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Second Edition
Phaco Chop
and Advanced
Phaco Techniques
Strategies for Complicated Cataracts
While chopping techniques are particularly advantageous
for complicated cataracts, they must be integrated with other
devices and strategies. Phaco Chop, the best-selling cataract
surgery book, has been revised and updated into a Second
Edition to reflect the many advances over the past few years.
More than half of the 30 total chapters are new. These detail
strategies for complicated cases and introduce femtosecond
laser nuclear fragmentation techniques.
Dr. David F. Chang is widely acknowledged as one of the best
cataract surgical teachers. His video instruction courses for
phaco chop and complicated cataracts have consistently
ranked among the best attended and top rated at the American
Academy of Ophthalmology and American Society of Cataract
and Refractive Surgery meetings for over a decade.
The Four Main Sections inside
the Second Edition:
• Phaco Chop Techniques
• Phacodynamics of Chopping
• Femtosecond Laser Nuclear Prechopping
• Complicated Cases and Complications: Strategies
and Management
Section One is a detailed guide for learning phaco chop. The
faculty from Dr. Chang’s popular phaco chop course outlines
their pearls based upon extensive experience teaching residents
and transitioning surgeons.
Section Two provides the general principles of instrumentation
and configuring machine parameters. Separate chapters
specifically address optimizing the Infiniti, Signature, and
Stellaris platforms for chopping.
MEDICAL/Ophthalmology
12-1431_Chang_PhacoChop_fullCover.indd 1
Chang
Second Edition
Phaco Chop
Phaco Chop and Advanced Phaco Techniques
and Advanced
Phaco Techniques
Strategies for Complicated Cataracts, Second Edition
Section Three introduces femtosecond laser nuclear
prechopping with separate chapters on the LenSx, LensAR, and
OptiMedica platforms.
Section Four covers small pupils and IFIS, rock hard and white
Strategies for Complicated Cataracts
mature cataracts, weak zonules, and extremely long and short
eyes with an emphasis on managing posterior capsule rupture,
advanced IOL fixation strategies, and avoiding and managing
capsulorrhexis complications.
Bonus Video Material!
Phaco Chop and Advanced Phaco Techniques, Second
Edition includes many 2D and 3D instructional videos that
complement and supplement the content of the book.
With your book purchase, you will receive a DVD that contains
26 surgical videos in high definition 3D format. With the
enclosed 3D glasses, learning intraocular surgical techniques is
taken to a new level.
Additionally, you will receive access to a Web site that includes
additional companion surgical videos narrated by Dr. Chang
in 2D format—watch, listen, view repeatedly, and learn the
techniques!
The narrated videos produced by Dr. Chang illustrate advanced
surgical techniques and technologies. Together with over 900
high-resolution operative photographs, this paired format
overcomes the limitations of learning new and advanced
surgical techniques from written text alone.
With its comprehensive and integrated emphasis on advanced
surgical techniques, optimizing phaco technology, and
complication management, Phaco Chop and Advanced Phaco
Techniques: Strategies for Complicated Cataracts, Second
David F. Chang
Edition will appeal to residents and transitioning surgeons as
well as high volume surgeons interested in honing their most
advanced phaco skills.
Contributing Authors: Takayuki Akahoshi, Lisa B. Arbisser, Robert J. Cionni,
ISBN 978-1-61711-075-7 Louis D. “Skip” Nichamin, Randall J. Olson, Mark Packer, Barry S. Seibel
90000
SLACK Incorporated
9 781617 110757
3/19/2013 2:29:47 PM
 CONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword by Robert H. Osher, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Section I Phaco Chop Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 Why Learn Chopping? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

David F. Chang, MD

Chapter 2 Horizontal Chopping: Principles and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Randall J. Olson, MD

Chapter 3 Vertical Chopping: Principles and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Louis D. “Skip” Nichamin, MD

Chapter 4 Comparing and Integrating Horizontal and Vertical Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

David F. Chang, MD

Chapter 5 Transitioning to Phaco Chop: Pearls and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

David F. Chang, MD

Chapter 6 Phaco Prechop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Takayuki Akahoshi, MD

Chapter 7 Biaxial Microincision Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Mark Packer, MD, FACS, CPI

Section II Phacodynamics of Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Chapter 8 Understanding the Phacodynamics of Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Barry S. Seibel, MD

Chapter 9 Optimizing Machine Settings for Chopping Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

David F. Chang, MD

Chapter 10 Optimizing the Alcon Infiniti for Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

David F. Chang, MD and Barry S. Seibel, MD
Sidebar: Ultra Chopper Theory and Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Alan S. Crandall, MD

Chapter 11 Optimizing the AMO Signature for Chopping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

David F. Chang, MD

Chapter 12 Optimizing the Bausch + Lomb Stellaris for Chopping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Louis D. “Skip” Nichamin, MD

Section III Femtosecond Laser Nuclear Prechopping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chapter 13 Femtosecond Laser Nuclear Fragmentation (LenSx Platform) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Robert J. Cionni, MD
viii Contents
Chapter 14 Femtosecond Laser Nuclear Fragmentation (LensAR Platform) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Louis D. “Skip” Nichamin, MD

Chapter 15 Femtosecond Laser Nuclear Fragmentation (Catalys Platform) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Barry S. Seibel, MD

Section IV Complicated Cases and Complications: Strategies and Management . . . . . . . . . . . 163

Chapter 16 Capsulorrhexis: Sizing Objectives and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

David F. Chang, MD

Chapter 17 Conquering Capsulorrhexis Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

David F. Chang, MD

Chapter 18 Pearls for Hydrodissection and Hydrodelineation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

David F. Chang, MD

Chapter 19 Strategies for the Rock Hard Nucleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

David F. Chang, MD

Chapter 20 Advanced Phaco Techniques for Brunescent Nuclei: Cross-Action Chop

Circumferential Disassembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Lisa B. Arbisser, MD

Chapter 21 Strategies for Small Pupils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

David F. Chang, MD

Chapter 22 Intraoperative Floppy Iris Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

David F. Chang, MD

Chapter 23 Strategies for Weak Zonules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

David F. Chang, MD

Chapter 24 Intraocular Lens Implantation With Abnormal Zonules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

David F. Chang, MD

Chapter 25 Phaco in Highly Myopic Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

David F. Chang, MD

Chapter 26 Phaco Within the Crowded Anterior Segment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

David F. Chang, MD

Chapter 27 Strategies for Managing Posterior Capsule Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

David F. Chang, MD

Chapter 28 Intraocular Lens Implantation Following Posterior Capsule Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

David F. Chang, MD

Chapter 29 Strategies for Unplanned Anterior Vitrectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Lisa B. Arbisser, MD

Chapter 30 Posterior Capsule Rupture and Vitreous Loss: Advanced Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Louis D. “Skip” Nichamin, MD

