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CME SERIES

phaco fundamentals
For The Beginning Phaco Surgeon

Supported by an unrestricted
educational grant from Bausch & Lomb

phaco fundamentals • 

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1. The Basic Phaco Machine
2. Concepts of Fluidics
3. Flow Balance & Tubing Compliance
4. Optimizing Phaco Fluidic Settings
5. Fundamentals of Ultrasonic Phaco Power

An exploration of the basics of safe,
technically advanced cataract extraction

6. Continuous, Pulse, And Burst Phaco Modes
7. Hyper Settings
8. Variable Duty Cycle
9. Variable Rise Time And Custom Settings
10. Creating A Clear-Corneal Cataract Incision
11. Hand Position & Pivoting
12. Bevel Position; Incision Spacing
13. Foot Pedal Control During Steps Of Surgery
14. Viscoelastics: Dispersive & Cohesive
15. Capsulorhexis Creation
16. Hydrodissection and Hydrodelineation
17. Concepts Of Nucleus Removal
18. Divide-and-Conquer Technique of Nucleus Removal
19. Stop-and-Chop Technique of Nucleus Removal
20. Quick Chop Techniques of Nucleus Removal
21. Cortex Removal
22. IOL Insertion
23. Incision Closure & Dressings
24. Post-op Medications & Follow-up

Uday Devgan, MD, FACS
Uday Devgan, MD, FACS is a cataract and refractive surgeon at the Maloney Vision Institute, the
premier private ophthalmic practice in Los Angeles, California. He performs the full spectrum
of corneal and lenticular refractive and restorative surgery and has instructed thousands of
surgeons in 30 countries. Dr Devgan is Chief of Ophthalmology at Olive View UCLA Medical
Center and Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of
Medicine in Los Angeles, where he is the only faculty member to have earned the prestigious teaching award
twice. Dr Devgan writes monthly columns in multiple ophthalmic journals worldwide and is a consultant for
many major ophthalmic companies. He can be reached at www.UdayDevgan.com for further information. 
• WORLD REPORT CME SERIES

Phaco Fundamentals 1.0

T

he causes of cataract are complex and that World War II aviators could tolerate shards of
obscure, ranging from the unrelenting aircraft canopy glass in their eyes prompted him to
forces of genetics and aging to the fate- use that material—actually polymethylmethacrylate,
ful impacts of environment, climate, or PMMA—to fashion the first intraocular lenses.
diet, disease and trauma. Yet its effect Ridley’s innovation inspired surgeons to remove the
is simple: the progressive cloudopaque lens while leaving intact the
ing of the eye’s crystalline lens to
capsular bag as a receptacle to hold
The machine age saw
the point of opaqueness, robbing
his IOLs, and extracapsular cataattempts to extricate
the patient of sight. Medicine’s efract extraction was born. ECCE’s
the lens via incision,
forts to slow or halt this progression
breakthrough was the capsulotomy,
have failed. Yet—as was obvious
removal of the anterior capsule to
but it wasn’t until
even to the ancient Indian surgeon
allow wholesale delivery of the
the second half of
Sushruta—the answer to cataract
nucleus, to be replaced by a PMMA
the 20th century that
lies in removing the obstruction to
lens with known refractive qualisurgeons, empowered
restore the passage of light onto the
ties. It’s a nifty trick that remains
by microscopy and
macula. The history of cataract surin many eye surgeons’ repertoires,
precision implements, and a staple of most residency traingery has been an unremitting quest
to remove the obstacle—the noing programs. Refinement of ECCE
finally succeeded at
longer-crystalline lens. Sushruta’s
technique led to extraction via
cataract extraction.
genius was simply to nudge the obsmaller incisions that afforded stastruction aside, a procedure called
ble intraocular pressure during surcouching that persisted well into modern times. The gery and sealed without sutures, a variation called
machine age saw attempts to extricate the lens via manual small-incision cataract surgery. With SICS
incision, but it wasn’t until the second half of the and low-cost IOLs, cataract surgery now penetrates
20th century that surgeons, empowered by micros- even the world’s poorest communities and surgical
copy and precision implements, finally succeeded at volumes have risen into the millions.
cataract extraction.
Yet the sheer mass of the cataractous lens posed a
Intracapsular cataract extraction involved removal physical barrier to smaller, less-traumatic incisions.
of the lens and capsular bag as one, with the refrac- Charles Kelman toppled this barrier with his idea of
tive power of the now-absent lens provided exter- emulsifying the nucleus inside the eye for removal
nally by massive “Coke bottle” spectacles. It’s hard via aspiration, a task accomplished with targeted
to believe today that ICCE was the state of the art ultrasound and dubbed phacoemulsification. Incias recently as 1980. Sir Harold Ridley’s observation sions have been shrinking ever since, with advances
phaco fundamentals • 

we wish to thank the thousands of World Report readers who requested the compilation and provided their views and suggestions. while 80% placed themselves in the basic or intermediate category. its processes and its operations. In India. The purpose of this book. which we are calling Phaco Fundamentals 2. increasingly aware of the benefits of early intervention. The editors of Ophthalmology World Report wish to thank Dr. showing that large numbers are 4-5 years old and likely to be replaced soon. this is not the case in much of the world. even lingering instances of couching. the different types of phaco systems.8mm Stellaris™ platform and its Akreos™ MI60 foldable intraocular lens. is a renowned U.100-plus respondents said Phaco Fundamentals was pitched to a comfortable level of difficulty. See figure 2. The incision-size benchmark for commercially available systems now has dropped below 2mm.0. and each provided a snapshot of their current practice. And we thank Bausch & Lomb for the unrestricted educational grant that made Phaco Fundamentals possible. by some experts’ telling. and empower surgeons to use it safely and to maximum advantage. Jeffrey Parker Editorial Director Ophthalmology World Report phaco fundamentals •  . doctors overwhelmingly cited the cost of equipment as the main Basic Intermediate Advadced barrier to their own adoption of phaco.000 registered readers. Uday Devgan. is to establish a foundation of knowledge about all aspects of the phacoemulsification system.100 in India. Devgan has dedicated a large part of his teaching to understanding and explaining the fundamentals of phaco in ways that  • WORLD REPORT CME SERIES Figure 2 Figure 3 WHAT IS YOUR PREFERRED CATARACT TECHNIQUE? EVALUATE YOUR PHACO SKILLS HOW OLD IS YOUR PHACO MACHINE? Sample size: 1107 Sample size: 1060 Sample size: 779 3% 13% 12% 35% SICS 9% 45% ECCE Other demystify the technology. We’re preparing chapters on many aspects of phaco practice. Surgeons are moving rapidly toward phacoemulsification as more and more patients. typical complications and their management and pearls of best practice. The Phaco Fundamentals series has given our World Report editorial team a unique glimpse into the state of cataract surgery in both India. where cataract usually is treated in its early stages before the patient’s vision is dramatically impaired. and top surgeons say the best defense against complications is to know the technology as well as the procedure. reliability and competitive market advantage. The compiled data. various IOL types and applications. and China where we have 17. followed by user friendliness and ability to maintain a stable anterior chamber during surgery. even while the ultrasound tip manipulates and blasts away at the nucleus. surgeon in private practice at the Maloney Vision Institute in Los Angeles and associate clinical professor of ophthalmology at the Jules Stein Eye Institute in the School of Medicine of the University of California. About 70% of the 4.1 requirement in a replacement system was affordability. one can still encounter almost the entire history of cataract surgery—a relatively even mix of ECCE. Los Angeles. Respondents said their No. There’s a lot that can go wrong. The study captured data about more than 2. but they also presented a long list of ideas for further study—suggestions that editors are using 55% 31% 42% 50% PHACO 5% 1-3 Yrs 4-6 Yrs 7-9 Yrs 10 Yrs & above to design the next cycle. as with Bausch & Lomb’s 1. revealed a wide range of surgical skills and experience—and a strong hunger for knowledge and surgical opportunity. including the learning curve when transitioning to phaco from ECCE or SICS. Dr. In both countries. In India and China. The author.000 doctors in China and 1. But what exactly is phacoemulsification? While it’s easy to conceptualize. This compiled edition was requested by more than 3. comprising one of the largest surveys of cataract ever undertaken in either country. Uday Devgan for his brilliant insights and clear explanations. the survey showed that Indian and Chinese ophthalmologists hold phaco in high regard. SICS and phaco punctuated by isolated pockets of ICCE and. The good news is that advanced surgical skills are spreading in both countries.000 ophthalmologists. See figure 3. Finally.000 phaco machines. While phacoemulsification has become the prevailing standard in the industrialized world. Nonetheless. low rates of induced astigmatism. See figure 1. only about 14% of respondents described their phaco skills as advanced. a compilation of the 24part Phaco Fundamentals series that was first syndicated in Ophthalmology World Report. where our circulation exceeds 10. lower rates of infection and other complications—as well as practical ones such as patient comfort. saying it was attractive for clinical reasons—anterior chamber stability. it’s actually one of the most complex forms of microsurgery—involving simultaneous machine-controlled irrigation and aspiration to maintain anterior chamber stability.S.Figure 1 in computer control and engineering and successive generations of foldable IOLs allowing surgeons to all but replicate the human lens with minimal trauma to the eye. Dr. are expecting their ophthalmologists to use the latest technologies.

Madurai. which can inform my own practice. I’m keen to obtain an elementary knowledge of phaco through your magazine and hope you can provide audio/visual discs and other training materials. Mentougou District Hospital. It’s essential ready for me. which is extremely useful for us on the front lines of clinical practice… Xie Lianyong. so I’m particularly excited about receiving the consolidated edition of “Phaco Fundamentals”. and many told us why. which is very useful for residents like me… Geetha Madhavan. I wish to thank you and Bausch & Lomb for offering the booklet covering all 24 lessons at no charge… S. I’ve spent 20 years at the grassroots.100 World Report readers requested this Phaco Fundamentals compilation. Your strong editorial focus on practicality is really helpful for me in my work. I’d like to see such serial coverage of other topics too. The series by Dr. Tamil Nadu O phthalmology World Report has become an important window through which I learn about new clinical techniques. Hebei Province P hacoemulsification has yet to penetrate most county level hopsitals. Gandhinagar. Nagpur. Please continue to publish this kind of series…. China has millions of people with cataract. but I can learn all about phaco through your magazine. I save every issue of World Report as a reference. Beijing M any thanks for the Phaco Fundamentals series. Dawn Hospital. Handan. Yicheng Hospital. Uday Devgan’s “Phaco Fundamentals” series. BW Lions Eye Hospital. Yancheng. SMHS and Associated Hospitals of Government Medical College. I also appreciate your reporting about various hospital management models and approaches. For a relatively inexperienced doctor like me. I especially like reading your Cover Story profiles. Chennai O phthalmology World Report carries a lot of cataract coverage and the “Phaco Fundamentals” series is really good. Sri Ramachandra University. speedy dissemination of knowledge and quality printing... Muthuramalingam. Ten thousand thanks! Zhou Jian. Maharashtra W ith a population of 1. from which I have profited deeply. She County First People’s Hospital. I am a regular reader of World Report and find it very informative in all aspects.3 billion. My hospital doesn’t yet have phacoemulsification. This way. It is a fantastic series for phacoemulsification beginners like me… Junaid S Wani. Xian Central Hospital. but my set is incomplete so I really hope to receive the collected issue of “Phaco Fundamentals”. Your reporting on both surgery and therapies is so useful that I can put it directly into practice. advances and ideas. Niu Lihe. I hope to see more articles about the management of post-cataract complications and difficult cases as well as the perspectives and experiences of experts from other hospitals. giving valuable insight into actual phaco operations…. and the scope for development is vast. I wish to have the full series in the collected form. Bangalore I ’m ardently awaiting my copy of “Phaco Fundamentals” I hope your magazine can organize more of this phaco fundamentals •  . which introduce practitioners’ work and career development. Miyun County Central Hospital. Hebei Province P lease acknowledge my request for the complete series of “Phaco Fundamentals”. I really appreciate the cataract-related content of your magazine. Shaanxi province I ’m an ophthalmologist and a loyal reader. Lü Jinyu. Zhang Xinkang. Surgery requires both technical skills and advanced equipment. which is excellent… Zhang Ximei. Phaco needs to be widely promoted and organized. Weian Sight Restoration Hospital.Uday Devgan has been a wonderful guide for a budding surgeon like me. I hope you can extend the the series to make it even more splendid… Chen Yanli. if conditions permit we’ll definitely purchase a system. I would like to have the booklet of the complete series of the “Phaco Fundamentals” so that I can preseve it for a lifetime… Maithili Kulkarni. Anqing City. Xian First Railway Bureau. Anhui Province type of training.Readers’ letters More than 4.. It publishes the latest information about surgical technique as well as the latest medical equipment. Here is a sampling of reader views about the 24-part series. Ophthalmology World Report is even more useful and authoritative. My department is only now embracing phacoemulsification. and hope to see more… Wang Peng. Shaanxi province  • WORLD REPORT CME SERIES phthalmology World Report has earned the admiration of many readers for its excellent reports. Shanxi Provincial Eye Hospital I am very much impressed by Dr. Yan’an City Hospital.. It is extremely helpful. Phacoemulsification is reaching just the tip of the iceberg. He Haining. Srinagar I have gone through the “Phaco Fundamentals” lesson series and found it very useful… Jalpa Vashi. and find the magazine to be very helpful. so grassroots practitioners like me really need resources like Phaco Fundamentals to shore up our learning. and the “Phaco Fundamentals” series integrates both. Compared to (its predecessor) Ophthalmology Times. pioneering phaco surgery for cataract.. Jiangsu Province O M y hospital focuses on cataract. Beijing I t’s indeed a fantastic effort on your part to come out with a very simplified yet comprehensive series on phaco fundamentals. and I really appreciate it.

