 Hi my name is Brian Kim and thank you for having me and the opportunity to share some of the things that I know and some tricks and pearls to help you with your cataract surgery. So this is my FAKO technique on how I disassemble the lens. On the video it says double chop and cross chop and I'll explain what that means. No FAKO and no vacuum refer to during disassembly of the lens I don't use any ultrasound or vacuum. So right here when the video plays please pay attention to the FAKO dynamic overlay. Ultrasound, aspiration and vacuum are never used during lens defragmentation. You place the chopper out to the equator in typical horizontal chopping fashion. You place the FAKO tips of incisionally into the soft depi nucleus and you can see from the side angle that both instruments are placed at the depth of the equator then the instruments are brought centrally to fracture the lens and the fracturing is purely mechanical no ultrasound or vacuum are used and so you can see the forces are centripetally towards the center and then the lens is fractured. Again this is purely under mechanical forces there's no ultrasound and no vacuum and I think that's important because I think it couldn't be safer that way. The chopper is placed out to the contralateral equator and the FAKO tip holds counter force as the chopper is pulled centrally to fracture the right heminucleus and you see that there. The right upper quadrant can be emulsified very easily with FAKO and ultrasound. Remember all the defragmentation maneuvers are under irrigation only and no ultrasound or aspiration or vacuum are used and then I take the chopper out to the contralateral equator again and I prolapse that right lower quadrant centrally and it's easier to access the lens fragment with a chopper. The chopper is safer than a FAKO tip and you cannot inadvertently grab anything. With horizontal chop you want to place the chopper so if this is my finger you want to um pronate your your wrist so that the chopper tip is pointing outward towards the periphery you want to push down on the lens itself and then glide out towards the equator make sure you get under the anterior capsular opening and as you glide that way you'll be able to probe you'll be able to supernate your wrist so that the chopper is now in the proper position and you know that you're in the proper position because you can feel kind of a kind of coming off the cliff you kind of kind of get off the edge and it goes kind of into this little pocket if you don't feel that that means you're still on top of the lens and so um you won't be able to get an effective chop but when you get out to that position you can feel that kind of dropping off the edge and if you want you can actually kind of nudge the lens and you'll actually feel it move laterally and so when you see that you know you're in good position and then with the fecotip you want to make sure you go within the anterior capsular opening but you want to kind of go a little bit vertical and push that um fecotip deep into the epinuclein material and then you bring both instruments together if in the case of a dense lens or a white lens you you can put the fecotip on the surface of the lens but then you want to make sure that you kind of have your chopper rotate a little bit more supinated so it's kind of angled towards you and then you can kind of bring those instruments together and you can still get an effective chop so this is the soft lens example I placed the chopper out to the equator and then you see I put the fecotip deep into the subincisional epinucleus I bring the instruments together and I fracture the lens no ultrasound or vacuum are used I placed the chopper out to the contralateral equator and I pulled the the instrument centrally for the cross chop maneuver and here I'm feco emulsifying and using vacuum to remove that quadrant I use the chopper to then prolapse that quadrant in the right upper area to centrally and then I emulsify the lens and so this is really the basic technique on how I'm removing the lens same maneuver place the chopper out to the equator fecotip subincisionally bring those instruments together and then fracture the lens take the chopper out to the contralateral equator and then fracture the right upper the right haeminucleus you can see that the emulsification portion of it is fairly routine that the tricky part of doing cataract surgery is to make sure that the disassembly can be done fairly easily and safely this is a white cataract now with this technique you cannot put the fecotip into the subincisional epinuclear material because it's not there because it's firm so you can put the fecotip on the surface of the lens and then you can fracture the lens using diagonal forces as you can see here and when you do it this way it still works and so going back to the white cataract video I'm bringing the chopper centrally and the fecotip centrally and it fractures the lens and it works fairly easily you place the chopper out to the contralateral equator and you pull that lens the chopper centrally and it emuls it fractures the lens and then the rest of it is just emulsifying the lens remember with dividing conquer and other fecotechniques you have to use a lot of ultrasound and vacuum and with this technique you don't have to do that so again you place the chopper out to the equator the fecotip is subincisional you bring the instruments together and you're able to fracture the lens you place the chopper out to the contralateral equator pull the chopper centrally and then you're able to fracture that hemunucleus as well so this is a brunessant lens with a posterior plate same maneuver and you can see I'm fracturing the lens however because there's a posterior plate the the lens is almost being held together almost like a crab claw or a flower petal so to speak and so you want to continue to chop and place the fecotip fairly deeply as you do the chops and the reason why this works is because you're not using feco or vacuum for these maneuvers and so you're not at risk for accidentally grabbing the posterior capsule or the iris and so look you see that very deep position of the fecotip I'm able to fracture that lens and you can see that it's able to segment very easily same here I'm placing that fecotip very deep and I'm able to fracture that lens again and that's how you're able to attack that posterior plate by placing that fecotip fairly deeply now of course this comes with experience as to how deep that should be and so this is really kind of a technique that should be employed once you've learned how to do dividing conquer stop and chop and the traditional chop techniques and so once you start to break up the pieces as I'm showing here again a deep position of the fecotip you're able to get through that posterior plate without having to fight that plate so much and so the lens removal ends up becoming fairly easy after that and so this is a final example this is a small smaller pupil case I'm placing the chopper out to the equator the fecotip is subincisional I bring the instruments together to fracture the lens the cross chop maneuver fractures the right heminucleus because the iris is small you can actually use it the chopper to prolapse that lens fragment centrally and you see that again here after the chop is performed and so the key for a small pupil case is to use that chopper to pull the lens centrally so my best pearls for double chop and cross chop use that technique to disassemble the lens using only mechanical leverage this eliminates the need for ultrasound or vacuum during lens defragmentation use a chopper to pull the fragments centrally and then you want to activate ultrasound and vacuum only when you're in the central safe zone and only when you're ready to emulsify the lens none of the disassembly steps should require any ultrasound or vacuum and double chop and cross chop because of this technique can be used for a wide variety of lens densities and pupil sizes thank you once again for having me I hope this helps you and I wish you the best again my name is Brian Kim best of luck