, either superior or
temporal without entering the anterior chamber. A corneal
side-port incision, for a second instrument, is created. The
anterior capsule is stained with trypan blue, usually under an
air bubble. A 2,7-mm incision is performed with a keratome
through the previously created scleral tunnel. A 5.5 to 6.0 mm
capsulorhexis is performed. Hydrodissection is completed by
carefully injecting fluid, not in an excessive amount, to dimin-
ish the possibility of sudden posterior capsule blowout. The
Ultrachopper is then used to initiate the division of the nucleus
into two halves, with the ­vacuum set at 100 mm Hg and the
flow rate at 25 cc/min, using ­continuous torsional phaco at

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Berrospi et al e3

100% power and longitudinal phaco at 50% power (Infinity,

Alcon Laboratories, Inc. Fort Worth, USA). It is true that when
using a peristaltic machine, the preset vacuum level is only
reached when there is complete occlusion of the outflow
line, typically at the phaco tip. In the case of the Ultrachop-
per the occlusion occurs at the lateral aspiration ports. How-
ever, it is also true that vacuum developed by the machine is
proportional to the viscosity of the aspirate and a low level
of vacuum is created when aspirating a mixture of cortex,
small fragments of nuclear material, ophthalmic viscosurgical
device (OVD) and balanced saline solution (BSS), as it occurs
when the Ultrachopper is dividing the nucleus. It is advisable
to first start the vacuum and not the ultrasonic energy (i.e.,
keep the foot pedal in position 2), so that the Ultrachopper tip Fig. 1 - The Ultrachopper has a flattened and curved blade and two
removes cortex, along with the OVD, leaving only BSS in the small aspiration ports. The device is assembled in a phacoemulsifi-
cation hand-piece (Image provided by L. Escaf, Barranquilla, Colom-
proximity of the aspiration ports located in the superior por- bia. Used with permission).
tion that is proximal to the flattened segment, assuring that
a constant flow of fluid will help to refrigerate the shaft (15).
Then the ultrasonic energy is activated and the vibrating blade
can make a deep thin groove into the nucleus without exert-
ing significant stress on the capsular bag and zonules. The
Ultrachopper does not pose a risk to the posterior capsule,
because the length of the blade (2.5 mm) reaches around 40%
to 50% of the nucleus thickness, even in the mid-periphery
of these hard rock cataracts, which usually are very large and
bulky (Figs. 1 and 2). The endpoint of using the Ultrachop-
per is reached when the depth of the cut performed, is deep
enough to let the whole length of the curved portion of the
blade, be inside the nuclear material, at an angle of around 30
degrees. It is not necessary to rotate the nucleus to complete
the creation of the deep groove in the nucleus. During the
step of using the Ultrachopper a second instrument through
the side port may be used to hold the eye relatively steady.
Moreover, in extremely hard nuclei a sustainer can be used to Fig. 2 - The Ultrachopper blade is 2,5 mm length, thus a “safety
perform counter fixation in order to facilitate a controlled and zone” of around 2,0 mm will stay untouched while using the device
gentle creation of the central deep cut. Typically, that step will to cut a hard nucleus, which usually has more than 4,5 mm in thick-
ness (Image provided by L. Escaf, Barranquilla, Colombia. Used with
take less than 1 minute, and usually around 15 seconds. When permission).
working with the Ultrachopper, the surgeon should be cau-
tious to avoid injuring the iris. Subsequently, using the blades
of an Akahoshi Combo prechopper, it is usually very easy to eye with the ­Kansas forceps. Cortical aspiration is performed
divide the nucleus without enlarging the incision (Fig. 3 and in the standard fashion with an I/A probe.
supplementary Video 1, available online at ophthalmology. A rigid or foldable intraocular lens is implanted in the cap-
pointofcarejournals.com); however, sometimes when a pos- sular bag.
terior leathery plate is present it could be necessary to use Since the constructed tunnel is not so long (only 1.5 to
two additional instruments to completely separate the frag- 2.0 mm), in order to guarantee the stability of the wound and
ments, one through the main incision and the other through control induced astigmatism, suturing is part of our protocol.
the side port incision. After finishing the nuclear division, the Two or three separated sutures are placed.
main incision is enlarged to 6.5 mm, through the previously We use this technique when the nuclear color and opales-
constructed biplanar sclerocorneal tunnel. Then, a Drysdale cence is over 6.5 with the Lens Opacities Classification System
nucleus manipulator is used to push the lower part of one III (LOCS III).
heminuclei, still inside the capsular bag, making it to do a Our results in about 50 cases have been very good so far.
complete tumble. With that maneuver, it is very easy to pro- We have not had any posterior capsule rupture or zonular
lapse the first heminucleus into the anterior chamber (Fig. 4 dialysis. However, the selected cases for this technique did not
and supplementary Video 1). Then a Kansas forceps, which have iridodonesis or phacodonesis, or evident zonular dialy-
has two rows of teeth on jaws in order provide a firm pur- sis in the preoperative examination. In addition, although we
chase on the nuclear fragments, is used to remove it from the did not evaluate the percentage of endothelial cell loss, since
eye, through the 6.5 mm incision (Fig. 5 and supplementary we did not have any case of persistent corneal edema, we
Video 1). The second heminucleus is aligned in position and think it could be comparable to manual extraction. Further
easily prolapsed to the anterior chamber with the Drysdale studies are warranted to compare results of this alternative
manipulator or any other instrument, and removed from the with other techniques in rock-hard cataracts.

