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Inside Eyetube.net | Apr 2012

Flip-and-Slice Technique

Hydroprolapsing the nucleus out of the capsular bag requires less phaco energy and results in less in-the-bag manipulation.

Cataract surgery patients, particularly those who receive premium IOL implants, have high expectations for their vision during the immediate postoperative period. I have developed a cataract extraction method I call the flip-and-slice technique that has become my go-to approach to deliver the best outcomes for my patients.

In the flip-and-slice approach to nuclear disassembly, the phacoemulsification plane is moved anteriorly from the posterior capsule and the endothelium is protected using an ophthalmic viscosurgical device (OVD). This technique incorporates some characteristics of the phaco flip or tilt techniques, with key modifications made possible because a viscoadaptive OVD is used to protect the corneal endothelium and to create a stable working space in the anterior chamber.


I begin the procedure with a controlled capsulorrhexis approximately 5.25 to 5.75 mm in diameter, performed under Healon5 (sodium hyaluronate; Abbott Medical Optics Inc.). My goal is to achieve a 360° overlap of the capsulorrhexis edge on the IOL optic. Immediately before performing hydrodissection, I burp some of the OVD out of the anterior chamber by depressing the posterior lip of the corneal incision with the flattened tip of a curved, single-use Kellan hydrodissection cannula (AS-7627; ASICO). I then perform gentle hydrodissection using the same cannula. As I hydrodissect, the nucleus tilts up and out of the capsular bag at approximately a 65° to 80° angle. Two-thirds of the nucleus hyroprolapses out of the bag while the bottom onethird remains in the bag. I then coat the leading edge (the equator of the prolapsed nucleus) with a crescent strip of Healon5 to protect the corneal endothelium.

Next, I flip the lens toward me, slicing it down the middle at the same time using a Koch nucleus spatula with a smooth, gently curved tip (K3-2354; Katena Products, Inc.). The depth of the slice depends on the density of the cataract. I then inject additional OVD through the sideport incision to tamponade the bisected lens down to a flat position, parallel to the iris, 180° inverted from its in situ position, with the posterior surface of the cataract facing the corneal dome.

If the lens is not already fully bisected, I begin phacoemulsification in sculpt mode. In most cases, only one or two grooves directly over the partially cleaved fault line are needed to complete the slice and create two heminuclear segments. At this point, I move to quadrant removal.

After the flip-and-slice portion of the maneuver is accomplished, little phaco energy is needed to emulsify the nuclear halves in a safe manner. Phaco times and other parameters from cataracts representative of several densities are shown in Table 1.


The flip-and-slice technique is quick and efficient. With less phaco energy expended and less balanced saline solution pumped through the anterior chamber, the potential for trauma is reduced and a healthier endothelium is seen postoperatively. This technique works well for most cataracts, including those in patients with intraoperative floppy iris syndrome (IFIS).

Benefits of the flip-and-slice technique include the following: it is efficient and safe; it provides good postoperative corneal clarity due to dramatic reductions in phaco energy and time; there is less endothelial cell loss compared with in-the-bag techniques; excessive in-thebag manipulation is avoided; prolapsing the nucleus into the anterior chamber avoids manipulation close to the posterior capsule; it is effective in eyes with small pupils or IFIS; it is effective in eyes with exfoliation; working in the supracapsular region minimizes zonular stress; and its high safety profile makes it an excellent technique for residents. The flip-and-slice technique is not useful in the presence of a Malyugin Ring (MicroSurgical Technology) or if the cataract is too soft or excessively hard; it is not recommended for black, rock-hard, grade 4++ brunescent cataracts, or if the lens is opaque white.

Videos of the flip-and-slice technique can be found at http://eyetube.net/?v=brere and http://eyetube. net/?v=somodo.

Cynthia Matossian, MD, FACS, is the founder and owner of Matossian Eye Associates in Mercer County, New Jersey, and Bucks County, Pennsylvania. She is an Adjunct Clinical Instructor in Ophthalmology at Temple University and a Clinical Instructor at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School. Dr. Matossian states that she is a consultant to and/or speaker for Abbott Medical Optics Inc., Alcon Laboratories, Inc., Bausch + Lomb, Ista, Allergan, Inc., Physician Recommended Nutriceuticals, and SofTec. Dr. Matossian may be reached at e-mail: cmatossian@ matossianeye.com; Web: www.matossianeye.com.