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

 ACKNOWLEDGMENTS
In my 2012 inauguration speech as the American Society of Cataract and Refractive Surgery (ASCRS) president, I high-
lighted our remarkable willingness to teach and help one other:
For busy clinicians, our personal time is precious. And yet I know of no other profession where so many of its
members regularly volunteer so much of their time to teach others the skills to become as good as the teacher. The
expression “pay it forward” describes the unselfish concept of having someone repay your good deed not to you, but
rather to a future stranger. We teach residents and colleagues not because of obligation or compensation, but out of
appreciation for those who so generously taught and mentored us.
This tradition is indeed a big part of what makes our profession special. I remain indebted to so many individuals who
taught me the clinical, surgical, and professional practice skills that have made my career performing cataract surgery so
rewarding. Along with my coauthors, I am fortunate to now have the opportunity to share this knowledge with others
through this textbook. Randy Olson, Skip Nichamin, and Barry Seibel are gifted teachers who have collaborated with me
on our phaco chop course at every American Academy of Ophthalmology (AAO) and ASCRS meeting since 1998. I want
to thank them along with each of the other talented friends who contributed chapters to this edition.
I am grateful to have a wonderful relationship with the entire SLACK publishing team that has produced this, our fifth
major book together. My good friend John Bond has shepherded me through each of these projects and has always pro-
vided the resources and support that I have needed. The production quality of this new edition was made possible through
the hard work of April Billick, Cara Hvisdas, and the proficient editing of Stephanie Wieland. Thank you all for being
simultaneously patient, flexible, professional, and cheerful in what is always a strenuous process. By pioneering 3D surgical
video technology, TrueVision of Santa Barbara, California has provided us with an amazing tool for eye surgical educa-
tion. I want to thank Forrest Fleming and his team for all of their support in my efforts to use 3D video to teach surgical
techniques. Special thanks go to Burton Tripathi for his expert technical help in producing the companion 3D videos for
this textbook.
I want to thank my family—Courtney, Alex, and my wife of 33 years, Victoria—for tolerating and supporting my time
consuming “hobby” of learning, teaching, performing, and studying cataract surgery. And finally, I want to thank my
nonagenarian father who, by overcoming the many hurdles facing a foreign medical graduate from China in the early
1950s to become an accomplished anesthesiologist, taught me the value of hard work and inspired my career in medicine.
 ABOUT THE AUTHOR
David F. Chang, MD is a Summa Cum Laude graduate of Harvard College and Harvard Medical School. He completed
his ophthalmology residency at the University of California, San Francisco (UCSF) where he is now a clinical professor.
Having chaired the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee, Dr.
Chang joined the ASCRS Executive Committee in 2009, serving as president in 2012-2013. He is also chairman of the
American Academy of Ophthalmology (AAO) Cataract Preferred Practice Pattern Panel, immediate past chair of the AAO
Practicing Ophthalmologist Curriculum Panel for Cataract/Anterior Segment, and in 2009 completed his 5-year term
as chair of the AAO Annual Meeting program committee. Dr. Chang is a board member of the ASCRS Foundation and
serves on the medical advisory board of 2 global humanitarian organizations (Himalayan Cataract Project and Project
Vision). He is also an adjunct clinical professor of ophthalmology at the Chinese University in Hong Kong and honorary
professor for the Zhongshan Ophthalmic Center of Sun Yat-Sen University in China.
In 2006, Dr. Chang became only the third ophthalmologist to ever receive the Charlotte Baer Award honoring the
outstanding clinical faculty member at the UCSF Medical School. He has received the highest honor for cataract surgery
from the ASCRS (Binkhorst Medal), the AAO (Kelman Lecture), the Asia Pacific Association of Cataract and Refractive
Surgery (Lim Medal), the United Kingdom and Ireland Society of Cataract & Refractive Surgery (Rayner Medal), the
Canadian Society of Cataract and Refractive Surgery (Award of Excellence/Stein Lecture), the Indian Intraocular Implant
and Refractive Society (Gold Medal), the Italian Ophthalmological Society (Strampelli Medal), and the Royal Australia
and the New Zealand College of Ophthalmologists (Gregg Medal). He has also been asked to give the Keynote Lecture for
the Asia Pacific Academy of Ophthalmology Annual Meeting.
Dr. Chang has been selected to deliver the following additional named lectures: Transamerica Lecture (UCSF), Wolfe
Lecture (University of Iowa), DeVoe Lecture (Columbia-Harkness), Gettes Lecture (Wills Eye Hospital), Helen Keller
Lecture (University of Alabama), Williams Lecture (UCSF), Kayes Lecture (University of Washington, St. Louis), Thorpe
Lecture (Pittsburgh Ophthalmology Society), Schutz Lecture (New York University Medical Center), Wallace-Evan
Lecture (Casey Eye, Oregon), Kambara Lecture (Loma Linda), Boyaner Lecture (McGill), Herbert Lecture (UC Irvine),
Rodriguez Lecture (Univ Arizona), Jules Stein Lecture (UCLA-Jules Stein), Paton Medal Lecture (Baylor/Cullen Eye),
Weinstock Lecture (Wills Eye Hospital), and the Proctor Lecture (UCSF/Proctor Foundation). In addition to the AAO
Achievement and Senior Achievement awards, Dr. Chang is also a 6-time AAO Secretariat Award recipient. He was the
inaugural recipient of the UCSF Department of Ophthalmology’s Distinguished Alumni Award (2005).
Dr. Chang is the chief medical editor of EyeWorld, associate international editor for the Asia-Pacific Journal of
Ophthalmology, and served for 5 years as co-chief medical editor for Cataract and Refractive Surgery Today. He
was the textbook editor of Cataract Surgery Today (CRST 2009), Mastering Refractive IOLs—The Art and Science
(SLACK Incorporated 2008) and Curbside Consultation in Cataract Surgery (SLACK Incorporated 2007), the series editor
for the 8 SLACK Incorporated Curbside Consultation ophthalmology textbooks, and the principal author of Phaco Chop
(SLACK Incorporated 2004).
 CONTRIBUTING AUTHORS
Takayuki Akahoshi, MD (Chapter 6) Randall J. Olson, MD (Chapter 2)
Director of Ophthalmology John A. Moran Eye Center
Mitsui Memorial Hospital Salt Lake City, Utah
Tokyo, Japan
Robert H. Osher, MD (Foreword)
Lisa B. Arbisser, MD (Chapters 20 and 29) Professor of Ophthalmology
Eye Surgeons Associates University of Cincinnati
Bettendorf, Iowa College of Medicine
Medical Director Emeritus
Robert J. Cionni, MD (Chapter 13) Cincinnati Eye Institute
Cincinnati Eye Institute Cincinnati, Ohio
Cincinnati, Ohio
Mark Packer, MD, FACS, CPI (Chapter 7)
Alan S. Crandall, MD (Chapter 10 Sidebar) Clinical Associate Professor
John A. Moran Eye Center Oregon Health & Science University
University of Utah Portland, Oregon
Salt Lake City, Utah
Barry S. Seibel, MD (Chapters 8, 10, and 15)
Louis D. “Skip” Nichamin, MD (Chapters 3, 12, 14, and 30) Clinical Assistant Professor of Ophthalmology
Laurel Eye Clinic University of California, Los Angeles
Brookville, Pennsylvania Geffen School of Medicine
Seibel Vision Surgery
Los Angeles, California
 FOREWORD
To write a good foreword, it may be helpful to begin by looking backward. I first met David F. Chang, MD in the late
1980s when I was drawn into a cataract lecture where a young ophthalmologist had the standing-room crowd in the “palm
of his hand.” It was immediately obvious why so many had converged to hear this speaker. His words were carefully pre-
pared, full of wisdom, and delivered with humor and enthusiasm.
Over the next 2 decades, few have experienced such a meteoric rise, developing a reputation as one of the finest teach-
ers and surgeons on the planet. Armed with a prodigious work ethic and boundless energy, ophthalmologists around the
world were treated to one brilliant lecture after another, chapter after chapter, and book after book. All were accomplished
with humility and integrity.
Major organizations quickly recognized Dr. Chang’s contribution and he was drafted into the leadership of the
American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS).
Industry identified his credibility and he was sought after for his thoughtful and innovative advice. Even other disciplines
in medicine, such as urologists, were impacted by his observations.
Among his recent accomplishments, Dr. Chang is the perennial organizer of the AAO Spotlight Session and he serves
as the Editor of the ASCRS publication, Eye World. He has delivered the most prestigious named lectures including the
Binkhorst and the Kelman lectures. He is currently serving as the president of ASCRS.
I was delighted when my dear friend David invited me to write the foreword to his Second Edition of Phaco Chop. I
could strongly support the importance of phaco chop while complimenting the other authors whose chapters are filled
with essential information. I knew I could also say loud and clear what we all know to be true: Dr. David Chang is a gifted
surgeon, a gifted teacher, and a gift to ophthalmology.

