Effects of the “Pop & Prechop” Supracapsular Phacoemulsification Technique on Endothelial Cell Counts and Corneal Clarity Brandon Rodriguez, MD Michael.

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Effects of the “Pop & Prechop” Supracapsular Phacoemulsification Technique on Endothelial Cell Counts and Corneal Clarity Brandon Rodriguez, MD Michael Klufas, 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 financial interests in any of the topics/products mentioned

Purpose To determine the effects of a novel supracapsular phacoemulsification technique, “Pop & Prechop,” on corneal endothelial cell counts (ECC) and corneal clarity

Methods Prospective data was collected on 24 patients at Weill Cornell Medical College Each patient underwent phacoemulsification with the “Pop & Prechop” technique Preoperative and 1 month postoperative confocal microscopy measurements were taken Corneal clarity was measured preoperatively, day 1, week 1 and month 1 postoperatively 0 = no edema 0.5 = trace edema 1-4 = grading of Descemet’s fold

Surgical Technique Soft-shell anterior chamber fill for endothelial protection After creating a 5.0 to 5.75 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 capsular bag Viscoelastic is then injected behind the nucleus to protect the posterior capsule and keep the prolapsed nucleus upright

Surgical technique A cyclodialysis spatula is then introduced through one paracentesis and is placed behind the lens A chopper is introduced through the opposite paracentesis or the main wound and placed in front of the lens

Surgical Technique Via a scissoring maneuver at the iris plane, the nucleus is easily cracked into two halves (“Prechop”) Further chopping into quadrants and smaller pieces is also possible Care is taken to minimize zonular stress and corneal endothelial trauma

Surgical Technique Once adequately prechopped, supracapsular phacoemulsification is carried out at the iris plane or in the anterior chamber, away from the posterior capsule Since the nucleus has been divided mechanically, less ultrasound energy is needed for disassembly and emulsification

Results N=24, all surgeries performed by trainees (fellow/resident) Mean preoperative ECC = 2473 cells/mm2 Mean postoperative ECC at 1 month = 2354 cells/mm2 Mean reduction of 4.8% Previous published literature of “in-the-bag” techniques (divide & conquer etc.) Mean reduction of 4 to 8% at 1 month

Results No statistically significant difference with ECC loss and axial length (AL) AL <23 mm = loss of 150 cells/mm2 AL >23 mm = loss of 104 cells/mm2 p value = 0.356 Mean corneal clarity scores: Day 1 = 1.02 Week 1 = 0.15 Month 1 = 0.0 100% of corneas were clear by 1 month There were no intra-operative or postoperative complications Post-op day #1, 20/20 vision & clear cornea

Conclusion “Pop & Prechop,” a novel modification of supracapsular phacoemulsification, is a safe alternative to in-the-bag techniques such as “Divide & Conquer” Compared to published data, endothelial cell loss is comparable among the different techniques, even when performed by trainee surgeons Longer term follow-up is needed to fully evaluate the impact on the cornea

References RRA Bourne, DC Minassian, et al. Effect of Cataract Surgery on the Corneal Endothelium. Ophthalmology. 2004; 111: 679-685. WM Bourne , LR Nelson, et al. Continued endothelial cell loss ten years after lens implantation. Ophthalmology. 1994; 101: 1014-22. TJ Liesegang, WM Bourne, et al. Short and long-term endothelial cell loss associated with cataract extraction and intraocular lens implantation. Am J Ophthalmol. 1984; 97: 32-9. B Lundberg, M Jonsson, et al. Postoperative Corneal Swelling Correlates Strongly to Corneal Endothelial Cell Loss After Phacoemulsification Cataract Surgery. Am J Ophthalmol. 2005; 139: 1035-1041. T Walkow, N Anders, et al. Endothelial cell loss after phacoemulsification: relation to preoperative and intraoperative parameters. J Cat Refract Surg. 2000; 26: 727-32. TP Werblin. Long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery. Refract Corneal Surg. 1993; 9: 29-35.