For several years, Charles Kelman, MD, of New York, NY, taught phacoemulsification by prolapsing the nucleus into the anterior chamber. David Brown, MD, of Ft. Meyers, FL, devised a technique called “phaco flip,” a method that involved flipping the nucleus upside down into the anterior chamber, and performing phacoemulsification in the anterior chamber. The technique could be performed rather quickly, but it was a return to anterior chamber phacoemulsification as Dr. Kelman first described it. Dr. Kelman's initial patients all presented with postoperative edema, which usually cleared within a few days. Dr. Brown claimed that his procedure produced clear corneas, and many surgeons who copied the technique declared the same. However, many disliked that with this method, not only was there cavitational and ultrasound energy being used close to the corneal endothelium, but there was also nuclear material floating around near the cornea.

Other surgeons tried the phacoemulsification technique and found that it was not as friendly to the cornea as initially proclaimed. William F. Maloney, MD, of Vista, CA, modified the technique with a method he called “supercapsular,” a technique in which he flipped the nuclear material upside down and then replaced it into the posterior chamber, in contrast to Dr. Brown, who performed phacoemulsification in the anterior chamber. Dr. Maloney said that early in the transition he made to that technique, his patients' corneas showed edema. The supercapsular technique works farther away from the cornea; it is performed deeper in the eye than anterior chamber phacoemulsification. Virgilio Centarian, MD, from São Paulo, Brazil, tried the phaco flip technique, and his patients' corneas looked terribly edematous. In those phaco flip procedures, his patients' endothelial cell loss was 30%, which is unacceptable. Just recently, Rick Wolfe, MD, reported at the meeting of the Australasian Society of Cataract and Refractive Surgeons in Melborne, Australia, that he performed phaco flip for a year and abandoned it because his patients' corneas had edema and striae the first day after surgery, and for several days that followed. In one of our investigational studies, we had an opportunity to see postoperative data on the pachymetry of the cornea. One of the surgeons is a phaco flip surgeon, and his patients' corneas were incredibly thick compared to the other patients' corneas, which is a measure of endothelial dysfunction. In fact, the investigators of the study sent us the data to ask whether we could explain why his patients' corneas were so much thicker than the other patients' corneas. In my mind, that cast the technique in a bad light.

Meanwhile, Dr. Brown, as well as Alan Aker, MD, of Boca Raton, FL; Jack Gurney, MD, of New York, NY; and others, proclaim the enormous benefits, speed, and efficiency of phaco flip. However, they have not shown endothelial cell counts or other studies. At the May 2000 ASCRS meeting in Boston, MA, I monitored a session on phacoemulsification techniques in which Andrew Fezza, MD, from Wills Eye Hospital (Philadelphia, PA), presented a history of 2,000 consecutive phaco flip cases that he had performed. Dr. Fezza extolled the speed and efficiency of the procedure, but shocked us all by saying that this technique lacked the “wow” factor. Because patients experience corneal edema for the first several days after surgery, they are not immediately thrilled with their quality of vision. On the other hand, the patients on whom we perform endolenticular phaco do experience that “wow” effect. I developed a technique called “chip-and-flip” that depends on a circumferential division of the nucleus, as opposed to a sectoral division. With this method, I divide the nucleus into a central endolenticular mass surrounded by an epinuclear shell. I sculpt and then sublux the central endonucleus by inserting a spatula underneath it, bringing it up into the plane of the pupil, phacoemulsifying it, and then trimming and flipping the epinucleus . After Kunihiro Nagahara, MD, from Sakaide City, Japan, introduced phaco chop (which is perhaps the most elegant endolenticular phaco technique), in 1993 at the meeting of the American Society of Cataract and Refractive Surgeons in Seattle, WA, I started to use a bevel-down needle in conjunction with power modulations, a technique called “choo-choo chop and flip”. My associates and I reported our results using choo-choo chop and flip with low power in the February 2001 issue of The Journal of Cataract and Refractive Surgery. The results of our surgery with respect to immediate postoperative visual acuity and clarity of the cornea were spectacular.

The great advantage of endolenticular phacoemulsification is that it is remote from the cornea. The bevel-down technique that I prefer allows material to be mobilized high within the endolenticular space, rather than traveling deep within the capsular bag and threatening the posterior capsule. The technique lifts the nuclear material to the level of the capsulorhexis, and evacuates it with high vacuum. In endolenticular techniques today, surgeons who disassemble nuclei by mechanical chopping use less phacoemulsification power than those who groove and crack. We basically evacuate nuclear material with high vacuum, rather than using ultrasound energy to create an emulsate, which we aspirate from the eye.

In our practice, we surveyed all of the corneal transplant cases performed by my associate, Richard Hoffman, MD, over an 8-year period, which had been preceded by cataract surgery. We found that the lag between cataract surgery and corneal transplantation was shockingly long—10 years. My concern is that the phaco flip eyes that have thick corneas and corneal edema in the postoperative period may clear, but there is uncertainty about what will happen a decade later. I believe that although the majority of phaco flip patients who show thick corneas, striae, and edema, eventually clear and see well, many of them are going to come to graft. I believe that because patients are undergoing cataract surgery earlier and younger today, we're going to see a rash of failed corneas 10 years later. I'm also very concerned at this time about the safety of the phaco flip procedure, and I think we need those surgeons who perform phaco flip to start producing data from prospective, randomized studies. I have performed phaco flip a number of times, and the patients' corneas look edematous. Without bragging, I think I can phaco as well as anybody. Even the corneas of some clear lensectomies that I flipped into the anterior chamber did not look as clear as the harder cataracts that I do in the bag, in the endolenticular space. It seems that we are starting to uncover a primrose path.

I. Howard Fine, MD, is a founding partner of the Oregon Eye Associates in Eugene, Oregon, as well as President of the American Society of Cataract and Refractive Surgery. Dr. Fine may be reached at (541) 687-2110; hfine@finemd.com