Robert H. Osher, MD
Professor of Ophthalmology
University of Cincinnati
College of Medicine
Medical Director Emeritus
Cincinnati Eye Institute
Cincinnati, Ohio
 INTRODUCTION
Like most surgeons, ophthalmologists need a good reason to alter something that they are already comfortable with
and which works very well for them. According to the latest Leaming surveys, roughly half of all cataract surgeons still
rely on some form of divide-and-conquer technique, because it is both reliable and effective for the majority of their cases.1
However, since Dr. Kunihiro Nagahara2 first introduced the concept to us in 1993, I’ve been a strong proponent of phaco
chop. In performing this technique exclusively for nearly 20 years, I have found that it is not only more efficient for routine
cataracts, but is particularly effective for complicated cases, such as those with small pupils, loose zonules, brunescent
nuclei, or mature white lenses. It is during stressful surgical situations such as these, that we always wonder if there is a
better and safer way. In this textbook, my coauthors and I will review why we believe that phaco chop is the better and
safer way, and how it can help us avoid complications in these high-risk cases. Of course, in order to reap the benefits of
phaco chop for difficult cataracts, one needs to have first mastered this technique in routine eyes.
The first section of this textbook will discuss the mechanics of chopping. We will describe and compare the 2 basic
techniques—horizontal and vertical chopping—and discuss where each is most effective. We will discuss the universal
advantages of chopping and how to maximize these benefits. Finally, compared to divide-and-conquer, the technique of
phaco chop is harder to master because many of the most difficult maneuvers are performed with the non-dominant hand.
This is one of the reasons why the learning curve may be more difficult than ophthalmologists initially anticipate. We will
attempt to guide you through the learning curve by discussing pearls for transitioning to chop from divide-and-conquer
based upon our collective experience in teaching residents and transitioning surgeons.
The second section will address the phacodynamics of chopping. More than any other operative technique, phaco chop
has benefited from continual innovation and advances in phaco technology. While this is a complicated and evolving
topic, understanding the principles of configuring the phaco machine for chopping is necessary if one is to maximize suc-
cess with this technique. The newest technology to impact chopping is of course the femtosecond laser, which can image
and then fragment the nucleus in situ using a variety of prechop patterns. We provide information on nuclear softening
and fragmentation strategies from the 3 femtosecond laser manufacturers that are farthest along in the development of
this technology.
The third section will discuss the avoidance and management of complications. Because a capsulorrhexis and the hydro
steps are prerequisites to safe chopping, we will discuss how to avoid problems with these maneuvers. We will discuss the
overall approach to complicated cataracts, and the ways in which phaco chop can help. Finally, we will discuss how to man-
age complications of chopping. Posterior capsule rupture, vitreous loss, and descending nuclei can complicate any phaco
technique and are discussed in detail.
Much of the core material in this textbook is based upon a phaco chop instruction course that, since 1998, has been
attended annually by hundreds of surgeons at both the American Academy of Ophthalmology (AAO) and the American
Society of Cataract and Refractive Surgery (ASCRS) meetings. The course continually ranks among the highest attended
instruction courses at both meetings, demonstrating high interest in this subject. The authors include the four faculty
members of the chop course, along with additional invited experts in specific methods of chopping. Because of time
limitations, we are unable to cover many important topics in sufficient detail in a 2-hour long course curriculum at these
meetings. This book provides us with an opportunity to expand upon these areas.
Several topics are covered by more than one author, which provides some intentional overlap. Many would argue that
teaching and performing cataract surgery is as much art as science. Thus, while the lead author has sought to provide a
unifying style and approach throughout the book, the opportunity to read differing perspectives, opinions, and approach-
es is also invaluable. With this in mind, exposure to our collective teaching and surgical experience will hopefully enhance
rather than confuse the educational process.
Finally, it is difficult to teach ophthalmic microsurgical techniques without the use of video. It is equally difficult to
provide enough background detail and explanation in a video presentation alone. For this reason, a companion DVD with
footage on phaco chop, complications, and complex cases has been produced. The first edition of this book was the first
instance in which a companion DVD was paired with an ophthalmic surgical textbook.

