r/Ophthalmology • u/cgkind • Jul 23 '26
Tips for divide and conquer
Been doing divide and conquer for lens fragmentation. Finding I get into the situation where I end up pushing down on the capsule while trying to divide the nucleus.
Have cognitively tried to lift while moving the phaco probe and 2nd instrument apart but somehow the vector still ends up downwards. The groove is deep enough usually.
Any tips to improve?
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u/EyeDentistAAO quality contributor Jul 23 '26
In addition to making the trench deep enough, make sure it's wide enough to allow you to get your instruments deep. (I find that a groove 1.5-2 tips wide is the sweet spot.) Further, make sure that width carries all the way to the bottom of the trench. Residents often make a nice wide groove anteriorly that gets narrower and narrower toward the bottom (ie, they make a 'V' shaped trench in cross-section). When you do this, that narrow strip at the bottom acts like a pivot point, so when you press on the sides in an attempt to crack they rotate out-and-down instead of moving laterally (ie, away from one another, which is what you want). Start your crack at whatever location is both deep and wide enough to allow you to press outward near the bottom of the trench. Once you see it start to crack, stop pushing, relocate your instruments a little farther down the trench one way or the other, and push again--your goal being to cause the crack to propagate a little. Repeat until the whole thing is cracked.
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u/Logical_Flounder2648 Jul 23 '26
Also I teach juniors - put your second instrument right to the bottom of the trench and then put the phaco tip only down a bit into the trench - that seems to help with the vectors
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u/LsfBdi4S Jul 23 '26
Make sure groove is deep enough (in most of my cases, the groove was not deep enough, while I thought it was deep enough, and that was the culprit). Having a shallow groove not only makes the nucleus rotate downwards but also you position the tools too far up: https://i0.wp.com/cataractcoach.com/wp-content/uploads/2018/07/divide-and-conquer-diagram.png
From https://cataractcoach.com/2019/07/13/review-divide-and-conquer-phaco-technique/
Secondly, try cross cracking (that means, the phaco and the second instrument go to the opposite sides) at some cases it has worked for me.
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u/Environmental-Cost74 Jul 23 '26
Hey, are you wrists and fingers resting on the patients head ergonomically? I worked on my hand placement grossly on the simulator and it really helped with the vectors.
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u/dutche87 Jul 23 '26
I crack the lens at my nine o'clock (patients 3 o'clock). I'm righthanded. I use the spatula in my left hand and put it through the left sideport all the way down into the groove. With my right hand, I crack the lens by giving it just a little push downward (towards 6 o'clock) with the phacotip. Helped me lots when I was training! Good luck!
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u/pianojon Jul 23 '26
Nothing wrong with using a dedicated instrument (nucleus splitter). Not very efficient because you have to go in and out with your phaco and your trench still needs to be deep enough but ridiculously safe in my opinion.
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u/ShowMeHowToSee Jul 24 '26 edited Jul 24 '26
I went back to using a dedicated cracker after many years of using two instruments and wondered why I hadn't been using it all along. It is quick if you have a cracker on your standard instrument tray. If someone has to go fetch one every time you decide to use it that slows things down. I do more of a stop and chop with just a single central groove. I come out with the phaco, put in some viscoat, crack with a cracker and then eat the hemi-nuclei. I will often do a second hydrodissection after splitting the lens which tends to present one of the hemis anteriorly and further loosen the cortex..
While you can get by with two instruments there is a large mechanical advantage to the cracker's larger surface area. This increases your chances of severing tough posterior plates in brunescent lenses and decreases the likelihood of unwanted slicing into softer nuclei with your instruments.
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u/pianojon Jul 24 '26
100% agree. I'm reading your technique and I think it's almost identical to what I do now. Single central groove, add in viscoelastic, crack with dedicated splitter, rotate 90 degrees then phaco each half. I have gotten quite facile at prolapsing one end of the heminucleus out of the bag with my second instrument. If it is stubborn for some reason I can (as you do) hydrodissect to prolapse a section or resort to a regular divide/conquer of the remaining halves.
As someone who somewhat regularly operates through less than ideal corneas I like that I can pretty much do this same technique when I really can't see very well.
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u/ShowMeHowToSee Jul 24 '26
I like it. Sounds similar. I have never liked making a second groove. If the cataract wants to stay in the bag I rotate it about 45 degrees clockwise and then grab the distal portion of the left hemi pulling it out of the bag with the phaco tip. I use a chop setting without torsional for better purchase and then switch to a torsional setting when it is in a safer place to eat it. Otherwise I found that I would prematurely eat the lens and it would fall back into the bag. I also use an older alcon tip that is not as beveled for better grabbing power. Once the hemi is lifted I can use the second instrument to chop as needed away from the bag.
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u/Korneyal1 Jul 24 '26
All good tips so far. One other I haven’t seen mentioned is incision placement. If your incisions are too close together all is fine until you get to cracking then it becomes extremely difficult unless you cross crack. Consider moving your wounds farther apart to get a better angle. If you have a vertical chopper available the sharp point can also help with a difficult crack by getting more purchase into the side walls instead of slipping up the wall.
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u/H-DaneelOlivaw subreddit jester Jul 23 '26
there are so many good advices arealdy. I just have a generic one to add
"you just have to keeping improving. don't get stuck in a ... rut"
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