1. Pop and Pre-Chop A Safe Supracapsular Phacoemulsification Technique
Jayati S. Sarkar, MD
Christopher E. Starr, MD, FACS
Department of Ophthalmology
Weill Cornell Medical College
New York-Presbyterian Hospital
New York, NY 10021
The authors have no direct financial interests in any of the topics/products mentioned

2. Purpose
To describe Pop and Pre-Chop, a novel safe technique of supracapsular nuclear disassembly during phacoemulsification.
We report the results of 50 consecutive surgeries performed by a trainee with a cumulative surgical experience of fewer than 100 cases.

3. Methods/Technique Surgical technique:
2 corneal paracenteses are made 180 degrees apart followed by a clear corneal wound 90 degrees away.
A soft-shell technique (dispersive + cohesive viscoelastic) is utilized to protect the corneal endothelium.

4. Methods/Technique
After creating a 5.0 to 6.0 mm capsulorhexis, hydrodissection is performed tangentially via the main wound. Pushing gently down on the peripheral nucleus with the cannula enables the lens to tilt or prolapse (‘Pop’) out of the bag.
Viscoelastic is then injected behind the nucleus to protect the posterior capsule and keep the prolapsed nucleus upright.
A cyclodialysis spatula is then introduced through one paracentesis and is placed behind the lens and a sinsky hook is introduced through the opposite paracentesis and placed in front of the lens.

5. Cyclodialysis spatula behind
Sinsky in front

6. Methods/Technique
Via a scissoring pre-chop maneuver at the iris plane, the nucleus is easily cracked into two halves
The nucleus can be further broken down into quadrants or smaller pieces using this pre-chopping maneuver
Supracapsular phacoemulsification is then performed. Since the nucleus is already divided, less phaco energy is needed for disassembly.

7. Scissoring pre-chop maneuver divides the nucleus into 2 hemispheres

8. Results
N=50 consecutive surgeries performed with the Pop and Pre-chop technique by a trainee
Mean Preop BCVA was 20/70 (range 20/40-20/800)
Mean Postop day UCVA was 20/40 (range 20/20-20/200)
Mean Postop week one UCVA was 20/30 (range 20/15 to 20/60)
Mean Postop month one BCVA was 20/25 (range 20/15 to 20/60)
Limited visual recovery in 3 pts with POM#1 BCVA of 20/50-20/60 range was due to preexisting epiretinal membrane in 2 pts and advanced glaucoma in 1 pt

9. Results
Mean phaco time during surgery was 20 secs (range 0 to 1.58min)
Mean corneal edema POD#1: 1+ ( range 0-4+)
Mean corneal edema POW#1: 1+ ( range 0-2+)
Mean corneal edema POM#1: 0
Posterior capsular breaks: 0
Other surgical complications: 0

10. Advantages and Disadvantages
Potential Advantages:
Less total phaco energy and time than other supracapsular and in-the-bag techniques because the lens is pre-chopped and divided manually.
Less corneal endothelial cell loss and postoperative corneal edema than other supracapsular techniques
Since the pre-chop maneuver occurs at the iris plane, it is simpler and carries less risk to the bag and zonules when compared to in-the-bag pre-chopping techniques
Ideal for novice surgeons and trainees as there is less phaco time and phaco-manipulation required and the entire procedure is performed away from the posterior capsule and zonules
It is recommended that a dispersive viscoelastic be repeatedly applied to the corneal endothelium throughout these procedures
In challenging cases of floppy iris or miotic pupils, the prolapsed lens can act as an iris retractor
The ‘Pop’ can be performed through an average sized capsulorhexis (5.0-6mm) and does not need to be larger as commonly believed.
Potential Disadvantages:
Supracapsular techniques carry the potential for greater damage to the corneal endothelium.
Caution should be taken in short eyes with shallow anterior chambers

11. Conclusion
The novel Pop and Pre-Chop phacoemulsification technique incorporates the traditional advantages of established supracapsular techniques (posterior capsular protection) and minimizes the known disadvantages (corneal endothelial cell loss).
Because of its increased safety and simplicity it may be a useful technique for the beginning surgeon.