TECHNIQUE
Cross chop: Modified rotationless horizonal chop
technique for weak zonules
Dooho Brian Kim, MD
Cross chop is a modified horizontal chop technique that enables safe and efficient lens disassem-
bly without torquing the lens within the capsular bag.
J Cataract Refract Surg 2009; 35:1335–1337 Q 2009 ASCRS and ESCRS
Online Video
Zonular dehiscence is a potential cataract surgery
problem that can lead to significant morbidity such
as vitreous loss, dropped nuclei, and late intraocular
lens dislocation or subluxation. Risk factors include
ocular trauma, pseudoexfoliation syndrome, and Mar-
fan syndrome.
One of the fundamental steps in cataract surgery is
separating the lens from the capsule by cortical cleaving
hydrodissection.1 The lens is then usually spun within
the capsular bag to facilitate nuclear disassembly by
sculpting or chopping maneuvers. In situations of zon-
ular weakness, rotating the lens may cause unnecessary
manipulation of the zonules. Using the Miyake-Apple
technique,2 Miyake and Apple have shown that the
zonules undergo significant stress when the lens is
torqued within the capsular bag. Although flipping ma-
neuvers3 may obviate the need for lens rotation, limita-
tions include the need for a large capsulorhexis and
supracapsular manipulation, which can traumatize
the corneal endothelium, especially in shallow anterior
chambers. The cross-chop technique is based on a mod-
ified horizontal-chop maneuver that enables lens disas-
sembly without intracapsular lens rotation.
SURGICAL TECHNIQUE
Cortical cleaving hydrodissection1 separates the poste-
rior capsule from the lens. Rather than rotating the lens
Submitted: February 19, 2009.
Final revision submitted: March 20, 2009.
Accepted: March 23, 2009.
From Professional Eye Associates, Dalton, Georgia, USA.
The author has no financial or proprietary interest in any material or
method mentioned.
Corresponding author: Dooho Brian Kim, MD, 1111 Professional
Boulevard, Dalton, Georgia 30720, USA. E-mail: kim@
professionaleye.com.
Q 2009 ASCRS and ESCRS
Published by Elsevier Inc.
in typical fashion, a right-angled Chang hydrodissec-
tion cannula (Katena) is then used to hydrodissect the
edges of the anterior capsulorhexis (Figure 1). This ma-
neuver dissociates the lens from the capsular bag with-
out stressing the zonules by rotation (Video 1). With the
chopper oriented approximately 80 degrees from the
phaco handpiece, the lens is divided into 2 heminuclei
by the horizontal-chop technique (Figure 2), as first de-
scribed by Nagahara (K. Nagahara, MD, ‘‘Phaco
Chop,’’ film presented at the ASCRS 3rd American–
International Congress on Cataract, IOL and
Refractive Surgery, Seattle, Washington, USA, May
1993). The He (Rhein) or Seibel (Ambler) chopper is
slid under the capsulorhexis edge around the lens equa-
tor so the chopper crosses the phaco handpiece in an
‘‘X’’ configuration (Figure 3). The phaco tip is buried
deep within the space between the heminuclei under
foot position 1, irrigation alone (Video 2). During this
maneuver, no ultrasound energy or aspiration is
used; because of the deep placement of the phaco nee-
dle between the 2 segments, the movement of the chop-
per toward the phaco tip causes the heminucleus to
disassemble (Figure 4).
Each fragment is then aspirated and emulsified with-
out rotating the pieces within the capsular bag. Once
the first heminucleus is removed, the other half can
be grasped with the phaco tip oriented bevel-sideways
facing the nucleus using ultrasound and high vaccum,
similar to the initial chop maneuver used during stop
and chop4 (Figure 5). The remaining nucleus can be
chopped and emulsified centrally within the capsular
bag without zonular traction removal (Video 1).
DISCUSSION
Cross chop is a safe and consistent method to disas-
semble the lens without torquing the lens within the
capsular bag. This is especially important for soft
lenses, which are difficult to rotate, or in a case with
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doi:10.1016/j.jcrs.2009.03.028
1336 TECHNIQUE: MODIFIED ROTATIONLESS HORIZONTAL CHOP

Figure 1. After cortical cleaving hydrodissection, the cannula is Figure 2. The initial horizontal chop divides the lens into 2
used to hydrodissect under the anterior capsulorhexis to the left heminuclei.
and right. This maneuver separates the lens from the capsule
without rotating it.