foot pedal position is additive to the previous positions. The irrigation is on. This is similar to the gas pedal in a car. and the vacuum and aspiration level is at its highest preset level. To create the vacuum and the aspiration flow of fluid. The height of the infusion bottle determines the relative infusion pressure and flow rate during0<eejFei_j_ed( the surgery. (2) the outflow tubing that removes the fluid via flow that is created by the phaco machine’s fluid pump. To keep the eye inflated during surgery. There is no linear control of the infusion—the infusion isi]Z[jcXi^dcd[e]VXd[ddiedh^i^dc& either turned on or turned off. The regulation of vacuum and aspiration is controlled by the foot pedal. ] . [ Figure 4: Foot pedal position 3 controls the delivery of the ultrasound energy into the eye. Ultrasound energy should only be applied once the tip of the phaco probe is in contact with part of the cataract.JC8I>DC 3 (ultrasound energy). as well as position 1 (irrigation). Each create vacuum/aspiration to remove the cataract.3.DDIE:96A (irrigation). [ Figure 1 illustrates additive pedal functions. JAIG6HDJC9 EDL:GL>G: Edh^i^dc(Xdcigdahi]ZYZa^kZgnd[i]Z jaigVhdjcYZcZg\n^cidi]ZZnZ Foot Position 3: Ultrasound Energy The bottom-most position of the foot pedal is position 3.AJ>9 phaco fundamentals •  . and the leakage of fluid from the incisions.DDIE:96A EDH>I>DC6C9. [ Figure 3: Vacuum and aspiration of fluid from the eye is the function of phaco foot position 1. such as would be needed for a denser cataract.AJ>9 compromising well anterior and posterior chambers. we see that there are three lines attached: (1) the infusion tubing carrying fluid into the eye. which controls the delivery of ultrasound energy into the cataract.JC8I>DC K68JJBA>C: [ Figure 2: Irrigation of fluid into the eye is the function of phaco foot position 1.so that while the pedal is in position 2 (vacuum/aspirafy the nucleus. ] e]VXd 7if_hWj_ed0<eejFei_j_ed( <eejF[ZWbFei_j_ed Fei_j_ed' ^gg^\Vi^dc Fei_j_ed( Vhe^gVi^dc Fei_j_ed) e]VXd Foot Position 1: Irrigation It’s important to realize that during phacoemulsifica0<eejFei_j_ed' tion. 7DIIA: under 1 cubic centimeter of space together. This foot pedal tradition. and (3) the line that carries the electrical signals to control the ultrasound energy at the tip of the phaco probe. The phaco machine aims to balance fluidics within the eye. >gg^\Vi^dcd[[aj^Y^cidi]ZZnZ^h the infusion is turned on.4 ?hh_]Wj_ed0<eejFei_j_ed' <eejF[ZWbFei_j_ed . There is linear control of the ultrasound energy level so that further pedal depression results in more ultrasound energy. Vhe^gVi^dc . with more depression of the pedal resulting in higher levels.DDIE:96A E=68D EGD7: >gg^\Vi^dcd[[aj^Y^cidi]ZZnZ^h i]Z[jcXi^dcd[e]VXd[ddiedh^i^dc& Fei_j_ed) T >GG><6I>DC A>C: he three main functions of the phaco machine ally works by depressing it towards the floor with the are: (1) to provide irrigation into the eye. 7if_hWj_ed E=68D. A>C: ?hh_]Wj_ed L6HI:. These three lines correspond to the three phaco foot pedal positions. ] The vacuum and aspiration levels that are created draw the fluid out of the eye and into a waste fluid collection via the outflow tubing.LESSON 01 The Basic Phaco Machine Figures 2. we need to ensure that the fluid inflow rate is greater than the fluid outflow rate. These three functions correspond to the tion) it is also providing the full function of position 1 three phaco foot-pedal positions. When we look at the phaco probe closely. we are already engaging the full function of both positions 1 and 2. once the pedal is in foot position is the primary instrument used to control the phaco ma-EDH>I>DC6C9. particularly to prevent collapse of the anterior and posterior chambers which can >GG><6I>DC .of position 2 (vacuum/aspiration). (2) to dominant foot (the right foot for most surgeons).AJ>9 7DIIA: Fei_j_ed' E=68DB68=>C: ^gg^\Vi^dc All phaco platforms share the same basic structure and concepts.AJ>9 EJBE Figure 1 Foot Position 2: Vacuum / Aspiration of fluid Phaco foot position 2 is the control of the relative aspiration and vacuum level of the fluid from the eye. and these will be explained fully in future columns.AJ>9 EJBE  • WORLD REPORT CME SERIES K68JJBA>C: L6HI:. where the car’s throttle is opened more as the gas pedal is further depressed. ] .DDIE:96A lead to severe complications. During the surgery we must always maintain the stability and E=68DB68=>C: structure within the eye. and (3) to deliver ultrasound energy in order to emulsi. the phaco machine must have a fluid pump. we are working in the very small space of the . while delivering Fei_j_ed( ultrasonic energy and vacuum in order to emulsify and aspirate the cataract through a small incision. The phaco foot pedalE=68D. There are two primary sources of fluid outflow during phacoemulsification: the outflow from the phaco probe created by the fluid pump. The most common types of fluid pumps are peristaltic and venturi. Note that if the pedal is in position 3. it is also providing the function chine during cataract surgery. Similarly. so that the top of foot position 2 provides less vacuum or flow than the middle or bottom range of the same foot position 2. There is a linear control of vacuum and flow.AJ>9 KVXjjbVcYVhe^gVi^dcd[[aj^Y[gdbi]Z ZnZ^h[jcXi^dcd[e]VXd[ddiedh^i^dc KbjhWiekdZ0<eejFei_j_ed) The irrigation function of the phaco machine is meant E=68D to provide a source of fluid EGD7: infusion into the eye during the surgery. By depressing the foot pedal to position 1.

We are concerned with the relative relationship and not the exact values. The primary rule for Figure 1 A[[f?D<BEM>EKJ<BEM ™DcZhdjgXZd[[aj^Y>C. The two factors that determine the rate of inflow are: the change in pressure and the radius of the inflow tubing. and size of the inflow and outflow tubing are different.ADL "7diiaZd[WVaVcXZYhVaihdaji^dc ™IldhdjgXZhd[[aj^YDJI. The composition. ] Modulating Phaco Fluid Flow: Poiseuille’s Equation The basic equation that governs all fluid flow during phacoemulsification surgery is Poiseuille’s Equation: F = ΔP π r 4 / 8 η L In this equation. there are two sources of fluid leaving the eye: (1) the fluid that is removed via the phaco probe as a result of the vacuum level generated by the fluid pump. we can ensure that the eye stays inflated and stable during surgery. ] Modulating Fluid Outflow For fluid outflow. By keep a constant infusion pressure and limiting the outflow. This is clearly illustrated in a common sense situation of drinking with straws. The viscosity of the fluid is relatively constant.ADL <:C:G6IDG VhXdbeVgZYidaVg\ZgWdgZijW^c\7l]^X]XVcVX]^ZkZ V]^\][adll^i]aZhhkVXjjbgZfjgZY#I]ZX]Vc\Z^c[adl^h ZmedcZci^VaangZaViZYidi]ZgVY^jhd[i]Zi^W^c\# of the eye during surgery. the size of VhXdbeVgZYidaVg\ZgWdgZijW^c\7l]^X]XVcVX]^ZkZ theV]^\][adll^i]aZhhkVXjjbgZfjgZY#I]ZX]Vc\Z^c[adl^h infusion channel within the phaco probe (or other ZmedcZci^VaangZaViZYidi]ZgVY^jhd[i]Zi^W^c\# infusion instrument) is kept as large as possible so as to Ed^hZj^aaZ not cause a bottleneck effect. nature.aj^Y^c[adlXVcWZbdYjaViZYWnX]Vc\^c\i]ZWdiiaZ]Z^\]iVcYi]ZgZ[dgZi]Z egZhhjgZ\gVY^Zci!VhlZaaVhX]Vc\^c\i]ZgVY^jhd[i]Z^c[adlijW^c\# phaco fundamentals • 11 . the higher the infusion pressure.sºEg ) Some degree of fluid leakage from the incisions is helpful to allow cooling of the phaco needle and to prevent thermal injury during surgery. [ Figure 1: Keep inflow greater than outflow to ensure stability Ed^hZj^aaZÉhZfjVi^dch]dlhi]VihbVaaZgWdgZijW^c\6 6#HB6AA7DG: 7#A6G<:7DG: K688JB gZfj^gZh]^\]ZgkVXjjbVcYgZhjaih^cVadlZg[adl! ADL. therefore. for simplicity we can simplify this formula. If we allow the outflow to exceed the fluid inflow.ADL "6he^gViZY[aj^Yk^Vi]Ze]VXdegdWZ "Adhhd[[aj^Y[gdb^cX^h^dcaZV`V\Z A[[f_d\bem ]h[Wj[h j^Wdekj\bem je[dikh[ ijWX_b_jo e\j^[[o[ Zkh_d] ikh][ho$ 10 • WORLD REPORT CME SERIES phaco fluidics is to keep the inflow greater than the outflow. The change in flow is exponentially related to the radius of the tubing. we experience surge within the eye and this can cause chamber instability. ] Modulating Fluid Inflow The source of fluid inflow is the bottle of balanced salt solution that is hanging on the phaco machine.ADL <:C:G6IDG ikh][ho$ modulated by changing the bottle height and therefore the pressure gradient. collapse of the eye. and L = length of the tube. can be modulated by raising or lowering the height of the bottle relative to the patient’s eye: the higher the bottle. [ Figure 3: Fluid inflow can be :fjVi^dc . and aspiration of the posterior capsule.sºEg) h^oZ^c[adl^gg^\Vi^dc\^chigjbZci Ed^hZj^aaZ :fjVi^dc ºE"egZhhjgZ\gVY^Zcig2gVY^jhd[i]ZijWZ . F = flow. The rate of the fluid outflow via the phaco needle is determined by the radius of the needle and tubing. as is the length of the tubing. the control of fluidics during phacoemulsification surgery is important to ensure efficient removal of the cataract while preventing complications due to tissue collapse. and (2) fluid leakage from the incisions. The rate of the fluid outflow loss via the incisions depends on their size and the relative fit of the instruments within these incisions.ADL =><=. Zkh_d] ikh][ho$ A[[f_d\bem ]h[Wj[h j^Wdekj\bem je[dikh[ Figure 2 ijWX_b_jo <bem?iH[bWj[ZJeJkX_d]I_p[ e\j^[[o[ 6#HB6AA7DG: 7#A6G<:7DG: K688JB Zkh_d] ADL.aj^Y^c[adlXVcWZbdYjaViZYWnX]Vc\^c\i]ZWdiiaZ]Z^\]iVcYi]ZgZ[dgZi]Z egZhhjgZ\gVY^Zci!VhlZaaVhX]Vc\^c\i]ZgVY^jhd[i]Z^c[adlijW^c\# ?D<BEM EKJ<BEM ºE2YZiZgb^cZYWnWdiiaZ]Z^\]i g"YZiZgb^cZYWn[adlijW^c\ h^oZ^c[adl^gg^\Vi^dc\^chigjbZci ºE2YZiZgb^cZYWn[aj^Yejbe g"YZiZgb^cZYWndji[adlijW^c\h^oZ VcYdji[adle]VXdcZZYaZh^oZ .ADL =><=. particularly in early in the learning stages of phacoemulsification. The change in pressure. [ Figure 2: Poiseuille’s Equation shows that smaller bore tubing (A) requires higher vacuum and results in a lower flow.LESSON 02 Concepts of Fluidics Due to the small volume of the anterior and posterior chambers. as well as changing the radius of the inflow tubing. This leaves us with a simpler equation: F ~ ΔP r 4 Flow is proportional to the change in pressure times the radius of the tubing to the fourth power. r = radius of the tube. ºE"egZhhjgZ\gVY^Zcig2gVY^jhd[i]ZijWZ ?D<BEM EKJ<BEM ºE2YZiZgb^cZYWnWdiiaZ]Z^\]i ºE2YZiZgb^cZYWn[aj^Yejbe g"YZiZgb^cZYWndji[adlijW^c\h^oZ VcYdji[adle]VXdcZZYaZh^oZ Figure 3 <bem?iH[bWj[ZJeJkX_d]I_p[ g"YZiZgb^cZYWn[adlijW^c\ . And the values of pi and 8 are constant. a small change to the radius results in a large change in the relative flow. <bem?iH[bWj[ZJeJkX_d]I_p[ T he basic concept of fluidics is that the inflow of fluid must be greater than the outflow of fluid. ΔP = pressure gradient. as compared to larger bore tubing (B) which can achieve a high flow with less vacuum required. The inflow tubing has a large radius in order Ed^hZj^aaZÉhZfjVi^dch]dlhi]VihbVaaZgWdgZijW^c\6 to maximize the flow and make sure that we keep our gZfj^gZh]^\]ZgkVXjjbVcYgZhjaih^cVadlZg[adl! <bem?iH[bWj[ZJeJkX_d]I_p[ inflow greater than the outflow. as well as the change in pressure generated by the phaco machine’s fluid pump. even for just a fraction of a second. Because the value for tubing size is exponential. more experienced phaco surgeons tend to move towards tighter incisions which can give more stable fluidics. η = viscosity of fluid. With the use of advanced phaco power modulations. Similarly.