David F. Chang, MD

REFERENCES
1. Leaming DV. Practice styles and preferences of ASCRS members—2011 survey. Analeyz Inc. http://www.analeyz.com/AnaleyzASCRS2011.htm
2. Nagahara K. “Phaco Chop” film International Congress on Cataract, IOL, and Refractive Surgery; May 1993; Seattle, WA.
SECTION I
Phaco Chop Technique

Why Learn Chopping?
David F. Chang, MD
All modern phaco methods rely on the principle of lens
“disassembly,” in which the firm nucleus is divided into
smaller, maneuverable pieces.1-9 This strategy of disassem-
bly achieves 2 advantages. First, the 10-mm wide nucleus
can be removed through a 5-mm diameter capsulorrhexis.
Second, the majority of the nuclear material is emulsified
near the center of the pupil at a safe distance from the iris,
posterior capsule, and corneal endothelium.
A capsulorrhexis is imperative because it preserves the
bag-like anatomy and function of the capsule (Figure 1-1A).
Not only does this provide the most secure fixation and
centration of the intraocular lens (IOL), but its continuous
edge renders the entire capsular bag much more resistant
to tearing during nuclear emulsification (Figure 1-1B).10-13
The “hydro” steps are equally important. Because there
is only one fixed phaco incision, rotation of the large diam-
eter nucleus is vital for maximum safety. Hydrodissection
separates the nucleus (both endonucleus and epinucleus)
from the capsule so that it can spin within the capsular
bag.14 It also loosens the capsular-cortical attachments,
which facilitates subsequent cortical clean-up (Figure 1-2).15
Although optional, the hydrodelineation wave cleaves
a thin epinuclear shell apart from the firm endonucleus.
Because the epinucleus is soft enough to be aspirated, this
method of disassembling the lens into 2 separate nuclear
components reduces the dimensions of the central mass
-3-
1
that must be chopped, fragmented, and emulsified. In addi-
tion, because it has some bulk and stiffness, the epinuclear
shell blocks the tendency of the exposed posterior capsule
to trampoline toward the phaco tip as the final pieces of
endonucleus are emulsified.
NUCLEOFRACTIS PRINCIPLES
If one imagines a wooden log, there are 2 very dissimilar
approaches to splitting it. After laying it horizontally on the
ground, one could saw through most of the diameter until
the last connecting bridge is weak enough to be cracked
or snapped apart. Alternatively, one could place the log
upright and use an axe to chop it. As long as the initial split
travels more than 50% of the distance, the cleavage plane
can be extended through the remainder of the log by manu-
ally prying the 2 sections apart.
This analogy conveys the conceptual difference between
the 2 most popular nucleofractis strategies: divide-and-
conquer and chopping.6 With divide-and-conquer, a deep
groove must be cut across the central diameter of the
nucleus. In thick, brunescent nuclei without an epinucleus,
the groove must extend much deeper and closer to the
posterior capsule. At that point, manually separating the
segments will crack the remaining posterior bridge of tissue
Chang DF.
Phaco Chop and Advanced Phaco Techniques: Strategies for
Complicated Cataracts, Second Edition (pp 3-9).
© 2013 SLACK Incorporated.
4 Chapter 1

A B

Figure 1-1. Vertical chop of a mature white cataract with trypan blue dye staining of the anterior capsule. (A) Nucleus is impaled
with high vacuum and burst mode. (B) Hemisections are separated following initial vertical chop. The capsulorrhexis stretches
without tearing.

apart. Like sawing through a log against the grain, signifi-

cant energy and multiple sculpting passes are required. The
same steps are repeated in order to subdivide each hemi-
nucleus.
Phaco chop would be analogous to placing the log
upright on one end and chopping it with an axe. As
Nagahara reasoned, the crystalline lens fibers are arranged
in lamellae oriented much like the grain within wood.
Because the chopping force is oriented parallel to these
lamellae, or “with the grain,” a natural fracture plane is
exploited and the nucleus can be split with surprisingly
little manual force. Again, once more than half of the log
is split, prying the 2 sections apart propagates the fracture
until the remaining wood is cleaved.
As with an axe, all chopping techniques utilize manual
instrument forces to segment the nucleus, thereby replacing
the ultrasound power otherwise needed to sculpt grooves. Figure 1-2. Hydrodissection wave moving toward the contrain-
Such energy efficiency is possible because the lamellar ori- cisional pole of the lens.
entation of the lens fibers creates natural fracture planes
within the hardened nucleus that the chopping maneuver
takes advantage of. modifications can be quite confusing to the transitioning
surgeon. For simplification, this author first proposed
that all chopping methods be conceptually divided into
2 general categories of chopping: horizontal and vertical.6
CLASSIFICATION: HORIZONTAL Both share the same benefits of being able to fragment the
VERSUS VERTICAL CHOP nucleus manually, but they accomplish this objective in dif-
ferent ways.
Since Nagahara first introduced the concept of phaco The classic Nagahara technique is an example of
chop at the 1993 American Society of Cataract and horizontal chopping, because the instrument tips move
Refractive Surgery (ASCRS) meeting, many different chop- toward each other in the horizontal plane during the chop
ping variations have evolved. The various innovators have (Figure 1-3).6 In vertical chopping, the 2 instrument tips
used an assortment of descriptive names based upon move toward each other in the vertical plane in order to cre-
the type of maneuvers involved in their particular tech- ate the fracture (Figure 1-4). Although David M. Dillman,
nique.4,6-9 However, this diverse array of slight technique MD later popularized the name “Phaco Quick Chop,” the
 Why Learn Chopping? 5

A B

Figure 1-3. Horizontal chop. (A) Initial movement of chopper tip is toward the phaco tip in the horizontal plane. Both instrument tips
must be positioned deeply enough in order to maximize the amount of nucleus in the path of the chopper. (B) Horizontal chopper
tip (Chang Combination Chopper, Katena Eye Instruments, Denville, NJ) featuring a curved, elongated microfinger design.

A B

Figure 1-4. Vertical chop. (A) Initial movement of chopper tip is toward the phaco tip in the vertical plane. The phaco tip must be
deeply impaled centrally, and the chopper tip incises just anterior to the phaco tip. (B) Vertical chopper tip (Chang Combination
Chopper, Katena Eye Instruments) featuring a short, sharpened tip to incise with minimal resistance.