© 2016 The Authors. Published by Wichtig International

e4 Ultrachopper assisted prechop

Fig. 3 - A hard nucleus is easily separated

in halves using the combination of an
Ultrachopper and a manual Akahoshi
prechopper. (A, B): The Ultrachopper is
passed over the surface of the nucleus
with moderate pressure. The second
instrument is used to hold the eye rela-
tively steady. (C): A thin groove is visible
in the hard nucleus. (D): The nuclear di-
vision is easily attained using a manual
Akahoshi Combo prechopper.

Fig. 4 - Using a Drysdale manipulator,

or a similar instrument, some pressure
is exerted on the inferior portion of the
medial wall of one heminuclei, causing
it to tumble and to prolapse out of the
capsular bag.

Discussion controlled trial performed in two centers in the UK (Moorfields

Eye Hospital, London, and the Oxford Eye Hospital, Oxford)
Phacoemulsification in rock-hard cataracts is challenging. between 1994 and 1998. Within the group of 45 patients with
In 2004, Bourne et al (1) published the results of a randomized hard cataracts, eyes that underwent phacoemulsification

© 2016 The Authors. Published by Wichtig International

Berrospi et al
had a significantly higher risk of severe cell loss (>15% loss
by 1 year) than those that underwent extracapsular cataract
extraction (ECCE) (52.6% vs. 23.1%). The authors concluded
that phacoemulsification may not be the optimal procedure
in rock-hard cataracts and that ECCE should be preferred (1).
It is true that phacoemulsification techniques and equipment
used around 20 years ago have significantly evolved, but
some more recent results have also shown high endothelial
cells loss in hard cataracts after phacoemulsification. In 2011,
Kim et al reported endothelial cell loss in hard cataracts with
phacoemulsification between 37.2 and 42.6% (2).
A validation of a scoring system for preoperative stratifi-
cation of intraoperative risks of complications during cataract
surgery was performed by Agrawal et al in a multi-centric
study in India between 2005 and 2006. The hardness of the
nucleus (classified as dense, total, brunescent, black and
white cataract) was included as a significant risk factor for
complications (3).
During the last 20 years, many techniques have been
described to deal with phacoemulsification in very hard cata-
racts, suggesting that there is not yet one that is consistently
effective in such cases (16-21).
In 1998, Akahoshi (5) described the two approaches of
phaco prechop: Karate prechop for cataracts from soft-to-
medium hardness (grade I-III), and Counter Prechop for hard
cataracts (grade III-V) and complex cases like incomplete
© 2016 The Authors. Published by Wichtig International
e5
Fig. 5 - The two heminuclei are ex-
tracted from the anterior chamber
using a Kansas forceps.
c­ apsulorhexis, weak ciliary zonules, pseudoexfoliation syn-
drome, etc. In the first technique, the sharp edge of a specially
designed cross-action forceps (Combo prechopper) is directly
inserted into the center of the nucleus, and the blades are
slowing opened while the instrument is gently pushed down,
until the nuclear division is attained. Then the instrument is
withdrawn and the round and dull portion of the blades are
used to complete the separation of the heminuclei. Finally,
the same maneuvers can be used to obtain four quadrants.
In the second technique (Counter Prechop) a second instru-
ment (Nucleus sustainer) is used to stabilize the nucleus. The
sustainer is introduced up to the equator of the lens to hold
the nucleus. With the blades closed, the Universal Prechop-
per, which has thinner and sharper blades than the Combo
prechopper, is inserted directly into the nucleus while the
sustainer applies counterforce. The tips of both instruments
must be positioned deeply enough to surround the hardest