ADL2)* Ide/hbVaa!g^\^Ydji[adlijW^c\# 7diidb/aVg\Z![aZm^WaZ^c[adlijW^c\ 12 • WORLD REPORT CME SERIES This high vacuum level can cause collapse of the outflow tubing if its walls are too thin and of high compliance. resulting in a ruptured posterior capsule and vitreous loss. Once we determine the proper tubing size and phaco needle size for our needs. In our next lesson we will explain the variables that are adjustable on the phaco machine: bottle height. phaco fundamentals • 13 .ADL KH E=68D9>6B:I:G '% % %#% %#& %#' %#( %#) %#* %#+ %#. this energy release causes an immediate and dangerous surge of fluid out of the eye.9mm needle. The maximum pressure achieved within this inflow tubing is determined by the height of the infusion bottle. the tubing rebounds and the surge occurs. Outflow Tubing The inflow tubing is large bore with walls that are thin. the flow drops exponentially.bbi^e 9>6B:I:G2%#. We’ll also examine the two primary types of fluid pumps that are used in phaco machines: peristaltic and venturi. This is called post-occlusion surge and is one of the main causes of posterior capsule rupture during cataract surgery.LESSON 03 Flow Balance & Tubing Compliance Surge is the situation when the outflow of fluid from the eye exceeds the inflow. a very substantial increase in the pressure gradient is required. The important thing to remember from Poiseuille’s Equation is that the flow is proportional to the radius of the tube to the fourth power. 0. Figure 2: Compliant tubing can collapse and cause surge during cataract surgery. As the needle size decreases.9mm needle. where the inflow is always greater than the outflow. This means that a small change in the size of the phaco needle can result in a very large change in the flow. the smaller bore outflow tubing can help ensure that the outflow is less than the inflow. In order to achieve the same flow while decreasing the needle size. Figure 1 9ecfWh_iede\ Ekj\bemWdZ?d\bemJkX_d] Inflow vs. +% )% G:A6I>K:. with all other factors equal it is surprising to see that the flow through the larger 1. Phaco Needle Sizing The size of the phaco needle is important for phaco fluidics because it affects the outflow rate. Remember that the tubing size and phaco needle size are explicit variables that play an important role in the fluidics. If we look at the inflow tubing we notice that it is significantly different than the outflow tubing. If we switch from a 1. and then once the occlusion breaks. Comparing two common size phaco needles. %#- %#.1mm. The purpose of this tubing is to provide a high flow of fluid under low pressure situations. Figure 4: A small change in the needle size can result in a large decrease in the flow rate. The outflow tubing has rigid. and aspiration flow rate. and this level is not very high. we can use different sized tubing.&*BB) G:A6I>K:. Because the flow varies exponentially with the radius of the tubing.BB G69>JH2%#)*BB G69>JH)2%#%)&%BB) of tubing due to high vacuum levels occurs most commonly during occlusion of the phaco probe. The outflow tubing is smaller bore with thick walls. even for just a fraction of a second. 3. &#% &#& &#' . we can then select the other parameters of the phaco machine.1mm phaco needle to a 0. and the tubing is very flexible.1mm needle. When the outflow tubing collapses. Figures 2. This collapse &#&bbi^e 9>6B:I:G2&#&BB G69>JH2%#**BB G69>JH)2%#%. and the tubing is very rigid and relatively non-compliant. with all other phaco parameters unchanged. and then rebounds back to its normal state after the vacuum level drops.adlgViZkVg^ZhZmedcZci^Vaanl^i] i]Ze]VXdcZZYaZY^VbZiZg# <bem_iH[bWj[ZjeJkX_d]I_p[ 6hbVaaX]Vc\Z^ci]ZcZZYaZh^oZXVcgZhjai^cV aVg\ZYZXgZVhZ^ci]Z[adlgViZ# %#. Figure 3: Flow rate varies exponentially with the size of the phaco needle radius/diameter. thick walls in order for it to have a low compliance which helps to prevent surge. When this occurs.ADL2&%% Figure 1: Comparison of Inflow and Outflow Phaco Tubing. the chamber tends to collapse and the posterior capsule can be sucked into the phaco probe in an instant. 4 9ebbWfi[ZJkX_d]Ijeh[i. G:A6I>K:.9mm versus 1. vacuum level. The maximum pressure achieved within the outflow tubing is determined by the fluid pump of the phaco machine and can easily exceed 500 millimeters of mercury. the relative flow will decrease by more than half—to 45% of the relative flow through the 1.1mm needle is more than twice that of the 0.d[h]o dXXajh^dcd[ijW^c\ $i^el^i]XVigVXi Xdbea^VciijW^c\ XdaaVehZhVcY hidgZhZcZg\n edhi"dXXajh^dc hjg\Zl]Zc ijW^c\gZWdjcYh 8dbea^VciijW^c\XVcXdaaVehZ VcYXVjhZhjg\ZYjg^c\XViVgVXihjg\Zgn# <bem_iH[bWj[ZjeJkX_d]I_p[ &%% -% I n order to maintain this flow balance.

Perhaps the most important parameter is the selection of phaco needle size. and then to taper it downwards to minimize the posterior displacement of the lens-iris diaphragm due to the infusion pressure. The vacuum level in a peristaltic-based system is only achieved upon occlusion of the phaco tip. a moderate amount of holding power is required to bring each quadrant into the phaco tip. holding power of the nucleus is important in order to securely fixate it while using the chopper to mechanically disassemble the nucleus.1mm needle size is preferred since it will give a significantly greater flow rate. This requires a relatively high vacuum.LESSON 04 Optimizing Phaco Fluidic Settings The challenge of cataract surgery arises in large part from the small confines of the working space. is typically sufficient for this purpose. If you sometimes notice corneal striae and anterior chamber instability during your surgery. Optimizing your settings In order to optimize the phaco fluidic settings. and the phaco needle size. the most common type in the US market. The effect of the vacuum level varies with the bore of the phaco needle due to the effect of surface area.I=:E=68DI>E>H G:FJ>G:9ID68=>:K: I=:EG:H:IB6M>BJBK68JJBA:K:A L>I=E:G>HI6AI>8HNHI:BH > Occlusion of the phaco tip is required to achieve the preset maximum vacuum level with peristaltic systems. With an unobstructed phaco needle. depending on the needle size. with 20cc/min being very slow and 50cc/min being very fast. In summary. with the most common sizes being the smaller-bore 0. Understanding the concepts behind the phaco fluidic settings is instrumental in optimizing the parameters for increasing the efficiency and safety of your phaco technique. The flow rate determines the speed at which things happen in the eye during phacoemulsification. Very much like a water-tower in a small town. phaco fundamentals • 15 . it is easy to tailor the fluidic settings to the surgeon and technique. ed to the phaco tip is determined by the peristaltic flow rate. Optimizing the phaco fluidic settings is instrumental to the efficiency and safety of phacoemulsification surgery.9mm needle and the larger bore 1. Using a higher vacuum level of 200-300mmHg and a flow rate of 30-50cc/min. The function of the phaco fluidics is to balance the inflow and outflow of fluid in order to maintain the working space. low-vacuum fluidics. determines the speed at which things happen in the eye.9mm needle is more suited to your technique. The same vacuum and flow rate settings can be used for the entire nucleus removal procedure during phaco chop. The first decision is the selection of phaco needle size. at any time. With knowledge of the concepts behind the variables. A vacuum level of less than 100mmHg and a flow rate of less than 30cc/min is sufficient for this purpose. The anterior and posterior chamber combined typically comprise less than 1 cubic centimeter of space and provide very little room for error. the flow rate. the height of the fluid above the eye creates a forceful infusion of fluid via gravity: the higher the infusion bottle. bring cataract material to the phaco tip. In order to help prevent surge. the greater the holding power given the same amount of vacuum. then the smaller-bore 0. the larger 1. the greater the holding power—and the holding power is used to fixate For phaco chop. there are two distinct parts of nucleus removal: sculpting of the nucleus and then quadrant removal. Upon occlusion of the phaco needle with cataract material the flow rate declines and approaches zero. (Figure 1) The higher the vacuum. Once the nucleus has been broken into smaller fragments.1mm needle. it is important to keep the inflow of fluid greater than the outflow of fluid at all times. For grooving and sculpting of the nucleus. The inflow of fluid comes from only one source. It is often advantageous to start with a high bottle height to ensure a sufficient inflow of fluid.1mm needle size. For quadrant removal. This is determined by the rate at which the peristaltic rollers milk the fluid along 14 • WORLD REPORT CME SERIES the cataract while we mechanically chop it. but the vacuum level is very low—very far from the maximum vacuum level that the surgeon has selected. The bottle height determines the inflow rate of fluid into the eye. EYYkbki_edH[gk_h[Z je7Y^_[l[CWn_ckcLWYkkc DXXajh^dcCDI6X]^ZkZY ADLkVXjjbaZkZa EDDG\g^e[dgX]dee^c\ DXXajh^dc>H6X]^ZkZY B6M>BJBkVXjjbaZkZa <DD9\g^e[dgX]dee^c\ D88AJH>DCD. The bottle height determines the inflow of fluid into the eye. For divide-and-conquer. the speed at which the fragments are attract- the outflow tubing. The larger the cross-sectional surface area of the phaco needle. From our previous lesson. you may benefit from increasing the bottle height. or 300-400mmHg with the 0. the work is being done by the ultrasonic energy and thus the flow and vacuum settings are quite low – just enough to aspirate the nuclear material removed from each forward stroke of the phaco probe. the flow rate is at the maximum. If. the eye will collapse and there is a high likelihood of posterior capsule rupture. lowflow fluidics. W ith a typical peristaltic phaco machine platform. With the phaco needle unobstructed the maximum flow rate is achieved and in large part. there are only a few parameters that are adjustable: the bottle height. it is important to match the parameters to the technique and the surgeon’s preference. while the larger bore needles are better suited for high-flow. If your preference is a slower but more controlled procedure. and prevent collapse of the eye. the outflow out-strips in the inflow. The vacuum level determines the “holding power” or “grip” of the phaco tip onto nuclear pieces. the suction via the phaco needle and the leakage from the incisions.9mm needle. the bottle of balanced salt solution. while the outflow of fluid comes from two sources. The flow rate for a peristaltic machine is typically given in cc of fluid per minute. If your preference is a quicker procedure with rapid nucleus removal. the maximum vacuum level. The analogy of drinking a milkshake via a small bore cocktail straw versus a larger bore drinking straw works well to illustrate this point. we recall that the difference in flow between a larger bore needle and a small bore needle varies exponentially due to Poiseuille’s Equation. the greater the inflow pressure and inflow rate. and different fluidic settings are required for each. the smaller bore phaco needles are suited for high-vacuum. such as 200-250 mmHg with the 1.

