The Phaco Flip Technique

There are several reasons why I like the phaco flip technique. It is an easily reproducible operation, and it can be performed in a wide range of clinical situations, including soft cataracts, very hard cataracts, bad zonules, and small pupils. This technique also has comorbidity with diabetes and glaucoma. Phaco flip requires few instruments due to the simplicity of the procedure, and because it has so many applications, the number of instruments that we maintain in the operating room is minimized.

THE TECHNIQUE
It is a common misconception that phaco flip is performed in the anterior chamber. To begin, the nucleus is flipped over so that it is inverted. I like to invert it to achieve an anatomical malalignment. If you just float the nucleus with hydrodissection, it will frequently fall right back down in the bag. Phacoemulsification is performed right from the pupil in the iris plane, as an intrapupillary procedure. Consequently, we are not working near the cornea. Many surgeons may be concerned that the phaco flip technique might compromise the cornea, but in fact, the cataract sits between the phacoemulsifier tip and the cornea, shielding the endothelium, so there really isn't any ultrasonic energy directed toward the cornea. Additionally, most of the phacoemulsification energy is applied underneath the lens.

SELLING POINTS
Another advantage of phaco flip is that the cataract is not broken up; it is sequentially phacoemulsified by small bites taken out of its nucleus. The phaco tip is able to shave away the cataract from the equator toward the center. This method prevents quarters and other nuclear material from floating around in the eye. I compare it to eating an apple to the core, going around and around until just a small piece of apple is left over. This also happens with the cataract, so that it stays intact until only a little of it remains. Any piece remaining is phacoemulsified until it is totally removed. The goal is to keep the cataract in one piece so that it is more manageable.

Even in hard cataracts, the incidence of corneal edema or striae is not any greater than with any other method of phacoemulsification. I think that when surgeons convert from one technique to another, they go through a learning curve, so that initially they may see more edema or striae. Once surgeons master the phaco flip technique, however, they'll see less. The cornea may be slightly thicker for 1 or 2 days following cataract surgery with the phaco flip technique, but the epithelial cell counts remain in the range of all other phacoemulsification procedures, between 5% and 7%. A significant reduction in cell counts would signify that the flip is not being performed in the deeper areas of the eye. I see my patients day one postoperatively, and the corneas always clear and show good visual acuity.

IN CONCLUSION
Phaco flip attracts a lot of attention, and physicians come to watch it all the time. It's a very simple procedure. It may take some mastery so that surgeons do not induce damage to the cornea, and also to produce a clear eye the next day, but I highly recommend it. I receive comments about how this technique has improved operating time for many surgeons. I'm very happy with phaco flip—I've been using it for 7 or 8 years, and I wouldn't go back to the other phacoemulsification procedures.

David C. Brown, MD, is the owner and Medical Director of the Eye Centers of Florida in Ft. Myers, Florida. Dr. Brown may be reached at (941) 939-3456; david.brown@ecof.com
Article adapted and reprinted with permission from Brown DC. Point/Counterpoint: Which Technique Do You Prefer for Phaco? Cataract & Refractive Surgery Today. 2001;2:18-20.