central core of the nucleus, and in that moment they are
advanced toward each other. When the tip of the prechop-
per reaches the center of the nucleus, the blades are opened
in order to bisect the cataract. It may be necessary to relo-
cate and reopen the blades several times, to obtain a com-
plete division. Similar maneuvers are repeated to divide the
nucleus in 4 to 8 fragments. In 1998, Akahoshi reported more
than 9000 cases of successful procedures, including in rock
hard nuclei, with only two cases of zonular rupture. Other
e6
groups of surgeons have also reported positive experiences
using phaco prechop in hard cataracts (5-9). However, other
surgeons have found this technique rather difficult (10, 13).
In addition, as it will be discussed below, obtaining the
fragments is only the first difficulty to solve in these challeng-
ing cases. The subsequent phase of emulsifying those pieces
of hard nuclei, is also very risky, both for the corneal endothe-
lium and for the posterior capsule.
Some variations of the phaco prechopping instruments
and/or techniques have been also described. In 2004, Viteri
published the V-prechop technique, which included perform-
ing two oblique nucleus fractures with the prechopper, with
the shape of a “V”, with the vertex pointing to the center of
the corneal incision, before hydrodissection. This technique
was described as an easier option than standard prechop,
especially in soft and medium cataracts (13).
The Salvitti Akahoshi Prechopping Forceps is a cross-
action instrument with wider blades to maximize surface
area in contact with the nucleus, and sharper tip to facilitate
insertion into the cataract material. It has been used in com-
bination with a liquefaction device (AquaLase), but in hard
nuclei it has been suggested that this alternative, which uses
high-pressure streams of warm (about 60°C) balanced saline
solution to fragment the cataract material, is not as efficient
as ultrasonic energy (22).
On the other hand, manual small-incision cataract sur-
gery (SICS) for decades has been another alternative in those
advanced cases (4, 23). Some years ago, in a trial in India,
270 patients with mature white cataract were randomized to
phacoemulsification or manual SICS. Uncorrected distance
visual acuity (UDVA) was comparable in the 2 groups at 6 weeks.
Yet, the manual SICS group had less corneal edema than the
phacoemulsification group. They found that an additional
advantage of manual SICS over phacoemulsification was that it
proved to be a much faster and cost-effective surgical technique
in those eyes with such advanced white cataracts (10). Other
researchers have found manual small incision cataract surgery
also more cost-effective than phacoemulsification (24).
However, in comparison to standard extracapsular cata-
ract extraction, small-incision cataract surgery requires more
nucleus maneuvers inside the anterior chamber during deliv-
ery, which increase the odds of corneal endothelial cells
trauma (4, 25, 26). Standard manual extracapsular extraction
is a time-proven technique and has been shown for several
decades to be safe in hard cataracts. Recently Mohanty et al
published their results in 207 patients with advanced cata-
racts (brunescent, black, total, white or dense) who under-
went conventional extracapsular cataract extraction (12).
They found that 2.9% of the cases had posterior capsule rup-
ture (in contrast with 7.5% of similar cases performed with
phacoemulsification in the study by Agrawal et al (3)). How-
ever, on the other hand, since the incision is larger (typically 9
to 12 mm), standard extracapsular extraction has more risk of
high postoperative-induced astigmatism, and wound-related
complications, like dehiscence.
The use of prechopping techniques in manual SICS has been