This is far more efficient than techniques like divide-and-conquer. and it displays as the “APT”. and 16 • WORLD REPORT CME SERIES push the foot-pedal all the way down.d[h]o "bZX]Vc^XVa^beVXi Ijhea[Yh[Wj[i  "XVk^iVi^dc$^beadh^dc 7FJ07Xiebkj[F^WYeJ_c[ 7FJ0 7Xiebkj[F^WYeJ_c[ 6EI2E]VXdI^bZ6kZgV\ZE]VXdEdlZg &*hZXdcYh&%%edlZg2&*hZXXdcYh6EI 6EI2 E]VXdI^bZ6kZgV\ZE]VXdEdlZg "bZX]Vc^XVa^beVXi "[aj^YVcYeVgi^XaZlVkZ "XVk^iVi^dc$^beadh^dc "]ZVih^YZh[[ZXi "[aj^YVcYeVgi^XaZlVkZ "]ZVih^YZh[[ZXi (%hZXdcYh&*%edlZg2&*hZXXdcYh6EI &*hZXdcYh&%%edlZg2&*hZXXdcYh6EI +%hZXdcYh&'*edlZg2&*hZXXdcYh6EI (%hZXdcYh&*%edlZg2&*hZXXdcYh6EI +%hZXdcYh&'*edlZg2&*hZXXdcYh6EI Id9ZXgZVhZ6EI 9ZXgZVhZE]VXdI^bZ Id9ZXgZVhZ6EI KVg^VWaZHigd`ZAZc\i] d[bVm KVg^VWaZHigd`ZAZc\i] L^i]8dchiVci. we are keeping the frequency constant but we are increasing the stroke length and therefore. as well as the total time during which phaco ultrasonic power was delivered. It accomplishes this by vibrating at a fixed frequency when the foot-pedal is depressed to position three. The phaco time can be decreased by applying the ultrasonic power when cataract pieces are at the phaco tip and are not aspirated by the vacuum forces alone. the phaco machine keeps track of the average phaco power. the total amount of energy. The phaco pinch test is a simple way to determine if your ultrasound power settings are likely to cause an incision burn in the eye. This method of breaking up the ultrasonic energy into smaller packets of pulses and bursts is called phaco power modulation and it will be the subject of the next lesson.gZfjZcXn Figure 3 Efjc_p[ZF^WYeI[jj_d]i Efjc_p[ZF^WYeI[jj_d]i Figure 4 KbjhW#bem7FJ06WhdajiZE]VXdI^bZ KbjhW#bem7FJ06WhdajiZE]VXdI^bZ ÆOZgdHZXdcYE]VXdÇÐ&hZXdcY 6EI2&. A fluid and particle wave is propagated into the cataract material. During wet lab testing. grasp the needle between your fingers. remove the protective silicone sleeve from the phaco needle.gZfjZcXn d[bVm 9ZXgZVhZ6kZgV\ZE]VXdEdlZg 9ZXgZVhZE]VXdI^bZ 9ZXgZVhZ6kZgV\ZE]VXdEdlZg L^i]8dchiVci. During surgery. It also creates cavitation and implosion as a microvoid is created just in front of the phaco needle. both the average phaco power and the phaco time. This is because for each of these three examples. it is possible to remove cataracts with less than 1 second of absolute phaco time. It is important to give as little ultrasonic phaco energy as possible during the cataract surgery. To maximally decrease the APT. T he stroke of the phaco needle creates a mechanical impact as the metal phaco needle hits the cataract material. We can measure and compare the amount of phaco energy that we use in surgery by calculating the APT: Absolute Phaco Time. it is about the same as 30 seconds at 50% power. This is done by multiplying the “U/ S AVE” by the “EPT”. we need to decrease phaco fundamentals • 17 . the APT (Absolute Phaco Time) is 15 seconds. yielding immediate clear corneas and happy patients. which the phaco machine does It makes sense that if you deliver 15 seconds of energy at 100% power.hZXdcYh)2%#+-hZXdcYh ÆOZgdHZXdcYE]VXdÇÐ&hZXdcY 6EI2&.” which stands for “ultrasound average” and “EPT. the needle will get hot and may even burn your fingers. These are displayed as “U/S AVE. Figure 1 Figure 2 KbjhWiekdZ. and heat is created as a by-product. With optimized ultrasonic phaco power parameters. It is important to avoid choosing phaco power settings that cause excessive heat build-up as this can burn the cornea and damage the delicate ocular structures.” which is “elapsed phaco time”. The ultrasonic energy can easily damage the corneal endothelial cells. program your selected settings into the phaco machine.LESSON 05 Fundamentals of Ultrasonic Phaco Power The phaco ultrasound probe delivers energy into the eye that can be used to break up the cataract to facilitate emulsification and aspiration. resulting in less energy delivery as well as shorter operative time. The most important way to decrease the APT is to use a mechanical method of nucleus disassembly such as phaco chop. phaco time can be reduced by delivering smaller pulses or bursts of phaco energy instead of continuous ultrasound. When we titrate the amount of ultrasound energy we place into the eye.d[h]o Ijhea[Yh[Wj[i KbjhWiekdZ. and excessive phaco energy can cause pseudophakic bullous keratopathy and corneal decompensation. given as a percentage of maximum. or 60 seconds at 25% power. The average phaco power can be decreased by limiting the foot pedal depression in position three or by decreasing the maximum phaco power level on the machine.hZXdcYh)2%#+-hZXdcYh for us automatically. Additionally. But it’s better to singe your fingertips than fry your patient’s cornea. If your settings cause excessive heat build-up.

the energy level increases. I can give 500 of these identical bursts at 10% power to equal just one second of continuous phaco at 100% power. And Burst Phaco Modes F^WYe9edj_dkeki 8Wi_YJof[ie\Fem[hCeZkbWj_ed E]VXdEdlZg3 E]VXd8dci^cjdjh E]VXdEajhZ :[[ZXid[Ejh]^c\ i]Z.ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 E]VXd7jghi F^WYe8khij 8dci^cjdjh:cZg\n9Za^kZgn KVg^VWaZEdlZgYZeZcY^c\dc [ddieZYVaYZegZhh^dc delivered in pulses.ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 E]VXd7jghi 8dci^cjdjh:cZg\n9Za^kZgn KVg^VWaZEdlZgYZeZcY^c\dc [ddieZYVaYZegZhh^dc The basic power settings are continuous. and an endpoint duty cycle of 50%.ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 8dci^cjdjh:cZg\n9Za^kZgn KVg^VWaZEdlZgYZeZcY^c\dc phaco machine to aspirate the cataract and then give small bursts of phaco energy only when necessary. the foot-pedal can be maximally depressed during grooving. we do not have linear control of the phaco power level. but instead prefer multiple burst mode because I can still deliver just one single burst by barely entering foot-position 3. I do not ever use this mode. the terms “burst” and “pulse” may seem similar. each burst of energy has the same power but the interval between each burst increases as the foot pedal is depressed: The further the foot pedal is depressed. Surgeons are familiar with the concept of “continuous” phaco energy which is delivered in a linear fashion: as the phaco foot-pedal is depressed. then as the foot-pedal is depressed. Or in absolute terms. Then to remove the quadrants. it is important to use a lower phaco power setting when using burst mode as compared to pulse or continuous modes. the pulses of energy delivered have variable power depending on how long the foot pedal is depressed. This means that I can give 50 of these identical bursts at 10% power to equal just one second of continuous phaco at 10% power. The maximum power setting can be preset and then one has control of the maximum amount of phaco power delivered—the longer the foot pedal is depressed. the greater the power of each sequential pulse of energy. at maximum foot pedal depression. Because the phaco foot-pedal now controls the rest interval between identical bursts. Because we can program these bursts of phaco power to be very short (as quick as a few milliseconds). “Pulse” mode simply gives the same linear control of phaco energy. but they refer to two entirely different concepts. F^WYeFkbi[ 7jghi:cZg\n9Za^kZgn KVg^VWaZ7jghi>ciZgkVaYZeZcY^c\dc [ddieZYVaYZegZhh^dc ZkZgnWjghil^aa]VkZi]ZhVbZedlZg . When the foot-pedal is maximally depressed. The defining feature of pulse mode is that after each pulse of energy delivered. “Burst” mode defines a specific and identical “burst” of phaco energy. Most phaco machines have two settings for burst mode: single burst and multiple burst. in burst mode. for burying the phaco probe into a nucleus for chopping. 3. the shorter the “off” period between each burst. the foot position 3 is barely entered.ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 E]VXdEdlZg3 I n the pulse mode. It comes as no surprise that most cataracts can be removed with an energy equivalent that is less than 2 seconds of absolute power at 100%. We use the vacuum and fluidics of the E]VXdEdlZg3 Finally. these identical bursts of energy are delivered more rapidly. For this reason. we can effectively give hundreds of tiny bursts and still total less than 1 second of total phaco time. In the continuous power setting. For my technique of quick-chop. for the epi-nucleus removal. and burst. pulse. and just a few bursts of energy are delivered for removal of the softer cataract portions. however the energy is always 18 • WORLD REPORT CME SERIES E]VXdEdlZg3 8Wi_YJof[ie\Fem[hCeZkbWj_ed F^WYe9edj_dkeki . Burst mode allows a true phaco-assisted aspiration of the lens nucleus. the foot-pedal is only partially depressed in position 3 so that only bursts of phaco power are used for segment removal. until the interval of time between bursts is infinitely small. Single burst delivers just one single burst of energy. thereby delivering continuous phaco energy to facilitate sculpting of the nucleus. Pulse. The more time it is depressed. the “off” period.ddiEZYVa9dlc . reduces heat and delivers half the energy into the eye. the rest interval between bursts is zero and the phaco probe essentially delivers continuous energy. with a burst time of 20 milliseconds. the greater the phaco power. and I still have the ability to deliver many more bursts and varying intervals with further foot-pedal depression. there is a period of time in which no energy is delivered between increasing periods of energy. a power of 10%. Finally. the bursts of energy will become continuous delivery of energy. continuous energy is delivered with variable power depending on how long the foot pedal is depressed. I typically use just one phaco setting: Multiple burst mode. Alternating between the “on” and “off” pulse.LESSON 06 Figures 2.ddiEZYVa9dlc E]VXdEdlZg3 E]VXd8dci^cjdjh 8dci^cjdjh:cZg\n9Za^kZgn KVg^VWaZEdlZgYZeZcY^c\dc [ddieZYVaYZegZhh^dc . For surgeons using a divide-and-conquer technique of surgery. When referring to modulations of phaco power. phaco fundamentals • 19 . 4 Continuous.ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 E]VXdEajhZ :[[ZXid[Ejh]^c\ i]Z. Figure 1 F^WYeFkbi[ . As a result.

