The Flip Supracap Technique

As Tal Raviv, MD, explains, flip supracap technique simplifies difficult cases and salvages complicated ones. It safely addresses loose zonules, a soft nucleus, a blown capsulorhexis, floppy irides, or cases when divide-and-conquer does not work. Many complications can be prevented by safely performing phacoemulsification outside the boundaries of the capsule. Because there is a learning curve to perform the flip supracap technique with minimal endothelial trauma, it should first be attempted on soft cataracts with deep chambers.

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Comments (12)

my preferred technique for soft lenses, and when capsule is compromised. i agree it should be familiar to all surgeons, so that they can use it when capsule compromised.

ranchump62 (60 months ago)

Thank you Dr. Raviv, for a great video, appreciated! I use a similar technique, routinely: I float out the entire lens, completely into the AC, and eat up the entire lens there, anterior to the capsulorhexis. To protect the endothelium: 1) I use a dispersive OVD to coat the endothelium; b) I use a reverse chop (between 2nd hand instrument and phaco tip), to break up the nucleus mechanically so I use minimal or no phaco power. It works for 99% of the up to 3+ NS lenses. I am sure this phaco float technique has long been described also.

Ming Wang,MD (60 months ago)

Whenever a large audience of ophthalmologists is polled on their preferred technique, only about 5% of them favor flip/supracapsular (with divide and conquer in the majority and chopping second). I believe this reflects our training over the last couple of decades, and predict future percentages will shift more towards chop and supracap. I typically perform 60% supracap and 40% chop, deciding predominantly on the density of the nucleus (supracap for < 2.5+ NS, and vertical chop for >2.5+NS cataracts). Factors such as zonular instability, small IFIS pupils, deep chambers will tip me towards supracap even in denser lenses, whereas manifest endothelial disease, will keep me in the capsular bag.

Tal Raviv (67 months ago)

The main goal of Phaco surgery is to remove Cataract with the almost safe and effective technique that can lead to the lowest degree of surgical damage and in the same time to the highest surgical respect to the ocular tissues. The present technique is good,but i want to add one point. The modern Phaco technology provides with very good stability of AC, effective phaco pulses, high safety and very good phaco-dynamics. In the other hand we have a big benefit of Visco devices and different chops. I prefer to work with the approach of Phaco in the bag with chop technique.In the video we can see the following signs:

wamsim (67 months ago)

During my last two phaco's the nucleus was flipped unintentionally, but instead of rotating the nucleus, i impeded the phaco tip into the nucleus and continued with "supracapsular horizontal chop".

Ashraf Hazai (67 months ago)

I have been using this flip/supracap technique for a few months since I started using Alcon's OZIL phaco, I flip the nucleus partially out of the bag and chop it as I go along. With adequate Viscoat and torsional phaco even with hard cataracts the cornea is clear the following day. I think its a great technique which all phaco surgeons should learn as it can help hugely in situations with unstable zonules and deep AC. Thank you for the great video.

Rizwana Khan (67 months ago)

In the never ending quest for the ideal phaco technic phaco-tilt is an interesting option. I did the classic David Brown Phaco Flip technic for 4 to 5 years with great enthusiasm but eventually moved to the chop technic because I had to admit my corneas were too often taking longer to clear. I think tho that I will take another look at this technic. I think some form of flip or tilt or mid-chamber technic should be part of every surgeon's armamentarium as it is unnecessarily laborious to use a pure post chamber technic in a very deep AC. Much smpler to flip it up and phaco it out. Philosophically I am inclined to agree with Prof. Thomas Neuhann who said "Cataract surgery involves learning a series of six or seven tricks to remove the lens." I firmly believe this should be one of those "tricks."

Brian (68 months ago)

This technique is useful in cases of significant phacodonesis to minimize zonular stress.

Ahmed (68 months ago)

Supracapsular phaco by definition takes place closer to the endothelium; however, it can be safely employed with minimal to no endothelial trauma in up to 3+NS. For lenses with greater densities I employ vertical quick chop. Certainly in shallow chambers or eyes with Fuchs, an in-the-bag technique would be preferable.

Tal Raviv (68 months ago)

The case shown in this video is probably NS+1 only, in my opinion very hard lenses (NS+3 or more) can lead to more endothelial compromise as most of the phaco is done in the anterior chamber near the endothelium.

Dr. Amer (68 months ago)

Possibly unclear due to the video title, I am not claiming a new technique description, but am merely illustrating a case in the flip/supracap category (and describing its benefits over divide and conquer or chop).

Tal Raviv (69 months ago)

This technique has been in existence since 1999. It is called PhacoTilt and has been well described in the literature by D. Grayson since that time. In fact, the instrument shown in the video is the Grayson Nucleus Manipulator (Bausch and Lomb/Storz Instruments) and was specifically designed for the PhacoTilt procedure.

Dr. Daystrom (69 months ago)