22

Principles of Nuclear Disassembly

Thomas A. Oetting

CONTENTS
Introduction, 197 Disassembly in Special Situations, 197
Basic Principles of Nuclear Disassembly, 197 Learning Nuclear Disassembly, 197
Classic Nuclear Disassembly Techniques, 197 Summary, 197
Nuclear Density, 197 References, 197

KEY POINTS
• Mastery of nuclear disassembly is a key skill for cataract surgeons. • Softer or harder nuclear cataracts are approached differently.
• Residents find nuclear disassembly difficult to master. • Patient issues like corneal guttata, zonular integrity, and capsule
• Surgeons should have several disassembly techniques at their disposal. integrity affect disassembly technique.

the epinucleus and the nucleus is possible in softer lenses and is called
INTRODUCTION
hydrodelineation. After proper hydrodissection, the lens can rotate
Nuclear disassembly is a critical part of the cataract surgery procedure. within the capsular bag to facilitate nuclear disassembly techniques
Cataract surgery trainees consider this portion of the procedure one of usually with phacoemulsification.
the most difficult to master.1 Nuclear disassembly is a risky phase of the Fluid pressure during hydrodissection can tear the capsule or
cataract procedure for capsular and/or zonular injury, which can lead cause anterior prolapse of the lens (intended or not). When the ante-
to vitreous prolapse and other complications. Surgeons have developed rior capsule is not continuous, hydrodissection should be delicate or
many useful techniques to disassemble the nucleus, including the divide- avoided because the capsule may tear posteriorly, causing the vitre-
and-conquer technique, chopping techniques, and mechanical fragmen- ous to prolapse or the lens to fall posteriorly. Hydrodissection is usu-
tation. Surgeons should have several disassembly techniques in their ally avoided if a defective posterior capsule is suspected. Risk factors
skill set to safely fragment lenses of various density. Surgeons may also for the latter include posterior polar cataract, posttraumatic cataract,
vary their disassembly strategy depending on other patient factors such and eyes that have undergone vitrectomy or intravitreal injections 4–8
as a small pupil, weak zonules, or preexisting injury to the lens capsule. (see Chapter 18).

Phacoemulsification
BASIC PRINCIPLES OF NUCLEAR DISASSEMBLY Most nuclear disassembly techniques use ultrasound and vacuum
Nuclear disassembly (or nucleofractis) is a critical step of small incision from phacoemulsification machines to remove nuclear material. The
cataract surgery. All the techniques for nuclear disassembly share the phaco needle tip holds the nucleus during mechanical disassembly
common principles of exposing the nucleus, freeing the nucleus, and (chopping) of the nucleus into smaller pieces. The fluid dynamics of
then using phacoemulsification to remove the nucleus in some fashion. phacoemulsification machines are covered elsewhere in this textbook,
but there are generally three distinct phases for phacoemulsification
Exposure of the Nucleus machines during disassembly (see Chapter 19).
The anterior capsule is removed centrally in the crystalline lens to allow One phacoemulsification phase, often called sculpt, uses a low vac-
access to the lens material including the nucleus. Typically, an initial uum and flow rate of fluid to allow controlled sculpting of grooves in
tear in the central capsule is carried into a round continuous tear using the lens. The second phase is often called chop and has a high vacuum
forceps or a needle.2 A discontinuous tear or other capsular injury can and ultrasound characteristics designed to hold onto the nucleus while
make nuclear disassembly more difficult and prone to vitreous prolapse chopping the lens into smaller pieces. The third phase is often called
or loss of nuclear pieces into the vitreous space (see Chapter 17). quadrant removal with a high vacuum and ultrasound power designed
to attract the disassembled nuclear pieces into the emulsifier.
Freeing the Nucleus
After the central capsule is removed, the surgeon has access to the lens Disassembly Location
material including the nucleus. Fluid dissection between the lens cap- Usually the disassembly of the nucleus occurs within the capsular bag.
sule and the lens is called hydrodissection and can free the lens from After hydrodissection the nucleus can freely rotate and is broken into
the capsule. Fine described cortical cleaving hydrodissection in which smaller pieces for eventual emulsification. However, some techniques
even the cortex was freed from the capsule.3 Fluid dissection between disassemble the nucleus in the supracapsular space or in the anterior