and clearer corneas and sharper vision immediately post-op. The reduction in the amount of en'EEH ergy delivered is due to the ratio of the on:off pulses. while the new platforms are able to deliver burst widths as fine as just 4 milliseconds. note that the total energy. which is known as the duty cycle. For surgeons who perform the divide-and-conquer method of nucleus dis&'%ejahZh$hZX assembly. -EEH 20 • WORLD REPORT CME SERIES dhZX &hZX 'hZX phaco fundamentals • 21 . The effective number of bursts per second increases as the rest interval decreases and using a burst width of 5 milliseconds and allowing 5 milliseconds of rest between each burst. and vacuum forces.LESSON 07 Figures 2. where each pulse is as long as each rest period. My preferred setting for phaco surgery is burst mode. This halving of the ultrasound energy will result in less endothelial cell &+ejahZh$hZX dhZX &hZX 'hZX damage. =heel_d]%IYkbfj_d] >of[hI[jj_d]i A^`ZV[^cZanhZggViZY`c^[Z!]^\]ejahZgViZh 'EEH \^kZi]ZXjii^c\[ZZad[Xdci^cjdjhZcZg\n# For surgeons who wish to continue to perform their EjahZY <gZViZggVc\Zd[edhh^W^a^i^Zh &hZX 'hZX ™EjahZBdYZ/ Vh]^\]Vh&'%ejahZh$hZXdcY ™7jghiBdYZ/ VhadlVh)b^aa^hZX$Wjghi :bjaViZ8dci^cjdjhE]VXd l^i]>7B<i]ZZcZg\n standard technique of phaco-emulsification. make the switch to a hyper pulse mode and you will immediately perform better surgery without a . A coarsely serrated knife with large. it would likely cut the best of all. A^`ZV[^cZanhZggViZY`c^[Z!]^\]ejahZgViZh \^kZi]ZXjii^c\[ZZad[Xdci^cjdjhZcZg\n# 8dci^cjdjh &+ejahZh$hZX &'%ejahZh$hZX :bjaViZ8dci^cjdjhE]VXd l^i]>7B<i]ZZcZg\n . 4 Hyper Settings can set a burst mode as small as 4 milliseconds. However if we use a very finely serrated knife. Using a very high pulse rate of 100 or more pulses per second results in the cutting ability of a very finely serrated knife. In our next lesson. As the pedal is depressed further in foot-position 3. it makes sense that a knife with a smooth blade would cut well.\\[Yje\Fkbi[i%I[YedZFFI change in your technique. resulting in a 50% duty cycle. which is 125 times finer and more precise than using manual control by the surgeon. While ™EjahZBdYZ/ previous generations of phaco Vh]^\]Vh&'%ejahZh$hZXdcY platforms had pulse rates of up to 20 pulses per second. =heel_d]%IYkbfj_d] >of[hI[jj_d]i <gZViZggVc\Zd[edhh^W^a^i^Zh The range of programmability of the pulse and burst phaco settings has expanded considerably. This results in being able to effectively control the duty cycle and the burst rate per second at the same time via the foot-pedal. -EEH EjahZY dhZX &hZX 'hZX dhZX &hZX 'hZX I]ZIdiVa6bdjcid[E]VXd:cZg\nYZa^kZgZY^h:FJ6A# Whether we give 2 pulses per second or 8 pulses per second. 8]Vc\^c\i]ZEEHl^aacdibV\^XVaan -EEH YZXgZVhZi]Z6EI/ Changing the number of pulses per second does NOT change the amount of power delivered into the eye. simply 8dci^cjdjhchanging from continuous phaco power to a hyper pulse rate of 100 pulses per second will allow them to cut the energy delivery in half. the smoother the power delivery will be—very similar to serrations on a knife. as represented by the green blocks. If we want to harness the sculpting and cutting ability of the phaco hand-piece for grooving of the cataract nucleus. (Math: 1 second / 10 millisecond cycle = 100 bursts per second). Similarly. which is 500 milliseconds. The ultrasonic power delivery is there to assist the fluidics once a denser piece of nucleus is encountered. the newer generation machines have the ability to deliver up to 120 pulses per ™7jghiBdYZ/ second. . widely spaced serrations would not cut as smoothly. the rest interval between bursts decreases until the burst width and rest interval are equal. 3. With the standard settings in pulse mode. the maximum number of bursts per second is 100. yet delivers half of the energy of continuous phaco power. [ Figure 1 ] The more pulses per second we can give. with a very fine burst width. the best we can do is about a half-second of energy per pulse. is the same. The majority of the forces that are used to remove the nucleus from the eye are fluidic forces—the flow.\\[Yje\Fkbi[i%I[YedZFFI 8dci^cjdjh Figure 1 T he advantage of this upgraded range of programmability is the smoothness and precision of power delivery. dhZX the pulse mode can deliver good cutting power with half the energy of continuous phaco energy. less heat production. [ Figures 3 and 4 ] The same applies when we compare 10 pulses per second to 100 pulses per second. we will explain duty cycles and their effect on phaco power delivery. Using the newer hyper settings we 8]Vc\^c\i]ZEEHl^aadejbV\^XVaan YZXgZVhZi]Z6EI/ Modern surgery is primarily phaco-assisted aspiration of the nucleus. aspiration.\\[Yje\Fkbi[i%I[YedZFFI 8]Vc\^c\i]ZEEHl^aadejbV\^XVaan 'EEH YZXgZVhZi]Z6EI/ 8dci^cjdjh [ Figure 2 ] Hyper settings in burst mode allow finer and more precise delivery of bursts of phaco power. the older machines had burst widths as narrow as 30 VhadlVh)b^aa^hZX$Wjghi milliseconds. If we use continuous phaco energy mode and try to use our foot to deliver small bursts of phaco power.

^h*%/*%!]ZcXZ+&ZkjoYoYb[ LWh_WXb[:kjo9oYb[ LZXVcX]Vc\Zi]ZYjinXnXaZid'% &%%bhZXdc =:6I %hZX )%%bhZXd[[ 8DDA &%%bhZXdc =:6I :mVbeaZVi'EjahZh$HZXdcY )%%bhZXd[[ 8DDA &hZX GVi^dd[DCidD.. a lower duty cycle of 20-40% can be used since the principal force for nucleus removal is the fluidics and not the ultrasound. Using the lower duty cycle allows more fluidic aspiration of nuclear fragments while minimizing heat and phaco power. with 10 pulses per second and a 40% duty cycle. 4 U ltrasound energy creates helpful cavitation and mechanical forces that are used to break up the cataract nucleus. If we change the ratio of the on period. with an on-time of 40 milliseconds followed by an off-time of 60 milliseconds.^h'%/-%!]ZcXZ(&ZkjoYoYb[ phaco fundamentals • 23 . we may select a duty cycle of 20%.. Alternatively. For example.gV\bZcih "8dda^c\d[E]VXdI^e "CdJaigVhdjcY:cZg\n In the pulse mode.^h*%/*%!]ZcXZ+&ZkjoYoYb[ %hZX =heel_d]%IYkbfj_d] Egd\gVbb^c\ k^VGViZh &%EjahZ$HZXdcY )%YjinXnXaZ LWh_WXb[:kjo9oYb[ When we choose a mode such as pulse mode.. *%YjinXnXaZ LZXVcX]Vc\Zi]ZYjinXnXaZid'% This is called a 50% duty cycle. as the rest periods are when we achieve cooling of the phaco needle and aspiration of the nuclear fragments. And we all know that clear corneas on post-op day one make for good visual acuity and very satisfied patients.i^bZ 40-60%. thus decreasing the amount of phaco energy delivered to the eye.. '%YjinXnXaZ &%%bhZXdc =:6I EDj_c[ )%%bhZXd[[ 8DDA &%%bhZXdc =:6I )%%bhZXd[[ 8DDA %hZX :mVbeaZVi'EjahZh$HZXdcY &hZX "JaigVhdjcY:cZg\n9Za^kZgZY GVi^dd[DCidD.. then we can favor the aspiration and cooling of the phaco needle over the heat generation and jack-hammer repulsion effects of the ultrasound.^h'%/-%!]ZcXZ(&ZkjoYoYb[ "?VX`"]VbbZgGZejah^dc:[[ZXi "=ZVi<ZcZiViZY the quadrants. as each complete cycle is composed of energy on for 50% of the time. we need to deliver sufficient energy to be able )%bhZXDCi^bZ to cut the grooves. [ Figure 4 ] We can then harness the benefits of a lower duty cycle which results in longer cooling time for the phaco needle. The concept to remember is that a higher duty cycle results in better cutting power but increased heat generation and more energy-related damage to the corneal endothelium. the pulse is “on” for 250 msec and “off” &%EjahZ$HZXdcY for 250 msec. Figures 3. Once we have the grooves placed in the nucleus and we have cracked it into quadrants. such as with the technique of divide-and9^gZXiEgd\gVbb^c\ conquer. to a shorter duration. [ Figure k^VGViZh 3 ] For instance. [ Figure 2 ] 22 • WORLD REPORT CME SERIES Figure 1 E<<j_c[ "6he^gVi^dcd[CjXaZVg. when ultrasound energy is delivered. no energy is delivered and nuclear fragments can be easily aspirated. I will achieve the same result—a total cycle time of 100 milliseconds. I can delineate the specific on and off periods for each cycle. resulting in clear corneas immediately after surgery. then energy off for 50% of the time. This can be done by dropping the duty cycle ratio as seen on the control panel of the phaco platform. For sculpting the nucleus. there are two distinct methods: entering a new duty cycle or direct pulse programming. In addition. I can decrease it from a 50% duty cycle to a 40% duty cycle. which alternates phaco power pulses with periods of rest. during the extended “off” time. the default duty cycle is 50%. The benefit of the new power modulation )%YjinXnXaZ software is that the duty cycle can be changed.. For this quadrant removal. The jack-hammer effect of ultrasound energy can cause repulsion of the nuclear fragments from the phaco tip. This default ratio can be changed to alter the ratio of ultrasound energy to the rest interval. which results in 100 msec “on” and 400 msec “off”. This requires a duty cycle of about +%bhZXD.i^bZ LWh_WXb[:kjo9oYb[ >cEjahZBdYZ! i]ZYZ[VjaiYjinXnXaZ^h*% =heel_d]%IYkbfj_d] Egd\gVbb^c\ *%YjinXnXaZ '%YjinXnXaZ EDj_c[ "JaigVhdjcY:cZg\n9Za^kZgZY "?VX`"]VbbZgGZejah^dc:[[ZXi "=ZVi<ZcZiViZY E<<j_c[ "6he^gVi^dcd[CjXaZVg. It is helpful to alternate periods of phaco energy with rest periods. Using the variable duty cycle programming allows the surgeon to deliver just the right amount of ultrasound energy during each phase of surgery. however. For example. we can use a lower duty cycle during the phaco-assisted aspiration of '*%bhZXdc =:6I %hZX '*%bhZXd[[ 8DDA '*%bhZXdc =:6I '*%bhZXd[[ 8DDA :mVbeaZVi'EjahZh$HZXdcY &hZX GVi^dd[DCidD. giving a ratio of 20:80.. When do we want higher or lower duty cycles? The answer depends on the phase of surgery. the default ratio is 50:50. [ Figure 1 ] To program in a change in this ratio. this energy also can create significant heat.gV\bZcih "8dda^c\d[E]VXdI^e "CdJaigVhdjcY:cZg\n LWh_WXb[:kjo9oYb[ 9^gZXiEgd\gVbb^c\ )%bhZXDCi^bZ +%bhZXD. if I am using 10 pulses per second and I’d like to slightly reduce the ultrasound energy.^h'%/-%!]ZcXZ(&ZkjoYoYb[ LESSON 08 '*%bhZXdc =:6I '*%bhZXd[[ 8DDA '*%bhZXdc =:6I '*%bhZXd[[ 8DDA Variable Duty Cycle Figure 2 :mVbeaZVi'EjahZh$HZXdcY &hZX LWh_WXb[:kjo9oYb[ GVi^dd[DCidD.GVi^dd[DCidD.

