March 2016

 

CATARACT

 

Pulse of ophthalmology: Survey of clinical practices and opinion

How are we performing nucleus division during cataract surgery?


by Mitchell Gossman, MD

 
 

Mitchell Gossman, MD

Mitchell Gossman, MD

Why do we use the method we do? No doubt it relates to what works best for our own dexterity, neurologic makeup, and personality, but some of it may be due to bias. Mitchell Gossman, MD

 

Continuing the discussion of the methods ophthalmologists use for cataract surgery, how are we performing division of the nucleus for phacoemulsification? We have many goals for this process, some of them contradictory: Lower phaco energy to help maintain a clear postoperative cornea Phaco energy dissipated farther from the corneal endothelium Phaco performed far from the posterior capsule in order to avoid capsule rupture during phaco Speed Rapid learning curve Inexpensive Usable on all densities of cataracts Hundreds of articles and book chapters exist on the many methods, but what are we actually doing? A survey was performed of 97 practicing ophthalmologists who volunteered to participate from the ranks of participants of the eyeCONNECTIONS online community and volunteers around the U.S. Responses are anonymous in order to encourage candor.

The first question was, Is the femtosecond laser your preferred method to disassemble the nucleus during cataract surgery? poll about femtosecond laser Reasons given for preferring femto were safety, efficiency, and less phaco power required. One respondent pointed out that while most of the time the femto procedure makes separation of fragments somewhat easier, one still has to divide and conquer or chop to some extent. For virtually all insurance-covered cataracts in the U.S., the nuclear division/softening part of femtosecond laser-assisted cataract surgery cannot be billed to the patient unless done incidental to other billable treatments such as astigmatism and presbyopia.

The second question was, For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for average density cataracts? If you use a hybrid method, select the one that fits best. poll of nucleus disassembly The third question was, For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for soft cataracts or clear lens extraction? If you use a hybrid method, select the one that fits best. method for nucleus disassembly

The fourth question was, For non-laser nucleus disassembly cases, which is your preferred method for nucleus disassembly for very dense (but still phacoemulsifiable) cataracts? If you use a hybrid method, select the one that fits best. The totals may not equal 100% due to rounding.

Non-laser nucleus disassembly poll The fifth question was, Please explain why you use the method you do for average density cases. There were 60 responses and are discussed below.

The sixth question was, Please explain why you use a different technique for different density cataracts, if this is the case. There were 44 responses and are discussed below.

As you can see, as with other parts of cataract surgery, there is great diversity in what methods are employed to divide the nucleus for phacoemulsification, and surgeons no doubt achieve excellent results or they would explore other methods.

Jay Erie, MD, Mayo Clinic, Rochester, Minn., prefers divide and conquer for most cases: The biggest advantage to me is that most of the phaco energy is expended in the bag; therefore, it is free phaco power with respect to potential endothelial trauma. Ravi Krishnan, MD, Eye Institute of Corpus Christi, Texas, prefers the carousel method with its virtue of speed and applicability to cataracts of any density. I use the phaco handpiece in quadrant removal mode to begin chewing at the nucleus from its equator, causing it to spin into the port. Steven Safran, MD, Lawrence- ville, N.J., thinks that horizontal chop has the advantage of safety: Horizontal chop can be done in a very controlled manner supporting the nucleus as you do it so theres minimal or no stress on the zonules. It can be done in the bag away from the endothelium with low phaco energy using a mechanical crossing motion. Two out of 3 surgeons use a different method depending on cataract density. There is a trend toward preferring one of the carousel methods for softer cataracts, a chop method for medium cataracts, and divide and conquer for dense cataracts.

My own methods are carousel for soft cataracts, stop and chop for medium cataracts, and divide and conquer for dense cataracts.

Why do we use the method we do? No doubt it relates to what works best for our own dexterity, neurologic makeup, and personality, but some of it may be due to bias.

Status quo bias. We human beings tend to stick with what we learn and accept change reluctantly when problems occur, new methods come along that seem irresistible, or evidence of superiority becomes irrefutable. As the saying goes, If it isnt broken, dont fix it. This is not to say that what we learned in training is not necessarily completely satisfactory, but there is the hazard of missing out on a better method.

Clustering bias. When mishaps or challenges occur during surgery, especially when they occur in clusters, we tend to question our methods and even our very skills, grasping at straws, trying new things that may or may not be superior or are in fact worse in our hands.

Argumentum ad populum. Everyones doing it, so it must be better.

Fallacy of novelty. If its new, it must be better.

Appeal to fear. If you dont adopt new methods, you risk being left behind.

I hope this will provide food for thought for those who are considering other methods, validation for those who continue to use certain methods after trying others and seeing no reason to change, and to help us overcome our biases.

Editors note: Dr. Gossman is in private clinical practice at Eye Surgeons & Physicians, St. Cloud, Minn. He has no financial interests related to this article.

Contact information

Gossman: n1149x@gmail.com

Related articles:

Double trouble: Diplopia following cataract or refractive surgery by Maxine Lipner Senior EyeWorld Contributing Editor

Cataract surgery on what could be “the most myopic eye ever operated on” by Liz Hillman EyeWorld Staff Writer

Considerations for cataract surgery in short eyes by Liz Hillman EyeWorld Staff Writer

ASA classifications correlate with cataract surgery outcomes by Vanessa Caceres EyeWorld Contributing Writer

Cataract surgery varies by race, state, even latitude by Matt Young and Gloria Gamat EyeWorld Contributing Writers

Gender inequality in some pediatric cataract surgery cases by Liz Hillman EyeWorld Staff Writer

Nucleus division during cataract surgery Nucleus division during cataract surgery
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