“Phaco Snap and Split” by Hideharu Fukasaku, MD, was
the first incarnation of this concept.16 Horizontal and verti-
cal chop will be detailed in the following 3 chapters.
PHACO PRECHOP
Among the many chopping variations, Takayuki
Akahoshi, MD and Jochen P. Kammann, MD have devised
instrumentation and techniques for prechopping the nucle-
us prior to insertion and use of the phaco tip.17 These
prechop techniques constitute a separate special category
but incorporate the principles of horizontal chopping. In
the case of a denser lens, one manual instrument must
generally hook the equator so that the penetrating and
chopping forces are not transmitted directly to the capsular
bag and zonules.
Prechopping techniques have many proponents, and a
subsequent chapter is devoted to this subject. Others find
that devising a way to perform chop without the phaco
tip is unnecessary. One potential problem with prechop
techniques is that a certain amount of debris is liberated
after the initial chop. Without the phaco tip to aspirate it,
this may impair visibility for the subsequent steps. Another
problem is that most prechop techniques and instrumen-
tation are designed to create 4 nuclear quadrants. While
adequate for soft and medium nuclei, it is more difficult to
create multiple, smaller pieces with prechopping, as would
be desirable for denser and larger nuclei.
A specific challenge to using any prechopper is the abil-
ity to judge how deeply it has penetrated into a thicker, firm
6 Chapter 1

A B

Figure 1-5. Stop and chop technique. (A) As with divide-and-

conquer, a deep, central trench is sculpted across the nucleus. C
The red reflex helps in judging the depth of the sculpting tip.
(B) Without vacuum, the 2 instrument tips are used to crack
through the posterior connecting plate. (C) Chopping is initi-
ated by first hooking the equator of one hemisection with the
chopper. Next, the phaco tip is lowered into the trench and
placed against one side of the nuclear hemisection.