but this isn’t always the best answer. The new phaco power modulation software on most platforms allows this automatically. LWh_WXb[H_i[J_c[ 8dda^c\WZilZZcejahZh &%%bhZXgVbe T E]VXd:cZg\nHVkZY '*%bhZXd[[ 8DDA &hZX This ramping up of the energy allows better followability of the nuclear pieces and less chatter at the phaco tip. This one simple change will likely cut your total phaco time and energy in half with virtually no effect on your technique. and make sure that you use an “end-point duty cycle” of HfjVgZLVkZEahZh 50%. between 20 and 80 milliseconds. Keeping in mind that you will E]VXd:cZg\nHVkZY be controlling the interval between identical bursts via the third position. such as when the pulse width &%%bhZXgVbe 24 • WORLD REPORT CME SERIES %hZX &%%bhZXgVbe :mVbeaZVi'EjahZh$HZXdcY 8[d[\_jie\LWh_WXb[H_i[J_c[ GVbeZY"JeEjahZh '*%bhZXd[[ 8DDA &hZX 9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n YZa^kZgZY^cidi]ZZnZ 8dda^c\WZilZZcejahZh ting a maximum level of 10-30% is suggested. Figure 3 '*%bhZXd[[ 8DDA &hZX Phaco chop surgeons will have an easier time adapting to hyper-burst mode. 2. you will Figure 4 have an easy time staying with about the same number9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n of pulses per second and keeping your maximum phacoYZa^kZgZY^cidi]ZZnZ >of[h9eeb8_cWdkWbF^WYe power the same. You will'*%bhZXd[[ be =:6I 8DDA =:6I 8DDAunable to vary GVbeZY"JeEjahZh the percentage power level with your foot pedal. while decreasing your duty cycle to 8dda^c\WZilZZcejahZh 8dda^c\WZilZZcejahZh 25-45%. if we initially attack the nucleus with lower power. 3 ] 8dda^c\WZilZZcejahZh HfjVgZLVkZEahZh GVbe^c\"JeZVX]ejahZ o reduce the repulsive force of phaco we can decrease the phaco power. Transitioning to the new phaco power modulation software is an easy way to improve your surgical outcomes and efficiency while decreasing the heat and energy placed into the eye. the desired phaco power level will not be achieved. we can ramp up the power to a higher level. depending on the platform). HfjVgZLVkZEahZh GVbe^c\"JeZVX]ejahZ '*%bhZXdc =:6I '*%bhZXdc =:6I Suggested settings for surgeons First. the phaco needle moves back and forth into the cataract at a fixed frequency (between 28.LESSON 09 Figure 2 Variable Rise Time And Custom Settings Fkbi[I^Wf_d]0 Fkbi[I^Wf_d]0 LWh_WXb[H_i[J_c[ LWh_WXb[H_i[J_c[ 8[d[\_jie\LWh_WXb[H_i[J_c[ GVbe^c\"JeZVX]ejahZ GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n 9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n YZa^kZgZY^cidi]ZZnZ &%%bhZXgVbe &%%bhZXgVbe Keep in mind that the ultrasonic phaco power is a repulsive force: like a jack-hammer. we can have the phaco energy ramp-up over the course of each individual pulse or burst.500 times/second and 40. initially at a 50%&hZX duty :mVbeaZVi'EjahZh$HZXdcY cycle. Fkbi[I^Wf_d]0 Fkbi[I^Wf_d]0 '*%bhZXd[[ 8DDA '*%bhZXd[[ 8DDA 8dda^c\WZilZZcejahZh Figure 1 '*%bhZXdc =:6I '*%bhZXdc =:6I GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n or burst width is so short that there is insufficient time '*%bhZXd[[ to fully ramp '*%bhZXdc up each packet of phaco'*%bhZXdc energy. remember to keep your phaco needle and all vacuum and flow levels the same as to what you are accustomed. There are situations where it is difficult to use a variable rise time. With a variable rise time. with millisecond precision. Instead. without changing your surgical technique. [ Figures 1. '*%bhZXdc '*%bhZXd[[ '*%bhZXdc =:6I 8DDA =:6I We’ve all seen this during surgery and often call it “chatter”— %hZX :mVbeaZVi'EjahZh$HZXdcY when the ultrasonic power mechanically pushes Fkbi[I^Wf_d]0 the nucleus off the phaco tip. 6YkVcXZhEdlZgBdYjaVi^dc^hVGZfj^gZbZci 8[d[\_jie\LWh_WXb[H_i[J_c[ LWh_WXb[H_i[J_c[ If you are accustomed to a pulsed phaco mode. no change in your surgical technique is needed. resulting in a ramped wave. and the resulting waveform on the oscilloscope looks like a square. Depending on your machine. Keep the burst width short. which means the power goes from zero to the preset level immediately. Also. then hold on to it with the vacuum fluidics of the phaco machine. you '*%bhZXdc '*%bhZXd[[ '*%bhZXdc '*%bhZXd[[ will likely have an easy =:6I 8DDAtime starting =:6I with a hyper-pulse 8DDA mode%hZX of 60-120 pulses/second. &%%bhZXgVbe Fkbi[I^Wf_d]0 %hZX :mVbeaZVi'EjahZh$HZXdcY LWh_WXb[H_i[J_c[ LWh_WXb[H_i[J_c[ Burst and pulse modes deliver square-wave energy by default. If you are accustomed to continuous phaco mode. and using the same maximum phaco power that you’re used to. you should keep the maximum phaco '*%bhZXdc '*%bhZXdc 6YkVcXZhEdlZgBdYjaVi^dc^hVGZfj^gZbZci power level'*%bhZXd[[ relatively low. You can then implement a variable rise time in order to further decrease the total phaco time and energy and enhance purchasing power and follow-ability. and it results in less energy and less heat delivered into the eye. if it %hZX takes 40 milliseconds to ramp-up the power :mVbeaZVi'EjahZh$HZXdcY &hZX from zero to the preset level. particularly when a nucleus is dense and requires more phaco power for emulsification. For'*%bhZXd[[ ex=:6I 8DDA =:6I 8DDA ample. You can further tailor your settings GVbeZY"JeEjahZh to better suit your technique and your patient population. you may have to enter >of[h9eeb8_cWdkWbF^WYe this as a “minimum burst interval” which should be E]VXd:cZg\nHVkZY set equal to your burst width in milliseconds to achieve the effective end-point duty cycle of 50%. The only thing that we will be changing is the way that the phaco power will be delivered.000 times/second. but the defined burst width is just 25 milliseconds. so set%hZX :mVbeaZVi'EjahZh$HZXdcY &hZX phaco fundamentals • 25 .

particularly if a hinge is created. Phaco surgery is commonly referred to as “sutureless. the longer incisions tend to seal much better. The suture should be placed Due to theL]Zc^cYdjWi/EaVXZVHjijgZ increased surface area created from a longer tunnel length. [ Figure 3 ] about half to two-thirds of corneal depth and well cen>DE. and for these reasons. while the shorter incision cause flattening BniVg\Zi>DE2'*id(%bb=\ and therefore are astigmatism-inducing. while the straight inci- Figure 1 HiZeeZYkhHigV^\]i>cX^h^dch ("hiZeh '"hiZeh higV^\]i DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I= sion has just one plane. There may be advantages with the stepped incisions. The longer tunnels may have more of an “oar-lock” feeling. the paracentesis. Patients may experience some initial post-operative &%"%cnadcdg&%"%k^Xgna hypotony. [ Figure 8 ] Well-constructed clear corneal incisions are an integral part of modern-day phacoemulsification and a technique that cataract surgeons should know. making a more square incision is recommended. yet not so much as to induce a large astigmatic effect. while the dominant (usually right) hand is at the main incision. 10-0 nylon or 10-0 vicryl is typically used.% ))#*%.aViiZc^c\ 6hi^\bVi^hbCZjigVa>cX^h^dch I^ehj[hJkdd[bi2BdgZ. Incisions can be made stepped or straight: a stepped incision has 2 or 3 different planes. with the non-dominant (usually left) hand at the paracentesis. the main incision can be made at the steep axis so as to help reduce astigmatism at this meridian. However.dgXZh>cX^h^dcH]ji tered on the incision.aViiZc^c\ 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç ))#%%. The tension should be enough to seal the incision well. it is better:cigVcXZ^cid68^hidd to place a suture to close the incision. [ Figure 4 ] If there is any doubt as to the water-tightness of the incision.aViiZc^c\ 6hi^\bVi^hb>cYjX^c\>cX^h^dch Adc\ZgIjccZah27ZiiZgHZVa^c\ 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç >DEejh]Zhi]Z^cX^h^dch]ji BniVg\Zi>DE2'*id(%bb=\ L]Zc^cYdjWi/EaVXZVHjijgZ BZY^jbIjccZa ™b^aYVhi^\bVi^XZ[[ZXi ™a^iiaZÈdVg"adX`^c\É ™aZhhaZV`^c\ BniVg\Zi>DE2'*id(%bb=\ L]Zc^cYdjWi/EaVXZVHjijgZ Bed][hJkdd[bi27ZiiZghZVa^c\ 6hi^\bVi^hbCZjigVa>cX^h^dch I^ehj[hJkdd[bi2BdgZAZV`^c\ 6hi^\bVi^hb>cYjX^c\>cX^h^dch &%"%cnadcdg&%"%k^Xgna BZY^jbIjccZa 26 • WORLD REPORT CME SERIES ™b^aYVhi^\bVi^XZ[[ZXi ™a^iiaZÈdVg"adX`^c\É ™aZhhaZV`^c\ 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç phaco fundamentals • 27 . [ Figure 2 ] The longer tunnel lengths allow better sealing of the incision and less induction of astigmatism. and they seal well. however this is usually quite manageable. they provide good access to the cataract. the more ™bdgZVhi^\bVi^X posterior entrance into™cdÈdVg"adX`^c\É the anterior chamber may be ™bdgZaZV`^c\ prone to iris prolapse through the incision. 8 H]dgiZgIjccZah2BdgZ. [ Figure 6 ] :cigVcXZ^cid68^hidd edhiZg^dg#iddXadhZid^g^h 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç BZY^jbIjccZa ™b^aYVhi^\bVi^XZ[[ZXi ™a^iiaZÈdVg"adX`^c\É ™aZhhaZV`^c\ 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç I n a typical phacoemulsification. >DEejh]Zhi]Z^cX^h^dch]ji For managing astigmatism. 6 HiZeeZYkhHigV^\]i>cX^h^dch ("hiZeh '"hiZeh 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç H]dgiIjccZa ™bdgZVhi^\bVi^X ™cdÈdVg"adX`^c\É ™bdgZaZV`^c\ higV^\]i DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I= For phacoemulsification.LESSON 10 Creating A Clear-Corneal Cataract Incision Figures 2.% >DE.dgXZh>cX^h^dcH]ji H]dgiIjccZa ))#%%&-% ™bdgZVhi^\bVi^X ™cdÈdVg"adX`^c\É ™bdgZaZV`^c\ )(#*%&-% >DEejh]Zhi]Z^cX^h^dch]ji :cigVcXZ^cid68^hidd >DE. [ Figure 7 ] The intra-ocular pressure at the end of the surgery exerts an outward force which pushes on the inner part of the incision and keeps the corneal layers tightly sealed. with the knot rotated to bury it 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç within the corneal stroma. [ Figure 5 ] Figures 7. In addition. [ Figure 1 ] Adc\IjccZa ™cdVhi^\bVi^XZ[[ZXi ™bdgZÈdVg"adX`^c\É ™cdaZV`^c\ HiZeeZYkhHigV^\]i>cX^h^dch 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç ("hiZehlengths cause '"hiZeh higV^\]iflatThe shorter tunnel more astigmatic tening at that meridian and they do not seal nearly as H]dgiIjccZa DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I= well. all of these incisions have one thing on common: they have long tunnel lengths. 4. 5. While there is less “oar-lock” effect. two incisions are created: the main incision and a secondary incision.” but the prudent surgeon knows the value of a well-placed suture when the situation dictates.dgXZh>cX^h^dcH]ji edhiZg^dg#iddXadhZid^g^h Bed][hJkdd[bi2AZhh. 3. so ensuring a long tunnel length will help prevent any incisional leakage. keep in mind that longer tunnels have less effect and are considered astigmatism-neutral. edhiZg^dg#iddXadhZid^g^h To suture the corneal incision. where maneuverability within the eye is somewhat limited. These are typically placed approximately 60 to 90 degrees apart. the use of clear-corneal incisions has become very common for many reasons: they are easy to construct.