also reported. In 2002 Wiriyaluppa and Kongsap (27) published
their combined option, using Prechopping, as described by
Akahoshi, to divide the nucleus before removing it manually
through a 5-6 mm corneal incision. Following bisection of the
Ultrachopper assisted prechop
nucleus, ophthalmic viscosurgical device was injected to pro-
lapse the first fragment into the anterior chamber with the
assistance of a spatula and then, using gentle pressure on the
posterior lip of the wound, it was extracted from the eye with
a 0.12 mm corneal forceps. In 2006 they described a modifi-
cation of their technique using a nuclear chopper and a 23 G
disposable needle or a Micro vitreoretinal blade, instead of a
prechopper forceps (28).
Bhatti (29) in 2005 described another manual small inci-
sion cataract surgery technique including the use of the Aka-
hoshi’s phaco prechop. Nuclear division was performed by
that author through a 5-6 mm corneal tunnel with a tech-
nique similar to Counter prechop, but, unlike Wiriyaluppa
and Kongsap, the fracture was performed partially outside
the capsular bag, after dislocating the proximal portion of
the nucleus into the anterior chamber. The prechopper was
inserted through the corneal tunnel into the posterior aspect
of the nucleus while the anterior aspect of the nucleus was
stabilized using counterpressure exerted through a sideport
by a dialer, so that it was not pushed towards the endothe-
lium by the prechopper. The fragments were then removed
with a vectis under copious viscoelastic (29, 30).
Ultrachopper is an ultrasonic blade that was described
in 2007 by Escaf et al, as a tool to perform nuclear fracture
in a more effective way (14, 31, 32). The Ultrachopper is a
modified phaco needle, with a thin, flat and curved tip. It has
two aspiration ports located in the superior portion, proxi-
mal to the flattened segment. As mentioned, this ultrasonic
blade may be used with any phaco system by connecting it to
the hand-piece; it can quickly be interchanged with another
phaco needle when necessary to go on with the emulsifica-
tion of the fragments. Some systems have the option of an
additional port for this device where an additional hand-
piece can be connected independently (Infinity and Centu-
rion from Alcon) to avoid the necessity of changing the tip of
the hand-piece. It has been shown that this ultrasonic chop-
per is very efficient in dividing rock-hard nuclei (14, 31, 32).
We found that mastering the Ultrachopper as the only tool
used to divide a rock-hard nucleus is not so easy, while using
it to construct an initial deep groove and then use a man-
ual Akahoshi Combo prechopper makes the step of dividing
these very hard nuclei very easy. On the other hand, using
sole the manual Akahoshi prechopper in these very advanced
cataracts is also difficult (9).
As mentioned before, in those challenging cases, nuclear
fractis is only the first obstacle to overcome. To emulsify
the very dense and bulky resulting fragments is also very
demanding and poses risks to the corneal endothelium and
posterior capsule.
We consider that there is still room for SICS in such cases
because manually removing the fragments is safer and more
predictable than using phacoemulsification. In addition, tak-
ing advantage of the capabilities of Ultrachopper for dividing
those rock-hard cataracts, makes the technique easier than
dividing the nucleus with manual approaches usually used in
SICS or employing the prechoppers (26-30).
In conclusion, this Ultrachopper-assisted prechopping for
small incision cataract extraction, is a very good alternative in
rock-hard cataracts, and should be in the armamentarium of
today’s cataract surgeon.
© 2016 The Authors. Published by Wichtig International
Berrospi et al
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