197
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198 PART IV Nuclear Disassembly

chamber (AC). These out-of-the-bag techniques are particularly useful lenses (1 -mm). The depth of the groove is about 70% to 80% of the
when the bag is less robust or when the lens is soft (see Chapter 24). depth of the nucleus. Typically, the red reflex and the 1 -mm needle
diameter help the surgeon gauge the depth and width of the groove.
The surgeon stays mindful of the posterior shape of the lens, which
CLASSIC NUCLEAR DISASSEMBLY TECHNIQUES is thicker in the center than the periphery.
There is no single best technique for nuclear disassembly. The technique • After sculpting, the surgeon uses the grooves to divide or crack the
used depends on a variety of factors including surgeon preference, den- nucleus into four equal quarters.
sity of the nucleus, capsule issues, zonular issues, pupil size, and sta- • The division of the nucleus along each groove can be done with
bility of the corneal endothelium. Table 22.1 lists several of the most one hand with a nucleus cracking forceps (Fig. 22.1A) or with
common techniques for nuclear disassembly. Three classic disassembly bimanual instruments applying force on each side of the groove (see
techniques are often compared with each other and to any newer strate- Fig. 22.1B).
gies: divide-and-conquer, phaco-chop, and stop-and-chop techniques. • The advantage of this technique is that it is relatively easy to learn
and can be performed with just one hand.11
Divide-and-Conquer Technique • The disadvantage of this technique compared with chopping tech-
Gimbel described the classic and continuously useful divide-and-con- niques is that it requires more ultrasound energy to sculpt grooves.12
quer technique in 1991.10
• The lens is divided in to four pieces within the capsule bag. Phaco-Chop Technique
• Initially two perpendicular grooves are made with the phaco nee- Nagahara first described the phaco-chop technique in 1993.13
dle that form a cross and intersect in the middle of the lens. These • Phaco chop eliminates the need for nuclear sculpting, which can
grooves are wider in dense lenses (1.5 mm) and thinner in soft lead to excessive ultrasound damage to the corneal endothelium.12,14

TABLE 22.1 Techniques for Disassembly

Strategy Advantages Disadvantages
Bowl then prolapse Sculpt out large bowl, One-handed, Increased exposure to ultrasound
prolapse nucleus anterior to capsule, does not require rotation, energy,
remaining nucleus removed in anterior chamber with phaco. nice for softer lenses. difficult with even moderate density
lenses.
Pop and chop9 Prolapse nucleus out of bag, Can be one handed, Requires large rhexis,
nucleus is half in bag -half in anterior chamber, easy to learn, phaco energy close to cornea.
nucleus is removed either directly with phaco or does not require rotation.
mechanically chopped.
Divide and conquer Sculpt two long grooves 90 degrees apart that cross in Can be one handed, Requires rotation of nucleus,
the middle, works for most all nuclei, increased exposure to ultrasound
use grooves to crack lens into 4 pieces, easy to learn. energy.
remove pieces high vacuum phaco.
V groove Sculpt two long grooves that join in subincisional area Does not require rotation, Increased exposure to ultrasound
forming V shape, does not require hydrodissection. energy,
use grooves to crack lens into 3 pieces, V-shaped grooves can be hard to
remove pieces high vacuum phaco. produce.
Stop and chop Sculpt one groove, Less exposure to ultrasound Two handed,
divide nucleus in half, energy. nondominant hand is critical to
chop halves into smaller segments, success,
remove pieces high vacuum phaco. requires rotation of nucleus.
Crater and chop Sculpt a crater near incision, Less exposure to ultrasound Two handed,
chop nucleus in half across from incision with crater energy. nondominant hand is critical to
assisting nuclear division, success,
chop halves into smaller segments, requires rotation of nucleus.
remove pieces high vacuum phaco.
Horizontal Chop nucleus without initial sculpting, Least exposure to ultrasound Two handed,
Phaco chop horizontal motion, energy, nondominant hand is critical to
remove pieces high vacuum phaco. in soft lenses can use no vacuum success,
to eliminate risk of capsule injury. requires rotation of nucleus.
Vertical Chop nucleus without initial sculpting, Least exposure to ultrasound Two handed,
Phaco chop vertical motion, energy, nondominant hand is critical to
remove pieces high vacuum phaco. great for hard lenses. success,
requires rotation of nucleus.
Mechanical Examples are prechop and miLoop, Least exposure to ultrasound May require rotation of nucleus.
lens is mechanically divided into 2–6 pieces, energy.
remove pieces high vacuum phaco.

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 CHAPTER 22 Principles of Nuclear Disassembly 199

Fig. 22.3 In Stop n Chop an initial grove is made and then the lens
is divided in two. The two halves are chopped into smaller pieces.

to learn than the divide-and-conquer technique because the non-

dominant hand is so critical for the chop maneuver.
• Phaco-chop techniques are often divided into horizontal and verti-
cal chop. This distinction refers to the relative motion of the phaco
needle and the chopping instrument. Horizontal chop is better
when the lens is soft, and vertical chop is better when the lens is
hard. Further details of the phaco-chop technique are included in
other chapters in this text (see Chapter 23).