thus giving a bevel. the better the control. Finally. This fine. the patient can assist you further by looking directly at the microscope light. Adjust your hand position so that there is no pushing on any aspect of the incision and you will find that the eye will return to primary gaze. you do not push down on the incision. By floating in the incision. I f you look closely at the phaco tip—at the phaco needle itself—you will see that it is cut at an angle. should float within the incision. With Lose Viscoelastic any distortion of the incision can deform andinstrument. with both hands resting comfortably with the shoulders relaxed. IT IS EASIER AND MORE NATURAL FOR MOST PHACO SURGEONS TO HOLD THE PHACO PROBE LIKE A PEN. This is dangerous since it limits the surgeon’s view and maneuverability within the eye. Floating within the incision is critical. thus. The position of the hands should be at the patient’s eye level. and two instruments within the eye. phaco fundamentals • 29 . and then I asked you to write forcefully enough so that even the bottom carbon copy was legible. In summary. There should be no forceful pushing on any aspect or edge of the incision. arms. Fluid 28 • WORLD REPORT CME SERIES the cornea and impair the view within the eye. you lift the back end of the phaco probe upward. The hands can lightly rest on the patient’s draped face/head or on a separate wrist-rest. and in order to push water away from us with the paddle. we need to pivot our instruments. you would utilize a very strong grip. gross movements of the forearms. as such. and shoulders are not well suited for ocular surgery. we can keep the eye in this primary position. when you want to move the phaco tip downward. the chamber stays formed and the cornea remains undistorted. if I asked you to write as neatly as possible on a single sheet of paper with your prettiest calligraphy writing. The action is very similar to the rowing action in a row boat: the paddle is placed within an oarlock (analogous to our incision). light grip is best suited for the phaco probe and for intra-ocular surgery. and keep the eye in primary gaze by pivoting the instruments. and the phaco tip will move downward. The control of the phaco probe and intra-ocular instru- Pivoting Hand Control : do NOT push down! The instruments. [ Figures 2. But the quality of the writing would be very poor. and. Any forceful pushing of the instruments within the eye will cause the eye to move away from the force vector—usually towards the medical canthus. On the other hand. remember that the ultrasonic energy from the phaco probe can produce a significant amount of heat and that forcefully pushing the phaco needle against the edge of the incision can burn the cornea in a matter of seconds. we pull the handles toward us. keep the instrument grip fine and delicate. elbows. Most phaco needles that are used today have a bevel to increase their utility and usefulness during cataract surgery. ments is primarily from the fingers and somewhat from the wrists. the patient will not be able to move the eye even under topical anesthesia. PARTICULARLY GIVEN THE probe’s PEN-LIKE SHAPE. 3. I do not teach them to my residents or students. 4 Hand Control : do NOT push down! Lose Viscoelastic and Fluid Very Shallow Anterior Chamber Hand Control : PIVOT in the incision Keeps Viscoelastic And Fluid in Eye Good. light grip. particularly the phaco probe. The surgeon’s best view and most maneuverable state is when the eye is in primary gaze while the patient is in the supine position. 3 ] This is accomplished without deforming the incision. keep the instruments floating gently within the incision. If I had a stack of ten sheets of paper interspersed with sheets of carbon paper. keep the hand position relaxed and comfortable. One-handed techniques of phacoemulsification are relatively out-dated. Deep Anterior Chamber Hand Control : PIVOT in the incision Corneal Distortion and Wrinkling PUSHING =BAD Cornea is Clear and Undistorted PIVOTING =GOOD esthesia. the main incision and the paracentesis.Pivot Action with Oars in a Rowboat LESSON 11 Hand Position & Pivoting WE SPEND MANY YEARS WRITING AND DEVELOPING THE NEURAL PATHWAYS FOR FINE HAND MOTOR CONTROL BEFORE WE EVER PICK UP A PHACO PROBE. [ Figure 4 ] Figure 1 Hand Control : Pivot in the incision The strength of the grip is inversely related to the fine motor control: the lighter the grip. With the delicate balance of fluidics in phacoemulsification. which will pivot the probe within the incision. This two-point fixation is another advantage of two-handed surgery. distortion of the incision can lead to excessive leakage and an unstable chamber leading to a high risk of capsule rupture. In order to maneuver within the eye without pushing on the incision. In cases of topical an- Figures 2. you would use a very fine. [ Figure 1 ] In the eye. Rather. Oar lock Pivot Action with Oars in a Rowboat Very Shallow Anterior Chamber Keeping the eye in primary gaze With two incisions.

this could limit movement our & second instruHand Control : BevelofUp Down ment within the eye. The bevel-up position would not achieve occlusion and. THUS GIVING A BEVEL. The bevel-sideways position is effective for quadrant removal. therefore it for is made while POOR grip for chopping GOOD grip chopping aiming up in the plane of the cornea. As soon as the phaco needle approaches the cataract. thus.0mm (or less) in width. The bevel-down position is best suited to achieving maximum grip of the nucleus. Bevel DOWN . Once the nucleus is held firmly. Incision Spacing In a previous lesson we explained the method of making a proper clear corneal incision for our phaco probe. Keep in mind that we need to actually create two incision in the eye: a small paracentesis of approximately 1. and firmly hold the nucleus in preparation for chopping. Bevel UP .30 30 LESSON 12 Bevel Position. or bevel-down orientation. Incision Spacing IF YOU LOOK CLOSELY AT THE PHACO TIP—AT THE PHACO NEEDLE ITSELF— YOU WILL SEE THAT IS CUT AT AN ANGLE. While we could certainly make it in the corneal plane to achieve a longer tunnel length. with the main incision Incisions for my dominant right hand and the paracentesis incision About 60ºhand. Between Incisions for my left Paracentesis AIM *FLAT* 60 The paracentesis can be made flat and parallel to the iris since it is such a small incision. To use a household vacuum cleaner to pick up a piece of paper. By holding the phaco probe like a pen. which means that the angle at which it is cut is 30 degrees relative to the long axis of the needle. you should be able to maneuver it easily Make from the bevel-down to the bevel-up position by simply Corneal Incision rolling the tip between your fingers. I prefer to have these Cataract Surgery incisions about 60 degrees apart. T Figure 1 Hand Control : Bevel Up & Down 30 30 30 • WORLD REPORT CME SERIES Bevel UP . The same is true for phacoemulsification with a peristaltic pump—occlusion is required in order to achieve the preset maximum vacuum level and effectively hold the nucleus. where the phaco needle’s action is similar to that of an ice cream scoop. the holding power would be weak as the vacuum level would never reach the preset maximum with our peristaltic pump.8mm. Having the correct placement of the incisions and the correct bevel positioning of the phaco probe within the eye. can make our surgery safer and more efficient. Achieved Occlusion IS Achieved have a longer tunnel length. with the opening directed towards the largest part of the quadrant so that the energy is applied into the cataractous material which would then tend to carousel into the phaco tip. and a main incision with a width of about 2.“Regular” Bevel DOWN . you know that it is helpful to fully occlude the tip in order to achieve maximum holding power. Figure 4 Make Paracentesis Figure 5 Make Corneal Incision Figure 6 Cataract Surgery Incisions About 60º Between Incisions Paracentesis AIM *FLAT* (plane of iris) 60 Main Incision AIM *UP* (plane of cornea) phaco fundamentals • 31 . There are also 45 and 90 degree tips available. and other varieties where the shaft itself may be bent or the tip may have a flare. with a light and delicate grip.“Regular” Bevel DOWN Occlusion IS Achieved GOOD grip for chopping The approach from a typical clear corneal incision down towards the cataract nucleus is an angle of 30 degrees Make – perfectly suited for our 30 degree phaco needle in the Paracentesis bevel-down position. The goal is to only partially fill the tip of the needle with nuclear material as the groove is made. bevel-sideways. it is very easy to achieve occlusion.“Upside Down” Hand Control : Bevel Up & Down Pivot Tip with Bevel UP Good for Sculpting / Grooving Figure 2 Hand Control : Bevel Up & Down Pivot Tip with Bevel UP Good for Sculpting / Grooving Figure 3 Hand Control : Bevel Up & Down Bevel UP Occlusion NOT Achieved POOR grip for chopping he most common bevel is a 30 degree bevel. Because the main clear corneal Bevel UP Bevel DOWN incision is much it becomes more important to Occlusion NOT wider. The bevel-up position is best suited to grooving techniques. MOST PHACO NEEDLES THAT ARE USED TODAY HAVE A BEVEL TO INCREASE THEIR UTILITY AND efficiency DURING CATARACT SURGERY. but I still recommend starting with a traditional 30 degree tip during the earlier stages of the learning. These varieties provide different options during nucleus removal. For ease of hand position and maximum maneuverability within the eye.5-2. it becomes relatively easy to perform phaco chop or other methods of nucleus disassembly.“Upside Down” Hand Control : Bevel Up & Down The beveled phaco needle can be positioned in a bevelup.

the phaco probe should deliver energy during the forward stroke. or even position 1 for simple irrigation only. The more important pedal during phacoemulsification is the phaco foot-pedal as it controls the irrigation. To emulsify the cataract. further depression increases stroke length of the phaco needle. Avoid high magnification for routine cases as this will unnecessarily limit your field of view. application of ultrasound energy in position 3 will emulsify it. further depression increases the number of bursts per second by limiting the rest interval between bursts. and centration. where the primary means of lens removal is aspiration. 4. and in position 3. the footpedal should be in position 1 so that the irrigation fluid will prevent the eye from collapsing as the main incision is opened and the phaco needle is introduced into the eye. however. phaco fundamentals • 33 . A soft nucleus may be removed with simple aspiration in position 2. Each step is additive. we can use aspiration in foot position 2 to bring the piece to the tip in preparation for emulsification. 3. Depending on the type of phaco power modulation used. zoom. any cataract with significant nuclear density will require ultrasound energy. we have irrigation. and ultrasound phaco energy is only given to assist. and ultrasound power delivery. In both phaco continuous and phaco pulse mode. and 3-ultrasound. whereby progressively greater depression of the pedal gives more phaco energy. the foot pedal depression in position 3 will give more ultrasound energy. The microscope should be reset and centered at the beginning of the case in order to provide a full range of adjustability. there is no need to deliver energy. In phaco burst mode. 5. but once learned. You will recall that the irrigation inflow is determined by the bottle height and the size of the inflow tubing. 32 • WORLD REPORT CME SERIES Figure 1 Phaco Foot Pedal Function Irrigation = 1 Aspiration = 2 Ultrasound = 3 Before Entering the Eye Aspiration = 2 Irrigation = 1 Aspiration to bring cataract to phaco tip Ultrasound on Forward Stroke Aspiration = 2 Ultrasound = 3 Ultrasound when cataract is at phaco tip Only Aspiration on Backstroke Ultrasound = 3 Aspiration = 2 The aspiration in position 2 can be controlled in a linear manner: the beginning of position 2 gives lower aspiration and as you depress the pedal further into position 2. so we can go back to position 2 for aspiration. you get more and more aspiration. Then when retracting the phaco probe. Ultrasound on Forward Stroke Ultrasound = 3 Only Aspiration on Backstroke T he primary microscope controls are focus. as well as ultrasonic power delivery. The three positions of the phaco foot-pedal are: 1-irrigation. where the acceleration is proportional to the amount of pedal depression. Fine control of fluidics and power can be achieved with practice. The goal of modern cataract surgery is ultrasound-assisted aspiration of the lens.LESSON 13 Foot Pedal Control During Steps Of Surgery Phaco Foot Pedal Function Irrigation = 1 Figures 2. Once we have a nuclear fragment or piece. so when we are in position 2. The traditional placement is to have the left foot control the microscope foot pedal while the right foot controls the phaco foot pedal. it allows an increased margin of safety and efficiency during phacoemulsification. Once the cataract piece is right at the phaco tip. Foot-pedal position during steps of surgery Before entering the eye with the phaco probe. The irrigation in position 1 is either on or off—there is no ability to titrate the amount of irrigation via the foot-pedal. 6 Before Entering the Eye Irrigation = 1 Aspiration = 2 Ultrasound = 3 During surgery we clearly need precise control of both hands to hold instruments and operate within the confines of the anterior segment. Additional functions include the ability to turn the microscope light on/off as well as to adjust the brightness. This is quite similar to the gas pedal on cars. aspiration. as they play a crucial role in controlling the foot pedals. 2-aspiration. Accurate foot pedal control requires patience to master. we have irrigation plus aspiration. aspiration. Position 3 also has the ability for linear control. We also need to coordinate fine control of both feet. This will allow us to minimize the amount of energy that is placed into the eye and will result in better outcomes. Taking the foot off the pedal completely is called position zero since the phaco probe is doing nothing.

