Consecutive drilling combined with phaco chop for full thickness segmentation of very hard nucleus in coaxial microincisional cataract surgery

BACKGROUND: The complete disassembly of nuclear is the most challenging step in hard cataract surgery through microincision. The classic phaco chop technique often does not succeed, resulting in incomplete nuclear segmentation. The authors describe a technique to improve the efficacy and safety of the initial chopping. METHODS: The consecutive drilling combined with phaco chop technique was devised for very hard cataract through a microincision of 1.8–2.2 mm. 3–4 holes are consecutively drilled into the endonucleus with the phaco tip bevel down, at an angle of approximate 60 degrees and depth of approximately two-thirds of the lens thickness. The initial drilling approaches the capsulorhexis edge and the last drilling approaches the lens geometric center. The nucleus is deeply impaled with the last drilling and firmly engaged with high vacuum, and then chopped with chopper centripetally from the lens equator. The chopper and phaco tip are spread apart laterally after they approach at the center of the nucleus, to create a complete fracture across the entire nucleus. This technique has been adopted in 80 eyes of 65 patients with cataract harder than nuclear opalescence 5 on the Lens Opacities Classification System III scale or mature white cataract with a hard nucleus in the past 12 months. RESULTS: In all cases, full thickness segmentation of the hard nuclear including the posterior plate was achieved with this consecutive drilling combined with phaco chop technique. Phacoemulsification and intracapsular implantation of intraocular lens was safely performed in each case. No intraoperative complication such as iris injury, anterior capsule tears, zonulysis or posterior capsule rupture with vitreous loss occurred during surgery. No postoperative complication such as fibrin formation, synechias, severe endothelial cell loss, or endophthalmitis was observed in any case at 6 months postoperatively. CONCLUSIONS: The technique is an efficient, safe, simple, and swift procedure for full-thickness nuclear segmentation, delivering advantage of microincisional phacoemulsifcation for hard cataract with few ocular complications. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1186/s12886-019-1033-1) contains supplementary material, which is available to authorized users.