‘Flip and slice’ technique offers a different take on cataract surgery

Premium surgical devices plus an innovative technique enhance surgical efficiency and day 1 postoperative outcomes.

Thomas John

Phacoemulsification has reached new heights, with improved surgical techniques being augmented by newer, advanced technology and resulting in better surgical outcomes, visual quality and lifestyle for our patients.

Among other factors, two that are particularly important for cataract surgery are the preservation of an intact posterior capsule and retention of corneal endothelium without significant cell loss to provide a clear cornea after cataract surgery. Viscoelastics have helped in endothelial protection during cataract surgery. There is a trend toward moving away from the posterior capsule by dislodging the nucleus from its capsular bag and performing phacoemulsification in a more anterior plane while emphasizing endothelial protection. In cases where endothelium is not an issue, as in a combined DSAEK with cataract extraction and IOL implantation, an upside-down phacoemulsification in the anterior chamber has been described.

In this column, Dr. Matossian describes her “flip and slice” surgical technique, where the phacoemulsification plane is moved anteriorly from the posterior capsular bag while protecting the endothelium with viscoelastics.

Thomas John, MD
OSN Surgical Maneuvers Editor

My standard approach to cataract surgery is a technique that I have dubbed “flip and slice.” It shares some characteristics of flip or tilt techniques described by others, but with key modifications made possible by viscoadaptive ophthalmic viscosurgical devices that protect the corneal endothelium and create a stable working space in the anterior chamber.

I begin the procedure with a controlled capsulorrhexis, followed by gentle hydrodissection with a curved, single-use Kellan hydrodissection cannula that has a flattened tip (ASICO AS-7627). As I hydrodissect, the nucleus tilts up and out of the capsular bag at an angle of about 65° to 80°. I coat the leading edge of the nucleus with a crescent strip of Healon5 (sodium hyaluronate, Abbott Medical Optics) to create the top layer of the viscoelastic “sandwich” around the lens.

Next, I flip the lens toward me, slicing it down the middle at the same time with my Koch nucleus spatula with its smooth, gently curved, duckbill-shaped tip (Katena K3-2354). The anterior aspect of the bisected lens is then sitting approximately 80% out of the capsular bag, or occasionally fully supracapsular with the posterior surface of the cataract facing the corneal dome.

I add a little more OVD as I tamponade the lens down to a flat 180° position. If the lens is not fully bisected, I begin phacoemulsification in sculpt mode. Generally, only one or two grooves directly over the partially cleaved fault line are needed to complete the slice into two hemi-nuclear segments. At this point, I move to quadrant removal; very little phaco energy is required to emulsify the nuclear halves in a safe manner.

The benefit of the flip and slice technique is that it is very quick and efficient. The typical effective phaco time is only 0.2 to 2.0 seconds at an average power of 10% to 15%. If sculpting is required, that can add up to another second of effective phaco time. A denser lens with a grade of 3+ to 4+ will add about an extra second of effective phaco time and raise the average power by about 10% to 20%.

Less phaco energy and less balanced salt solution pumping through the anterior chamber reduces routine trauma and results in a healthier endothelium postoperatively. This technique works very well for most cataracts, although it may not be appropriate for very soft or very dense nuclei.

Viscoadaptive OVD makes it possible

Healon5 is the ideal OVD for the flip and slice technique because it provides a controlled environment in the anterior chamber. Its high viscosity puts counterpressure on top of the lens as it flips. And, because the OVD fills the entire dome superiorly inside the anterior chamber, there is no damage to the endothelium as I flip the nucleus.

Surgeons can revert to their preferred OVD for lens insertion. I use Healon5 throughout the case unless I am implanting acrylic lenses, which tend to unfold too slowly with this OVD.

Some find removal of Healon5 challenging, but with the right technique, the viscoelastic practically removes itself. After IOL placement, I simply place the irrigation and aspiration tip slightly under the lip of the optic and hold it steady. As the inferior portion of the compartmentalized Healon5 comes right to the I&A port, the optic drops down into the bag. I then place the I&A port on top of the optic to aspirate the superior compartment, again with minimal movement of the tip. Swirling the I&A tip around, as one might have to do with other OVDs, is not ideal. Keep the tip stationary and viscoadaptive Healon5 will come to it.

Healon5 coating leading edge of tilted cataract.

Koch manipulator being used on its side to bisect and flip lens. Images: Matossian C

Lens in process of being flipped and bisected simultaneously.

Lens being flipped where posterior surface of cataract now facing corneal apex.

Healon5 being used to flatten the flipped lens supra-capsular.

Healon5 being used to complete cleaving the sliced cataract into two semi-nuclei.

Pair with premium phaco technology

The flip and slice technique is designed to be paired with the latest phacoemulsification technology. I use the WhiteStar Signature system (AMO). Its micropulse power modulation had already reduced phaco power delivery tremendously and the fluidics had significantly improved safety by preventing surge and chamber shallowing after occlusion.

But the latest iteration has made an already good phaco system even better. The dual pump with Fusion Fluidics allows for greater safety and control with no sacrifice in efficiency or power. I typically use both the peristaltic and venturi pumps during the procedure. I find the venturi settings make both epinucleus and cortical cleanup more efficient.

I also now combine longitudinal and transversal phaco during every procedure. This makes the procedure very efficient with minimal ultrasound delivery because the phaco tip is cutting in multiple directions at once. With Ellips transversal phaco enabled, the anterior chamber is stable, with little chatter or turbulence of nuclear fragments. This results in quiet eyes and clear corneas on the first postoperative day.

A retrospective analysis of my last 50 cases showed that 96.3% were 20/40 or better on the first postoperative day, 77.8% were 20/30 or better, and 44.4% were seeing 20/25 or better on postoperative day 1. Monofocal lens patients fare even better because they are not adjusting to multifocality.

Phaco technology with all of the devices on the market is so good compared to what I used early in my cataract surgery career that it is hard to point to dramatic advances today. But incremental improvements have a meaningful effect, particularly in premium IOL cases. Despite our caveats, patients who are paying out of pocket for accommodating, multifocal or toric lens technology have high expectations for their vision in the first days after surgery.

With the combination of Fusion Fluidics, Ellips transversal phaco and the flip and slice technique described here, I am able to deliver on those expectations.

• Cynthia Matossian, MD, FACS, is founder and CEO of Matossian Eye Associates, a private group practice with three offices in Pennsylvania and New Jersey. She also serves as a clinical instructor in the Department of Family Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School. She can be reached at 609-882-8833; e-mail: cmatossian@matossianeye.com. Dr. Matossian is a consultant to AMO.
• For video of Dr. Matossian’s technique, go to OSNSuperSite.com/video.aspx.