Stop-and-Chop Technique
Koch described the stop-and-chop technique in 1994, and it has served
B
both as a primary disassembly technique and as a transition to the
Fig. 22.1 (A) A one handed nucleus cracker is used to divide the phaco-chop technique.15
lens in the bag. (B) two hands are used with the phaco needle • The technique starts off like the divide-and-conquer technique with
and a hook to divide the lens into two pieces. a central groove used to divide the lens in half.
• Then that technique is stopped and the two halves are chopped,
hence the name stop and chop (Fig. 22.3).
• The advantage of this technique is that less ultrasound is used than
in the divide-and-conquer technique.12,15 The initial groove in this
technique allows for more space for pieces to free from each other
during segment removal. For many surgeons, the stop-and-chop
technique is their primary technique; but for others, it served as a
bridge to get to the phaco-chop technique, which may offer some
advantages (see Table 22.1).

NUCLEAR DENSITY
The optimal nuclear disassembly technique depends on several factors,
with the density of the lens being the most notable (Fig. 22.4). The most
difficult lenses to disassemble are either very soft or very hard. With
medium density lenses, the classic nuclear disassembly techniques
described previously work very well for most cases; however, soft and
hard lenses present problems for the classic techniques and require
Fig. 22.2 Phaco chop procedure is used without an initial groove special strategies. Fig. 22.4 shows how different techniques are used
to divide the lens within the capsule bag. depending on the density of the lens.

• With the phaco-chop procedure, the phaco needle holds the lens Soft Lenses
while a hook-like chopper mechanically splits the lens material Soft lenses are difficult because the vacuum from the phaco needle
(Fig. 22.2). can aspirate the soft material so quickly that the phaco tip injures the
• The phaco-chop procedure is particularly indicated when grooving capsule. For soft lenses, an effective strategy is to simply prolapse the
is difficult such as when zonules are weak or in soft lenses when lens into the AC during hydrodissection. This allows for a very safe
groove depth is difficult to estimate. This procedure is more difficult removal of the material away from the capsular bag often with minimal

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200 PART IV Nuclear Disassembly

Fig. 22.4 The nucleus disassembly strategy depends on the

hardness of the lens. Fig. 22.6 The strategy for nuclear disassembly with capsule
damage depends on the hardness of the lens.

Hydrodissection can create pressure between the nucleus and the cap-
sule and extend an existing capsule tear or open an area of weakened cap-
sule. Nuclear disassembly techniques that do not require hydrodissection
or those that allow for a more controlled dissection between the capsule
and nucleus are preferred when the capsule is potentially deficient.
Capsule tears can start posterior or anterior to the lens equator.
Anterior capsular radial tears most commonly are iatrogenic and come
from an errant capsulorrhexis but can also be caused by penetrating
trauma or laser peripheral iridotomy. Posterior polar cataracts can have
an area of central weakened posterior capsule in the area of the polar
opacity. A rapidly developing cataract after pars plana vitrectomy may
be caused by capsular injury from the surgery. More recently, capsular
injury after repeated intravitreal injections has become more appar-
ent.5–7 A rapid onset of cataract after laser vitreolysis can indicate an
iatrogenic posterior capsular tear.8 The strategy for nuclear disassembly
Fig. 22.5 A wire snare can be used to mechanically divide hard in the setting of capsular depends on the density of the lens (Fig. 22.6).
lenses before phacoemulsification.
Soft Lens
ultrasound energy. Another strategy, so called soft chop, is to use hori- If the lens is soft with a capsular tear present, the surgeon can simply sculpt
zontal chopping techniques but with minimal vacuum (Video 22.1). out a central bowl with the phaco machine. The remaining material can
then be removed after gentle hydrodelineation or dispersive viscoelastic
Hard Lenses dissection. This allows the lens material to prolapse on itself with less out-
Sometimes the best strategy with extremely hard lenses is to manu- ward pressure against the capsule, which can extend an existing tear.
ally extract the lens in one piece with no disassembly. Ruit showed in
a beautiful randomized study that skillful extracapsular surgery was Medium Lens
comparable to phaco in a cohort with dense lenses.16 Another interest- If the lens is of medium density, the surgeon can sculpt a central
ing option is to use mechanical fragmentation of the lens within the groove and then crack the lens without rotation or hydrodissection.
bag with a loop that is compressed to split the nucleus (Fig. 22.5).17 Hydrodelineation is then directed into the side of the groove to free
After the lens is split into 2 to 6 pieces with the loop, the pieces can the lens material. Because the lens is already cracked centrally, fluid
be removed with the phacoemulsification machine or manually. The can vent into this vacant space to reduce pressure on the capsule. The
prechop technique is better than sculpting techniques like the divide- groove also allows the lens material to fold in, which also creates less
and-conquer technique for hard lenses.12,14 outward pressure on the capsule.

