More on the ‘flip and slice’ technique for cataract surgery

A surgeon outlines this method and details the circumstances that merit an alternate approach.

Issue: November 25, 2010

ByCynthia Matossian, MD, FACS

In the June 25, 2010, issue of Ocular Surgery News, I described my “flip and slice” technique for cataract surgery. I received multiple inquiries about the technique, prompting me to write this follow-up article to answer those questions. The flip and slice is my go-to technique; however, there are specific conditions where I select an alternative approach in order to achieve the most effective results. In this article I would like to briefly reiterate when I use my preferred flip and slice method and when I do not.

Flip and slice is ideal for most cataracts

For standard cataract surgery, 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, a sodium hyaluronate ophthalmic viscosurgical device (OVD) from Abbott Medical Optics. This creates a crucial top layer of the viscoelastic “sandwich” to protect the corneal endothelium.

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 flattened 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.

Choosing the right tools is key

I find that Healon5 is the ideal OVD for my 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.

Knowing when to differentiate

As effective as my flip and slice method is for the majority of my standard cataract surgeries, there are some specific circumstances in which I choose an alternative method of nuclear disassembly.

If the cataract is too soft, the Koch manipulator will slice through the lens without flipping it fully. In that instance, I use the manipulator to make multiple slices and then add more Healon5. I then flip it as much as possible before beginning phacoemulsification with my quadrant setting, without using the sculpt mode.
If the lens is a rock-hard 4+ brunescent cataract, the Koch manipulator will only put a small nick in the lens. It cannot slice the lens. In this case, I still flip the lens, but I begin phacoemulsification with the sculpt setting, making a deep groove on the posterior aspect of the flipped cataract until I am able to bisect the lens into two semi-nuclei. Then I phacoemulsify each half.
For patients getting a Crystalens implant (Bausch + Lomb), I do not use my flip and slice method, because I find that these implants do better with a capsulorrhexis that minimally overlaps the edge of the optic. A capsulorrhexis just under 5 mm is too small to safely flip the cataract. Bausch + Lomb’s original recommendation to make large rhexes resulted in several Z syndromes in my patients. The smaller rhexis size that I now use prevents me from using my flip and slice technique but has eliminated Z syndromes.
In patients with intraoperative floppy iris syndrome requiring a Malyugin ring, I do not use my flip and slice technique. I have learned that the flipping movement in these cases can disengage the Malyugin loops from the pupillary margin, causing the cataract to sit on top of the Malyugin ring. Therefore, I strongly discourage any surgeon from flipping the lens with a Malyugin ring in place.
If the patient’s pupil is small, but not small enough to require a Malyugin ring, then my flip and slice technique is effective, because the very act of flipping it results in the lens sitting a minimum of 50% out of the capsular bag, with excellent exposure.
To decrease the risk of a ruptured posterior capsule, I “burp” some of the Healon5 out of the eye by gently depressing the proximal lip of the main corneal incision before hydrodissection.
With this flip and slice technique, I am working away from the posterior capsule, thus decreasing the risk of an inadvertent rent or tear of the capsule.

We are judged by our outcomes

Patients tend to hold high expectations for their vision in the first days after surgery, particularly in this age of premium implants and the price tags that they command.

With the combination of my flip and slice technique, the proper OVDs and adhering to my above-stated outline as to when to select an alternative approach for lens removal, I am able to deliver on those expectations. I invite you to view my flip and slice technique at http://eyetube.net/videos/default.asp?somodo.

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 is an adjunct clinical assistant professor in the department of ophthalmology at the School of Medicine, Temple University. She can be reached at 609-882-8833; e-mail: cmatossian@matossianeye.com. Dr. Matossian is a consultant to AMO, Alcon, Inspire, ISTA and Allergan.