zonular weakness such as trauma, pseudoexfoliation,
or syndromes such as Marfan.
The rotationless hydrodissection technique is a useful
adjunct to cross chop as prophylaxis for zonular stress.
When traditional hydrodissection is difficult, as in cases
of intracapsular distension after hydrodissection or in
cases of shallow anterior segments such as in nano-
phthalmos, the rotationless hydrodissection technique
is highly effective in mobilizing the nucleus without
requiring lens torsion. However, traditional hydrodis-
section does not necessarily jeopardize the zonule and
rotating it in a passive manner after effective separation
is a safe procedure. In cases of known zonular weak-
ness, a capsular tension ring can provide additional
protection, especially when a dehiscence is localized.
Multiple techniques for sculpting, chopping, and
prechopping5 to defragment and remove the lens exist;
however, most require intracapsular manipulation

Figure 3. The chopper is slid under the capsulorhexis edge around Figure 4. The phaco tip is pushed deep between the heminuclei be-
the lens equator so the chopper crosses the phaco handpiece in an fore the cross chop is performed. The chopper is pulled centrally and
‘‘X’’ configuration. meets the phaco tip to divide the heminucleus.

J CATARACT REFRACT SURG - VOL 35, AUGUST 2009

 TECHNIQUE: MODIFIED ROTATIONLESS HORIZONTAL CHOP
Figure 5. Once the first half of the lens is removed, the remaining half
is grasped with the bevel sideways and facing the heminucleus.
Ultrasound energy and high vacuum are used to impale and then
pull the segment centrally, away from the capsular fornix, prevent-
ing zonular stress.
and rotation of the lens to be effective. Although flip-
ping maneuvers such as chip and flip2 do not involve
intracapsular rotation, there are inherent risks to intra-
cameral structures when the lens is prolapsed into the
anterior chamber, especially with small pupils, a small
capsulorhexis, or shallow chambers.
Other techniques are limited by the level of nuclear
density, but cross chop is adaptable to a range of lenses.
The initial horizontal-chop maneuver works well for
harder lenses and is performed by burrowing and im-
paling the nucleus under ultrasound and high vacuum
(Videos 3A and 3B); however, soft nuclei can also be
chopped without difficulty. Rather than impaling the
lens in this fashion, the phaco tip can be pushed deep
into the nucleus under irrigation alone before the
chop maneuver is initiated (Video 4). By eliminating
ultrasound and aspiration during this step, inadvertent
J CATARACT REFRACT SURG - VOL 35, AUGUST 2009
1337
rupture of the posterior capsule is preventable. Hydro-
chop6 is an alternative chop technique for soft lenses.
The chopper design is a factor because certain types,
such as the Chang chopper, have a concave chopping
surface to harness the lens. This requires a specific
angle of approach by the chopper relative to the phaco
needle. Choppers with this design may not be ideal
for the cross-chop technique since this maneuver is per-
formed from a different angle to the chopping surface.
Cross chop can be used for routine cases or reserved
for cases with weak zonules, but there are some disad-
vantages. Since the nondominant hand plays the most
active role during the maneuver, those unaccustomed
to this may face a steeper learning curve. In contrast,
chopping surgeons will have an easier transition since
their techniques require significant bimanual dexter-
ity. Torquing and rotating the lens is inherently an
efficient technique. Since cross chop minimizes this
step, the technique is relatively more time consuming
in lens disassembly and removal.
REFERENCES
1. Fine IH. Cortical cleaving hydrodissection. J Cataract Refract
Surg 1992; 18:508–512
2. Ahmed IIK, Cionni RJ, Kranemann C, Crandall AS. Optimal timing
of capsular tension ring implantation: Miyake-Apple video analy-
sis. J Cataract Refract Surg 2005; 31:1809–1813
3. Fine IH. The chip and flip phacoemulsification technique. J Cata-
ract Refract Surg 1991; 17:366–371
4. Koch PS, Katzen LE. Stop and chop phacoemulsification. J Cat-
aract Refract Surg 1994; 20:566–570
5. Akahoshi T. Phaco prechop: manual nucleofracture prior to pha-
coemulsification. Operative Tech Cataract Refract Surg 1998;
1:69–91
6. Braga-Mele R, Khan BU. Hydro-chop technique for soft lenses.
J Cataract Refract Surg 2006; 32:18–20
First author:
Dooho Brian Kim, MD
Professional Eye Associates,
Dalton, Georgia, USA