nucleus. Adequate depth is necessary before separation

is commenced, but over-penetration can be risky for the
capsular bag. Finally, prechopping requires additional steps
and instrumentation that are avoided when the phaco tip
itself is utilized for the chopping technique. This is the
same reason that most divide-and-conquer surgeons do not
remove the phaco tip to use a manual cracking instrument
to separate the heminuclei and quadrants. By prechopping
and softening the nucleus, the femtosecond laser further nucleus in half with a traditional groove and cracking step
reduces the amount of ultrasound or manual instrument (Figure 1-5A and 1-5B). He then would stop sculpting and
energy needed to remove the lens. As would be expected, chop each heminucleus into 3 pieces using Nagahara’s hori-
the denser the nucleus the greater the reduction in ultra- zontal chop technique (Figure 1-5C).
sound energy and time afforded by femtosecond laser
Stop and chop became popular because it eliminated
nucleotomy is.18
the difficult first step of chopping the entire nucleus in half
without any sculpting. However, the majority of sculpt-
ing with divide-and-conquer takes place during the initial
STOP AND CHOP groove. Thus, although stop and chop utilizes some chop-
ping, it cannot deliver the full benefits that pure horizontal
In 1994, Paul S. Koch, MD published his variation of and vertical chopping techniques can.
Nagahara’s pure chopping technique that he named “stop
and chop.”3 Koch felt that an inherent disadvantage of
Nagahara’s concept was that the chopped fragments would
remain tightly wedged within the capsular bag like jigsaw
ADVANTAGES OF CHOPPING
puzzle pieces. He noted that Dr. Howard V. Gimbel’s tech-
Virtually without exception, surgeons who are able to
nique of fracturing across a trench first involved sculpting
master it will continue to prefer chopping. There has been
a crater at the center, which provided mobility to subse-
a steady increase in the percentage of surgeons preferring
quently fractured pieces.2 Seeking to marry the advantages
chop during the past 15 years. According to the ASCRS
of these 2 techniques, Koch described first dividing the
Leaming surveys, this percentage was 11% in 1997, and
Another random document with
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temper. I was proud and sullen, and—ungrateful.”
“Not always that.”
“I think I hated almost everybody. I did not want to be governed or
counseled. And Stephen was so—rigid and prompt. He treated me
like a little boy—”
“Oh, hush!” I interrupted.
“Some of it is true. He admits it. And when that awful affair
happened I expected he would disown me. He is so proud, then he
never did anything bad in all his life. So I felt that I had no mercy to
expect from him.”
“But you were mistaken,” I said eagerly.
“I couldn’t have gone there and in that way but for you. Perhaps he
has told you—” and his eyes questioned mine.
“No,” I answered, glad that we had not discussed it.
“I went to him. I believe it was the first manly step of my life. But,
oh, I felt so forlorn and miserable—I can’t tell you! If he had been
cold and cross I believe I should have gone and thrown myself in the
river.”
“He was not.”
“Oh, Rose, it was like the story of the prodigal son. ‘Fell upon his
neck and kissed him.’ I remember his kissing me the day father was
buried, and I do not believe any one ever did since till then. It melted
all my soul. Somehow I think he is wonderfully changed. His
goodness is so tender.”
“And you love him?”
“Love isn’t any word. I absolutely adore him! I did not think it was
in me, or in him. And all through the weeks that followed, for I was
very ill and miserable, he was so good. I never talked to any one
before, except you, somehow I could not. But he found his way to my
heart and said he would help me, that we would both try together, for
he had many faults to correct, that God had given us the tie of
brotherhood for a high and holy purpose, that we were to help and
strengthen each other; as if, Rose—as if I could do anything for him!”
“Yes, you can,” I replied. “You can keep him tender and cordial and
brotherly.”
“So he said. We did not come to this all at once, and Mrs.
Whitcomb’s cheerfulness helped. I had to try hard to be patient. I
was so used to flying out at everything. You see, at uncle’s they all
knew that I had a bad temper, they expected me to explode or sulk
on the slightest provocation, and only laughed or tormented me. If I
had been taught to control myself, it would never have been so
dreadful.”
“It is good to have the lesson learned now.”
“I never can forget it, never! I am not an angel yet, Rose, cherubim
or seraphim, I suppose Miss Fanny would say;” and he smiled oddly,
“but I am trying. I do not disdain the helps as I used to. I do not feel
that patience and self-control are exclusively girlish virtues.”
“No,” I returned, “we girls will not rob you of them.”
“You are generous. But then you always were. I am beginning to
learn that the grand corner-stones for the human soul are truth and
love, the truth that leads us to be fair and just to others, and the love
to our neighbor.”
“Here we are,” I said. “Do you want to come in?”
He followed me and we did our errand.
“I could not understand last summer why you loved to do these
things;” he began when we were homeward-bound.
“You considered it an evidence of a depraved taste?”
He smiled rather sadly.
“I supposed people consulted their own pleasure first. Doing any
rather distasteful deed and hunting around until you found a bright
side to it was like so much Sanscrit to me.”
“He came not to please—Himself;” I said solemnly.
 “I understand a little now. Yet when He had redeemed the world
there must have been a great joy in His own mind, as well as in
heaven.”
“We cannot do anything like that,” I said. “But as He loved us, so
we are to love the brethren, the whole world.”
“To be willing to do for them. To seek not our own pleasure
altogether. It is very hard, Rose, and sometimes I get discouraged.
Then Stephen tells me of his failures. It doesn’t go on continually. It
is a little doing all the time, work and healing, and he says it will have
to be so in this world.”
“Yes,” I answered. “We cannot hinder nor change. God sets the
work before us, and though the pleasant fields are all about us, we
have no right to choose our own paths. He knows best in what ways
He wants us to walk.”
“I talked to your father yesterday. I did not think I could talk to
anybody but you and Stephen. I was sorry for all the pain and
anxiety I had caused him—and—it was almost like having a father of
one’s own. I don’t wonder that you all have such sweet pleasant
natures.”
We met Lily and Tim taking a walk, their hands full of grasses and
wild flowers, so we turned them about and all went home together.
The visit proved a very delightful one. We went to the Cascade
one day, taking a lunch with us, and on another day the Churchills
sent their family carriage over and we had a royal time, crowding it
full, and taking turns in driving.
We all noticed the great change in Louis. Not that he was perfect
or saintly. In fact I think he was more of a boy, when it came to that,
than the summer before. He still had a dangerous tendency to
quickness of temper, sometimes he would flush deeply when
annoyed, but he always spoke afterward in a low, even tone of voice,
as if he had gained the mastery within. His feelings were more
healthy-toned, he had a heartsomeness that was genuine. You never
mistrusted it as you did Stuart’s.
 We ended the festivities with a croquet and tea-party on Saturday
afternoon, asking in a half dozen young people who all enjoyed
themselves amazingly. To the surprise of everybody, right in the
midst of the gayety who should drop down upon us but Stephen
Duncan.
“I was homesick to see you all,” he began, with a comically
lugubrious face.
“If you think you are going to be purely ornamental you are much
mistaken;” declared Fanny. “Here is a mallet and here is a place.”
“If you will excuse me—”
“But I will not. No running away to the study to talk with papa, or to
play with Edith. If you will come uninvited to a party you must take
the consequences.”
“Can I not soften your heart, if like the old man I should ‘sit on the
stile and continue to smile?’”
“Not any smiles. I am obdurate.”
He pretended to be much aggrieved, but in reality he was very
gay. I had never seen him so amusing and entertaining.
“I don’t see how you get acquainted with such loads of nice
people;” said Allie West. “And you always have such good times
here.”
The good times came without any trying. There are numberless
gates called Beautiful all along life, at which you give such as you
have, and find it more precious than silver or gold.
It was a lovely moonlight night, so after supper we walked part of
the way with the merry crowd. It did not seem to me that I had ever
been so happy in my life. I could not tell why but I felt as if I must
have wings somewhere that were lifting me off the ground at every
step.
We rambled around under the trees and by the way side. Louis
came back to my vicinity and we fell into a rather grave talk about
the future.
 “I never thought I should want to stay here so much,” he said. “I
was glad enough to get away last summer. I cannot forgive myself
for being such a boor! Now I shall want to come again and again.”
“Well why not?” I returned.
“I am afraid you will become tired of me.”
“Try us and see. We are not easily wearied.”
“You are all so generous with yourselves.”
I smiled a little. “Why not give of your best?”
“True.” Then there was a silence. We reached the gate presently.
“Do not go in just yet;” he pleaded, so we remained in the silvery
light that was flooding the whole earth. Moonlight always stirs the
tender and thoughtful side of one’s soul.
“I am glad that to-morrow will be Sunday. I can just think how I
shall enjoy going to church and hearing your father preach.”
This from him who had despised religion and sneered at sermons.
It did startle me.
“And to have Stephen here.”
“I am rejoiced that you feel so kindly toward one another,” I replied.
“You are getting to be brothers indeed.”
“And then will come weeks and weeks of study,” he went on in a
musing tone. “I like it. Books seem to me—well, better than some
people. Only—if you could all come down in the winter. Stephen and
Mrs. Whitcomb were planning for it, but there! it was a secret and I
have betrayed it.”
“I can keep secrets;” and I smiled up into his remorseful face.
“Yes; I have proved that. Rose”—after a pause—“I have half a
mind to tell you another, to ask some—advice; at least, I would like
to know how it appears to you.”
“Will it be of any real avail?” I asked, noting the perplexed lines on
his countenance. “I am not as wise as you think. Because I just
happened to stumble into one matter without making a mess of it—”
 “This is only an idea. I cannot ask Stephen. I think it would please
him and he might judge wrongfully.”
“If I can help you;” I replied encouragingly.
“It is about the future. It may never come to anything to be sure,
and perhaps I never can be good enough. Stuart will go into
business. He does not love study and he needs an active life. He
wanted Stephen to put him in a store this Autumn. But I—”
I knew then what he meant. Somehow I could not help laying my
hand on his arm with a touch of confidence.
“Whether I ever could so govern my temper and my impatient
desires;” bowing his head humbly. “But if I had some guard about
me, if I felt that I must try continually—would it be wrong to think of
it?”
“Surely not;” I returned warmly. “Nor to do it if God gives the
strength and the grace.”
“I like to think of that grand, earnest Saint Paul, with his ‘thorn in
the flesh.’ Perhaps it was some giant temper or desire. I fancy it
must have been, for you know how he persecuted the Christians
unto death. And though God would not take it away, there was the
promise of His grace being sufficient.”
“As it is, always.”
“There are some years to live before I decide positively. But if they
were spent in a worthy manner, and I mean them to be, with God’s
help.”
“Oh, you could, surely. And papa would be your best friend;” I
rejoined eagerly.
“Keep my secret—I have your promise,” he said in a hurried
manner, for a step sounded on the walk.
“It is sacred to me until you wish to take others into your
confidence.”
Stephen spoke and we turned, walking slowly up to the house.
Louis sat down on the step beside papa. I stood undecided whether
to go in or not, when Stephen took my arm and drew me around the
corner of the porch. There was a long grape arbor whose gloom was
made a pleasant twilight by the silver sifted through the openings
between the leaves, and we took a turn up and down.
“I want to tell you,” he began almost abruptly, and his voice had a
hard, strained sound, “that I heard—the last of what you said. I could
not help it. And I know your secret.”
I was a trifle annoyed, but I controlled myself.
“Oh,” I said, “then you will be tender and helpful and do all in your
power to strengthen Louis. He feels so humble. I would hardly have
thought it of him. And there are so few young men who have any
desire to take such a life upon them. With his means and his talents
he can do so much good.”
He stopped suddenly. “Rose, what are you talking about?” he
asked. “Did not Louis—”
“He confessed to me his desire—no, it was hardly that, as he is
afraid he can never be good enough for a clergyman. But you will
assist him—you do not disapprove of it?”
“Louis! Ah, I understand. It would be the delight of my heart. But I
thought—I knew he liked you so much. Oh, my little darling!”
He turned and gathered me in his arms. My heart beat and my
cheeks were in a blaze as the whole story came to me, dazing me
with its strange, sweet suddenness. I believe I cried and then I
laughed hysterically, but somehow the cool, steady voice quieted me
and made me feel the truth and earnestness of what he was saying,
so presently I grew still with a great awe.
“You will come,” he was saying. “We both need you. We want just
this steady, cheerful, loving influence. I think I have a tendency to be
impatient when people cannot see my ways, perhaps requiring a
little too much, and your sweetness will temper this. Then we can
both help him.”
Could I? How strange that any one should care for me alone. Not
for mamma, or Fanny, but to want me!
 “Mr. Duncan,” I began as we were going back to the porch—“have
you forgotten that my hair is—red?”
“Well, what of that?” in a gay tone.
“I do not believe you—like it.”
“You foolish little girl, set your heart at rest. Do you remember
when I came upon you suddenly last summer? You were standing on
the porch in a tiny glint of sunshine, and looked like some of the old
pictures! Why, I believe it was your hair that I fell in love with first of
all.”
“I am glad it was, for I am not half as good as you imagine I am.”
“Children,” mamma said, standing on the porch step. “Do you
realize how late it is?”
I felt that she knew all, perhaps had known it long before, indeed.
But I was glad that the knowledge had come to me so suddenly, and
not any sooner. Even now I was half afraid of it. Her kiss and tender
clasp re-assured me.
“Mother!” Stephen Duncan said with reverent sweetness.
 CHAPTER XVII.