Hard Lens
DISASSEMBLY IN SPECIAL SITUATIONS Dr. Charles Kelman described the V-groove technique in 1994.4,18 With
this technique, two grooves are made that intersect in the subincisional
Corneal Endothelial Issues space to form a V shape (Fig. 22.7A). The V groove is then used to break
Disassembly techniques that lessen sculpting and anterior ultrasound the lens into three pieces without rotation and without dissection (see
cause less damage to the corneal endothelium. Disassembly within Fig. 22.7B). This technique is ideal in the face of zonulopathy or a cap-
the capsular bag rather than in the AC decreases corneal endothe- sular tear because the nucleus can be disassembled without rotation or
lial cell loss but increases the risk to the posterior capsule. Chopping hydrodissection (Video 22.2).
techniques and mechanical disassembly techniques typically use less
ultrasound than the divide-and-conquer technique.12 The use of the Zonular Deficiency
antioxidant glutathione may decrease cornea endothelial cell injury. Surgeons should use the technique they are most comfortable with
when zonules are loose. Many surgeons feel that chopping techniques
Capsular Tears place less stress on the zonules, assuming that they are proficiencient
Tears in the anterior or posterior capsule makes nuclear disassembly with this technique. Other chapters will outline techniques using cap-
difficult. The primary concern is that any pressure against the cap- sular tension rings and other devices to stabilize the capsular bag dur-
sule will extend the tear, allowing nuclear material to fall posteriorly. ing nuclear disassembly (see Chapter 34).

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 CHAPTER 22 Principles of Nuclear Disassembly 201

Fig. 22.9 Dr David Phillips is shown using a Kitaro simulated

eye to practice nuclear disassembly in a real OR.

LEARNING NUCLEAR DISASSEMBLY

Senior residents find nuclear disassembly to be the most difficult part
of cataract surgery to master.1 Resident surgeons can transition in a
stepwise fashion to learn disassembly techniques. Simulation, such as
practicing surgery on model or animal eyes, is an important way for
B residents learn these techniques prior to operating on patients.
Fig. 22.7 (A) In the V groove technique 2 grooves are made that
join in the subincisional space forming a “V” shape. (B) Using
Transition to Phaco Chop
the V shaped grooves the lens is divided into 3 pieces. Bimanual maneuvers are difficult at first for resident surgeons.
Techniques that can be done with one hand, such as the divide-and-
conquer technique, are preferred to develop basic lens disassembly
skills.19–21 The faculty attending can guide the second instrument at
first, even if it requires an extra incision. The stop-and-chop proce-
dure serves as an excellent technique for transitioning to the phaco-
chop procedure. The additional space in the endocapsular bag makes
placement of the chopper easier. Also the space from the groove
makes it easier to remove the chopped pieces, which can get inter-
locked together because the chops between pieces are not always
sharp breaks.

Simulation
Simulation can shift the learning curve to make resident cases safer.22
The use of simulated eyes has dramatically improved the realism of
nuclear disassembly (Fig. 22.8). Practicing on model eyes in the operat-
ing room creates a higher fidelity simulation by using the same micro-
scope and phaco machine used for patients (Fig. 22.9). Completely
virtual simulation devices such as the EyeSi have also improved our
Fig. 22.8 A Phillips Studio Simulated Eye (#PS-12) is used to
ability to simulate nuclear disassembly.
simulate nuclear disassembly.

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202 PART IV Nuclear Disassembly

10. Gimbel HV. Divide and conquer nucleofractis phacoemulsification:

S U M M A RY development and variations. J Cataract Refract Surg. 1991;17(3):281–291.
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certain techniques. Softer or harder nuclear cataracts are approached phaco-chop, divide-and-conquer, and stop-and-chop phaco techniques
differently and can be the most difficult for nuclear disassembly. Ocular in microincision coaxial cataract surgery. J Cataract Refract Surg. 2013
issues such as corneal guttata, zonular integrity, and capsule integrity Oct;39(10):1463–1469.
affect the choice and method of disassembly technique. Residents find 13. K. Nagahara, MD, “Phaco Chop,” presented as a video at the 1993 ASCRS
nuclear disassembly difficult to master, but simulated eyes and other Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington,
simulation techniques have made mastery of them safer for patients. USA, May 1993; “Phaco-Chop Technique Eliminates Central Sculpting
and Allows Faster, Safer Phaco,” Ocular Surgery News, international
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 CHAPTER 22 Principles of Nuclear Disassembly 202.e1

Video 22.1: Soft chop (Courtesy of EyeRounds.org University of Iowa).

Video 22.2: V groove (Courtesy of EyeRounds.org University of Iowa).

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