A new technique to extract soft nuclei

The V-slice offers several benefits: No rotation, no loss of control, little, if any, edema.

By Ariana Diamond, BS; Jeffrey Yee, MS, MD; Jack Parker, MD

Ultra-dense cataracts are among the most difficult cataracts to phaco-emulsify.

On the opposite end of the spectrum, extremely soft cataracts can present their own challenges. Cracking and chopping techniques are often ineffective in these cases because they lack sufficient brittleness. Also, it is often difficult to achieve nuclear rotation after hydrodissection because the rotating instruments can cheese-wire through the lenses. In addition, soft lenses commonly adhere to the capsular bag, further hindering nuclear rotation.

For novice surgeons, these soft cataracts can be both frustrating and anxiety-provoking because traditional techniques do not get the job done efficiently.

However, at our residency program at the University of Alabama-Birmingham, we developed a new technique that is efficient, cost effective, easy to learn and safe. We call it the “V-slice.”

What the V-slice procedure accomplishes. In this still from a video used by Jeffrey Yee, MS, MD, in training his residents, the nucleus is subjected to a five-step procedure, leading to nucleus extraction. More stills are available on page 42.

A new strategy

For the above reasons, especially for beginning residents, soft cataracts can present surprisingly difficult challenges that, if not managed carefully, can result in intraoperative complications. The University of Alabama-Birmingham is not alone in this experience, but seemingly it is a common experience at ophthalmology training programs, judging by the correspondence we have received from other programs.

The peculiar difficulties posed by soft cataracts have inspired a litany of specialized phaco instruments and techniques over the years. Some involved specialized forceps that manually segment the lens into pieces^1-3; others aim at mobilizing the entire (undivided) lens out of the capsular bag and into the anterior chamber where it can be more safely removed.^1,4,5

At the UAB Callahan Eye Hospital, we have had only limited success with these various techniques because:

1. The delicate, specialized instruments required were either unavailable or damaged;

2. The techniques themselves proved too technically challenging for beginning residents to easily learn.

And now, the step by step.

V is for V-slice
In this series of images, the V-slice technique is demonstrated by a third-year resident at the University of Alabama-Birmingham on a very soft cataract. In Figures 1 and 2, the central segment Seibel chopper is used to create a two-slice, V-shaped configuration. Next, in Figure 3, the hydrodissection cannula, Akahoshi, is used for hydrodelineation and hydrodissection. In Figure 4, Viscoat (Alcon) is injected between the slices; in Figure 5, the Connor Wand is used to scoop up the central pizza-slice-shaped segment. Advantages of the V-slice, says Dr. Yee, are the creation of the three slices, which eases extraction. Also, the V-slice does not require nucleus rotation. The V-slice has helped eliminate resident surgeons’ nervousness regarding soft cataract surgery. “We came up with this technique to deal with those challenges,” says Dr. Yee.

The play by play

The operation begins per routine: after creating a 5.0-5.5 mm diameter capsulorhexis, the surgeon slides a blunt-tipped chopping instrument over the nuclear face and around the lens equator at the 5- and 7-o’clock positions; then the surgeon passes the instrument through the lens, aiming for 12-o’clock, at 1/2 to 2/3 depth. (If any resistance is encountered, the maneuver is aborted to avoid placing undue stress on the zonules.) The result is to produce a central, V-shaped nuclear segment that is bounded laterally by two crescent-shaped pieces.

Gentle hydrodissection and hydrodelineation are performed. Often, the triangular middle segment is prolapsed from the bag. Viscoelastic may be injected into the two sliced grooves to further define the pieces.

Subsequently, the surgeon introduces the phaco handpiece through the main wound along with a blunt second instrument through the paracentesis. Then, the surgeon aspirates the V-shaped central piece, since it is usually totally separated and free floating at the level of the capsulorhexis.

Attention may then be turned to the two lateral pieces, which are frequently removed in similar fashion. Usually, extremely low, or zero, phaco energy is required for the procedure.

Pluses and a minus

Advantages of this technique: it permits nuclear division in a controlled fashion, prior to hydrodissection when visibility is maximal; it obviates the need for nuclear rotation; the procedure may be performed one handed; and no special/dedicated instruments are required.

In addition, because extremely low phaco energy is required, the corneal endothelium is subject to less intraoperative trauma. As a result, there is frequently less (and often zero) postoperative corneal edema, so visual recovery may be faster and more comfortable.

Moreover, this technique often significantly shortens the surgery, since we efficiently dispensed with the most troublesome and time-consuming elements of the operation.

The most significant disadvantage of the technique is that it may only be appropriate for soft nuclei, since attempting the maneuver against harder lenses may risk excessive stress to the lens zonules.

Since developing this technique in 2013, we have used this technique as our primary means of soft cataract removal in our resident clinics, and we have averaged one case a week over this time period. During this time, no complications related to the V-slice have been experienced, which is perhaps a testament to the inherent safety of the technique, given that the operation is most commonly used in our resident clinics.

Nevertheless, the V-slice should not be regarded purely as a strategy for beginning surgeons: While the technique is simple to teach and easy to learn, it is also the most effective strategy we have encountered for soft cataract removal, regardless of surgical experience.

Conclusion

We have additionally found this technique useful in cases of posterior polar cataracts, which may be removed using the V-slice with minimal risk to the posterior capsule.

Provided that the surgeon chooses a lens of suitable density, the V-slice may represent a simple and easy strategy for controlled nuclear division and mobilization in cases of soft cataract, which may make the procedure safer and easier, especially for beginning surgeons and also in cases of posterior polar cataracts. OM

The authors created the V-slice technique while Dr. Parker and Ms. Diamond were a resident and medical student, respectively, at The University Of Alabama. Dr. Yee was the attending physician.

REFERENCES

About the Authors
	Ms. Diamond is a fourth-year medical student at the University of Alabama School of Medicine. She received her undergraduate degree in Biology from the University of Alabama at Birmingham (UAB).
	Dr. Yee is associate professor of Ophthalmology at the University of Alabama at Birmingham Department of Ophthalmology.
	Dr. Parker is a graduate of UAB residency and medical school and currently a corneal fellow at Parker Cornea in Birmingham, Ala. Contact him at Jack S. Parker, MD, Callahan Eye Hospital, Birmingham, AL, (205) 933-1077, or e-mail jack.parker@gmail.com.
	Financial disclosures: Dr. Parker is a consultant for D.O.R.C/Dutch Ophthalmic International and Ziemer Ophthalmic Systems. No author has a financial or proprietary interest in any material or method mentioned.