WISHED there could be no such thing as breakfast the

next morning, but there was, and I had to go through
with it, feeling that I was no longer I, that Rosalind
Endicott was some dream-girl of the past. Stephen was
very good and did not notice me much, and Fan
appeared wonderfully pre-occupied. Mamma helped me over the
trying places, and papa just said with his tender morning kiss,—“And
this little girl, too.”
When I was all dressed for church I opened a little drawer to get
my gloves. There lay the box containing Stephen’s gift. I had never
worn it, but it seemed to me as if I ought to put it on now. He liked
me and the misunderstandings were at an end. I had accepted a
share of his burthens, his crosses, whatever they might be, so I
clasped it around my neck. It was so beautiful. I did not envy the
queen her diadem.
We walked to church together. Louis glanced back now and then. I
believe he began to suspect.
It was quite different from the Sunday when I had gone to church
with that strange sense of Fan’s new love. I felt quiet and restful, yet
it was such a great thing to have another’s heart in one’s keeping, to
take in a new life beside the old.
They both left us on Monday. Stephen was to come up soon
again. In the meanwhile, letters.
“I have one of yours to begin with,” he whispered.
It was a silent day for us. No one appeared to care about talking,
yet we were not gloomy. Indeed, I think mother, Fan and I
understood as we never had before, how much we loved one
another.
 I went on wearing my cross. In the first letter there came a pearl
ring for me. Fan had a handsome diamond but she seldom wore it
except when she was going to the Churchills. I slipped mine on my
finger with a slight presentiment that I should turn the pearl inside if
any one looked at me.
Richard Fairlie and Jennie came home bright and happy as birds.
They took possession of the great house, altered a little, re-arranged
to their liking and had Mrs. Ryder in their midst. There was no grand
party, but some pleasant tea-drinkings and hosts of calls. No one
could afford to slight Mrs. Fairlie, and people began to realize what a
noble girl Jennie Ryder had always been.
I am almost ashamed to confess how much talking it took to settle
our affairs. Stephen wanted to be married in the Spring. That was
too soon, mamma and I thought. But there were so many good
reasons.
Miss Churchill heard of it presently and came over to have a
consultation with mamma.
“It will have to be sometime,” she said. “It will make a little
confusion, a break, and no end of strangeness in adapting
yourselves to the new order. But here are Nellie and Daisy right
behind.”
“I don’t want to lose all my girls in this fashion,” said mamma.
Miss Churchill smiled and then admitted that she had a plan to
propose.
They wanted Fanny. The murder was out then.
“Kenton and I have discussed the matter a good while. Winthrop
will have the farm when we are done with it—he is the only nephew.
Kenton has been sorry for some years that we did not take him when
his father died. He is very fond of country life, and surely there are
enough to toil and moil in the cities. Then, although Lucy was
improved by her summer trip, we can understand that it is not
permanent. She wears out slowly. I should like her to have a happy
year or two with Fanny, and I should like the marriage well out of the
way of any sad memories.”
 “You are very thoughtful,” returned mamma.
“And it will hardly be like parting with Fanny, for you—as you can
see her every day. One thing and another has brought us so near
together. Kenton and I are growing old and the presence of these
young people will keep us from getting too queer and whimsical.”
It was settled some time in January.
“We shall have to do the best we can,” said mamma. “The
wardrobes must be simple. It is our station that they go out of, and
we never have been ashamed of our poverty.”
“What does a few clothes signify,” commented papa. “If the young
men are not satisfied we will give them a double portion of dry-goods
and keep our girls.”
Fan laughed over the idea.
So it was arranged that she and Fanny should go to New York. I
did not desire to accompany them, and I was sure they could choose
as well for me as if I hunted the whole town over. Besides, I wanted
the nice quiet time with papa, since I was the one who would have to
go away.
“Isn’t it funny!” said Fan. “I feel like the heroine of some hundred
year old novel, going up to town to buy wedding clothes, instead of a
girl of the period of puffs, paniers, chignons, Grecian bends, and all
that! Why Rose, think of it! We have never had a silk dress in all our
lives, except that once we had one ruffled with an old one of
mamma’s; and we have been very tolerably happy.”
“Yes, just as happy as one need be. All that could be crowded into
our small lives.”
“I dare say we should be absolute curiosities to some people.
Everybody now-a-days has a silk walking-suit, and some handsome
thread lace, and I don’t believe there are any poor people but just us.
But then we have had the love and comfort and enjoyment and no
time to worry about our rich neighbors. It has been a life full of
pleasantness and peace.”
 That was true enough. There were many, many things beside
raiment, if one could only get at the real completeness and harmony,
the secret of soul life.
Jennie Fairlie would help us sew. With their good servant she
declared she had nothing to do. Miss Churchill sent us both an
elegant poplin suit, or at least the materials. It was a simple
wardrobe to be sure. One pretty light silk dress, one dark silk with a
walking-jacket. We made morning robes and some inexpensive
house garments. Then it would be summer so soon, and there was
nothing equal to fresh, cool white. We were not used to crying for the
moon, we had found early in life that it was quite a useless
proceeding.
Altogether we kept our secrets pretty well, and when the truth
leaked out at last, everybody was so surprised that they could only
exclaim. Aunt Letty Perkins was brave enough to come and see if it
was really so.
“Well, I am beat!” she declared. “And doing well, too! I always said
there never was anyone like Mis’ Endicott for luck. Girls often do
hang on so where there is a lot, and you’ve enough left. Fanny is the
flower of the family to be sure, but she is making a big step to get in
with the Churchills. Ain’t afraid she’ll be puffed up with pride and
vanity, are you?”
“I think I can trust her,” replied mamma with a funny smile in the
corners of her mouth.
I remember the morning as one recalls a half dream, the misty
impression between sleeping and waking. The peculiar confusion
pervading the house, the strange mislaying of handkerchiefs and
gloves, the voices that were so full of tears and gay little laughs, the
half sentences, the clasp of hands as one went in or out of a room,
the long, loving glances as if each would fain garner all the past into
one sweet remembrance. Winthrop and Stephen, one rather grave
but very tender to mamma and the little ones, the other full of life and
vivacity, the happiest of the happy.
Fan had one little say though her eyes were bright with tears.
 “I hope I can be as good and sweet in my life as mamma has been
in hers. And I will not ask any higher happiness.”
We walked up the church aisle. The children stood around, back of
them Louis, Nelly and mamma, and then a host of eager parish
faces. Does any one take it all in then, the solemn questions, the still
more solemn promises?
Mr. Churchill gave us both away. Papa’s voice had a little falter in
it, and I dared not look up. “For better, for worse,” “till death do us
part,” rang clearly in heart and brain. The forever of human love,
when it is love and no base counterfeit.
A little kissing, a few tears, some tremulous whispers and sad, sad
good-byes. We whose farthest journey had been the brief sojourn at
Martha’s Vineyard, took up the great pilgrimage of a new life.

I cannot tell you anything about it, or Stephen. It was a happy

confusion of strange places and watchful care, bits of affection
shining out of the tiniest rift. Honeymoons, I suppose, are much
alike, but it is right for each to think his and hers the best and most
delightful.
One afternoon the carriage set us down in so quiet a street that I
could hardly believe it was New York. And when I entered the house,
my new house, I doubted more than ever, for everybody was there.
One kissed me until I thought the breath of life was surely gone, then
another took me up. I have a dim suspicion that my sleeves were
worn threadbare, and if my hair had not been all fast in my head, I
am afraid the difference would have been discoverable.
“Why you are rounder and rosier than ever!” declared Fan,
inspecting me.
She was elegant as a princess, and had her light silk dress
trimmed with applique lace.
 It seemed as if I never could get done looking at mamma, and
papa hovered around me as if I was indeed an unusual sight.
Somehow I managed to get up-stairs to my own pretty room, to
wash my face, what there was left of it, and straighten my gown. And
there was Beauty, my lovely half-grown kitten that some one had
brought from the old home.
I heard Stuart’s voice outside the door and called him in.
“Stuart,” I said with much dignity, “this is Miss Beauty Endicott, a
nice, orderly, well brought-up kitten, and mine. I want you to respect
her and treat her with the courtesy of a gentleman.”
“Oh, fudge!” he returned. “What are you doing with a kitten when
you are married? I thought it was only old maids who were death on
cats.”
“It is boys who are death on cats,” I replied severely. “And then—I
never did expect to be married. I always supposed—”
“Oh, you couldn’t have been an old maid! your nose never can be
sharp, and your chin has that great dimple in it, and you are such a
funny little dumpling altogether! If you say much I’ll put you in my
pocket and carry you off. No doubt Stephen would feel immensely
relieved, but what could the cat do?”
“You are an incorrigible boy!”
“But we will have jolly times for all that,” and he whistled to Tim,
who put her head within the door.
“Fan,” I exclaimed with remorseful tenderness as I was going
down stairs with her arm over my shoulder; “I have Mrs. Whitcomb.
But you know you half gave her to Stephen. And as you are not to
keep house—”
“I will lend her to you a little while longer.”
We had such a merry, enjoyable supper, such a lovely long
evening, and were brimfull of happiness.
But the next morning papa gathered up his flock, “what there was
left of them,” he said with a certain comical grimace.
 “I don’t know as you need lament,” answered Stephen. “I think the
sons are coming in pretty rapidly.”
“And if there should be seven! Mother what would we do with them
all?”
Mamma smiled a little as Stephen went around and kissed her.
“Remember that I am the first one; I will never be crowded out of
my place.”
“No,” she answered softly.
They all went away that noon, and left us to begin our home life.
We had talked it over, what we were to do for the boys, what for
ourselves, and what for the world outside. For the true life is not
bounded with a narrow—thou and I. The world takes us in, and over
and above all, God takes us in. His vineyard, His day, and first and
always His everlasting love.
 Young Folks’ Heroes of the Rebellion.
By Rev. P. C. HEADLEY.

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The Glorious March to the Sea by the brave Sherman and his boys will never be
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The Naval History of the great civil war is exceedingly interesting, and the life of
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 “Old Stars” was the pet name given the brave general by his soldiers, who
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☞Sold by all booksellers, or sent by mail, postpaid, on receipt of

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LEE AND SHEPARD, Publishers, Boston.

 YOUNG FOLKS’ HEROES OF HISTORY.
By GEORGE MAKEPEACE TOWLE.
Handsomely Illustrated. Price per vol., $1.25. Sets in neat boxes.

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HIS VOYAGES AND ADVENTURES.
“Da Gama’s history is full of striking adventures, thrilling incidents, and perilous
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HIS ADVENTURES AND CONQUESTS.
“No hero of romance possesses greater power to charm the youthful reader than
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Even at this distance of time, more than two hundred and fifty years after his head
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Sold by all Booksellers, and sent by mail, postpaid, on receipt of

price.

LEE & SHEPARD, Publishers BOSTON.

 Transcriber’s Notes

pg 64 Changed: She smiled in her irresistable fashion,

to: She smiled in her irresistible fashion,
pg 128 Changed: papa would say,” was my rejoiner
to: papa would say,” was my rejoinder
pg 150 Changed: And she enjoys everything so thorougly.
to: And she enjoys everything so thoroughly.
pg 168 Changed: our engagements and geting everything
to: our engagements and getting everything
pg 183 Changed: Here were sandwitches dripping with jelly
to: Here were sandwiches dripping with jelly
pg 185 Changed: great double lucious blossoms
to: great double luscious blossoms
pg 208 Changed: with a certain funny lugubriouness
to: with a certain funny lugubriousness
pg 238 Changed: Dosn’t she take care of sick people
to: Doesn’t she take care of sick people
pg 264 Changed: nothing but complaint and discouragment
to: nothing but complaint and discouragement
pg 264 Changed: went to neigboring towns
to: went to neighboring towns
pg 274 Changed: I struck out blindy
to: I struck out blindly
pg 284 Changed: I have gussed
to: I have guessed
pg 285 Changed: It is not—Winthop Ogden.
to: It is not—Winthrop Ogden.
pg 287 Changed: bound by a promise of secresy
to: bound by a promise of secrecy
pg 300 Changed: no expensive trosseau
to: no expensive trousseau
pg 317 Changed: spoken of the probabilty
to: spoken of the probability
pg 337 Changed: It was the begining
to: It was the beginning