This gives dispersive OVDs the ability to coat ocular structures quite well. and they are able to use it as their exclusive viscoelastic for the entire surgery. to keep the anterior 34 • WORLD REPORT CME SERIES capsule flat during capsulorhexis creation. and they behave differently. we can prevent the eye’s collapse. phaco fundamentals • 35 . At the beginning of surgery. This is very useful to keep the anterior chamber formed. This coating of dispersive OVD is helpful to protect the corneal endothelium from the ultrasonic waves during surgery. also referred to as ophthalmic viscosurgical devices (OVDs). which means that they cannot coat or flow very well. [ Figure 1 ] IOL injector system and allow lubrication that will facilitate IOL delivery. • Expand the empty capsular bag for IOL insertion: cohesive Again. Avoid the super-cohesive OVDs here as they may be so solid that they can deflect the IOL as it is inserted. using a moderate OVD has the best of both. Dispersive OVDs have the consistency of syrup or molasses and they are able to flow like very thick liquids. Once the very first incision is made. the goal is to perform an exchange: inject the OVD while the aqueous is forced out of the eye. It’s important to understand that there is a spectrum of viscoelastics and that a moderate OVD may have some dispersive properties as well as some cohesive properties. for different stages during a single surgery. It is for this reason that is has become an integral part of our surgeries. the dispersive viscoelastics work very well to keep the corneal endothelium protected during phaco. otherwise it can block the trabecular meshwork and the patient will experience very high intra-ocular pressures after surgery. By replacing the aqueous with a thicker viscoelastic. they are able to maintain space and pressurize the eye quite well. However. the eye has a tendency to collapse as the aqueous leaks out. the greater the propensity for the eye to collapse. and this coating is not easily washed away by the flow of balanced salt solution during surgery. The cohesive viscoelastics tend to stick together as a single mass and are therefore usually easier to fully remove. prolapse of iris tissue usually may be prevented or treated with a cohesive viscoelastic. are viscous substances that allow us to make phacoemulsification easier and safer. Cohesive OVDs are more solid than liquid and they have the consistency of gelatin. For many surgeons. • Prevent iris prolapse during surgery: cohesive The ability to pressurize and maintain space is best accomplished with a cohesive. • Lubricate the IOL injector system: dispersive The thinner dispersive OVDs can lightly coat the At the end of surgery it is important to thoroughly remove the viscoelastic from the eye. and the greater the risk to the patient. because they are much thicker. Therefore. Use of a viscoelastic can make phacoemulsification easier for the surgeon as well as safer for the patient. Ideal viscoelastic characteristics during surgery: • Maintain AC depth during capsulorhexis creation: cohesive To maintain space and keep the anterior lens capsule flat. The larger the incision. and to keep the empty capsular bag open for IOL insertion. thereby Moderate Cohesive Super Cohesive More Solid forcing the aqueous to exit from the anterior chamber through the same incision. Other surgeons may prefer having two viscoelastics. the cohesive OVDs work very well. to maintain space and keep the empty capsular bag open. Ability to Coat & Protect Dispersive More Liquid T here are two main classes of viscoelastics: dispersive and cohesive. one cohesive and one dispersive. to move and manipulate iris or other tissues. The dispersive viscoelastics can be harder to remove since they have a tendency to spread out and coat the ocular structures. when the viscoelastic is placed into the eye. the cohesive viscoelastics are the most helpful during this step.LESSON 14 Viscoelastics: Dispersive & Cohesive Figure 1 Filling The AC With Viscoelastic Figure 2 Spectrum of Viscoelastics Ability to Maintain Space & Pressure Viscoelastics. • Corneal endothelial protection during phacoemulsification: dispersive Because they have the ability to coat. This is accomplished by placing the cannula across the anterior chamber and injecting distally.

and at the end of the case it allows secure placement of a standard posterior chamber IOL within the capsular bag. keeping in mind the intial position of the first (2. the 2. This ensures that we are tearing the proper size capsulorhexis. 4. While this works. the method for cataract surgery was intra-capsular extraction. 3. My capsulorhexis forceps are marked with two lines.0mm diameter for cataract surgery. When the sharp tips of the forceps are poked into the center of the anterior lens capsule. hence the name extra-capsular extraction. Step 4 We complete the capsulorhexis using the same technique.5mm hash mark of the forceps tip should be in the exact center of the anterior capsule. Because it is a complete circle. The two keys to achieving this stable AC and flat capsule are: use a good cohesive viscoelastic and float within the incision. called a cystotome. The typical IOL has an optic diameter of 6mm and our 5mm capsulorhexis is therefore able to cover the edge of the optic and hold it securely in position after the completion of surgery. Step 4 Start the capsulorhexis. and the 5mm hash mark should be at the outer edge of the capsulorhexis.0mm through the intended rhexis. mark should be in the exact center. Step 3 End of the procedure . If it extends too far radial and out to the zonules.5mm) represents the radius of your intended 5. our Technique has advanced dramatically. This allows sufficient access to the nuclear material.5mm) hash mark as a guide. These measures prevents collapse of the an- Poke sharp tips of forceps into the center of the anterior lens capsule. to facilitate creation of a capsulorhexis with an exact 5mm diameter every time. Today. Step 2 To propagate the tearing of the capsulorhexis. while leaving the capsule and zonular structures intact. The first hash mark (2. and the torn central remnant is removed from the eye and discarded.5mm) hash mark as a guide. If capsulorhexis radializes. our preferred method is creation of the continuous curvilinear capsulorhexis (CCC).0 mm Do not allow the anterior chamber to shallow or collapse. For most cases. it is important to keep the torn capsule folded over as this allows the tear to proceed in a more controlled manner.0mm capsulorhexis. a single puncture is made in the central part of the anterior lens capsule.5mm mark delineates the radius of our intended capsulorhexis. This can be done using a bent needle. and try to bring it centrally once again. I recommend understanding the force vectors required for capsulorhexis creation by practicing using your fingers to tear large 10cm circles in newspaper. keeping in mind the intial position of the first (2. or by using the bent needle cystotome to place a series of punctures in the intended areas. it is important to stop. Dashed line is the intended Capsulohexis Size of 5.0mm hash mark should be at the outer edge of your capsulorhexis.LESSON 15 Capsulorhexis Creation Float within the Incision Figures 2.now the capsulohexis has the ideal 5. Step 1 To start the capsulorhexis. and pivoting the instruments. 36 • WORLD REPORT CME SERIES terior chamber. our ideal capsulorhexis is a well-centered. Decades ago. where the entire cataract and its capsule where removed from the eye. This allows for greater control and prevents run-off and radicalization of the capsulorhexis and allows for more control. This assures a consistent post-operative refractive outcome and happy patients.0 mm Poke sharp tips of forceps into the center of the anterior lens capsule. not distorting the eye. Step 3 As we proceed to tear the circular capsulorhexis. and now more than 99% of the time we remove just the cataractous material. round opening of the anterior capsule with a diameter of about 5mm. or by using the tips of the capsulorhexis forceps. at 2.5mm and at 5mm. the 2. and the 5. you may not be able to retrieve it.5mm) represents the radius of your Half way5. The first hash mark (2. 5 Step 1 Dashed line is the intended Capsulohexis Size of 5. the 2. we will notice that half way through the rhexis. and in this case you can finish by going in the opposite direction with the capsulorhexis. T he evolution of capsulorhexis began with the use of a needle to make multiple punctures in the anterior lens capsule to create an opening through which to access the cataract nucleus. inject more cohesive viscoelastic. You will remember from previous lessons the importance of floating within the incision. Step 2 Figure 1 Float within the Incision Do not allow the anterior chamber to shallow or collapse. It is important to keep the anterior chamber well formed and the anterior lens capsule flattened during the creation of capsulorhexis.5mm hash capsulorhexis. phaco fundamentals • 37 Half way through the . Step 1 Step 3 Step 2 Start the capsulorhexis. the capsulorhexis provides a high degree of strength and stability to the capsular bag and keeps the IOL secured centrally. This will highlight the importance of keeping the torn capsule folded over. it makes for an unstable capsular bag and predisposes to a higher complication rate.

This is an optional step that is performed with the idea that the epi-nuclear shell can act to protect the posterior capsule during phacoemulsification of the endo-nucleus. the tip of the cannula should be placed central relative to the edge of the capsulorhexis and not beyond it. Hydrodelineation is employed by some surgeons to separate the endo-nucleus from the epi-nucleus. we are ready to perform nucleus removal using aspiration and ultrasound energy from the phaco probe. and more waves are better. This will allow proper hydrodelineation. they will loosen the cataract from the capsular bag and some fluid may become trapped between the lens and the posterior capsule. 38 • WORLD REPORT CME SERIES Figure 1 Create a tight seal How much force is used? Very little. and instead prefer to remove the entire nucleus without separating it into these layers. The key here is to be gentle so that no undue force is used as this could cause the capsule to rupture and the nucleus to sublux into the vitreous. since the key is slow and steady. gently press on the plunger of the syringe in order to send the balanced salt solution around the posterior aspect of the cataract. and a successful fluid wave will result in the “golden ring” appearance at the area of separation between the epi-nucleus and the endo-nucleus. This requires a steady hand and a good sense of fluid control. you are being much too forceful. the fluid should create a forward fluid wave.a forward fluid wave. Keep the cannula steady so that it forms a tight seal between the capsule edge and the cataract. Once the cataract has been freed from the capsule with hydrodissection and split into endo-nuclear and epi-nuclear sections with hydrodelineation. if you take the 3cc syringe with the 27-gauge cannula and inject it outside of the eye. With a tight seal. the fluid will reflux back along the path of the cannula rather than dissecting forward. H ydrodissection is performed between the capsule and the cataract cortex in order to free the adhesions of the cataract from the capsular bag and allow it to rotate fully. Next. As the waves propagate. If your application of force causes the fluid to shoot across the room.dissection Hydro . both of which are performed using a blunt 27 gauge cannula on a 3cc syringe filled with balanced salt solution. Dig the tip of the cannula into the nuclear material while keeping it within the confines of the 5mm capsulorhexis. it is helpful to use balanced salt solution to loosen and separate the cataract in order to facilitate its removal. while the epi-nuclear shell is softer and easier to remove. phaco fundamentals • 39 .delineation Between the Capsule and the Cortex Between the Nucleus and the Epi-nucleus / Cortex Once the capsulorhexis has been created. The central endo-nucleus is of a higher density and requires more ultrasound energy to remove. You want to see at least one fluid wave propagated around the cataract. The two primary techniques are hydrodissection and hydrodelineation. To release this fluid. You should stop shy of the lens equator as you do not want to puncture the lens capsule or damage the zonules. To prevent the fluid from the cannula from going between the capsule and the nucleus during hydrodelineation (which was already accomplished during hydrodissection). use the cannula to gently tap on the center of the nucleus and the fluid will be pushed anteriorly. LESSON 16 Hydrodissection and Hydrodelineation Figure 2 Figure 3 Hydro . If you move too much and loosen this seal. To give you an idea of the force required. it would form a gentle arc of fluid that would extend only a few inches. Many surgeons do not perform this step. Care is taken to place the blunt cannula under the edge of the anterior capsulorhexis and directed toward the lens equator.

C ataract surgery is a delicate pyramid. In our next set of lessons. Both the patient and the surgeon are disappointed. we end up with good vision and a happy patient. phaco fundamentals • 41 . the result is a beautiful surgery. This is in contrast to a venturi system where the maximum pre-set vacuum can be created instantly and occlusion is not required. The cataract surgery success pyramid starts with good patient selection. in fact. it’s important to make sure we are building a cataract surgery success pyramid. and without performing them correctly. it is helpful to break the nucleus into quadrants or fragments. and good preparation by the surgeon. anesthesia. a round. The patient develops cystoid macular edema and a vision of 20/200 or worse. and a very happy patient. the ultrasound energy can be repulsive. and draping of the surgical field. an excellent visual outcome. the task of nucleus removal becomes quite difficult. Figure 2 Figure 3 Cataract Surgery Success Pyramid 20/20 20/200 Happy Patient Chronic CME Well sealed neutral incisions Vitreous to the leaky wound Efficient Nucleus/Cortex Removal Broken Capsule and Vitreous Loss Round Capsulorhexis/No Zonule Stress Radialized Capsulorhexis/Broken Zonules Well made incision/Deep and Maintained AC Short Leaky Incision and a Flat Anterior Chamber Good Anesthesia/Good Exposure/Prior Preparation Ineffective Block/Poor Exposure/Poor Patient Selection posure of the surgical field. Remember that in a peristaltic machine.LESSON 17 Concepts Of Nucleus Removal The ultrasonic phaco probe is used for just a single part of the surgery: removal of the cataract nucleus. The cataract surgery complication pyramid is not so pretty and not so happy. Since most surgeons who read this lesson will already have significant experience with patient selection. Our next level is making proper incisions of the right size in order to keep the anterior chamber deep and inflated during surgery. we will explore each of these methods. stop-andchop. we can focus our teachings on concepts of nucleus removal. This allows for efficient nucleus and cortex removal and IOL insertion. The techniques of nucleus disassembly include divide-and-conquer. we will run into problems. well-centered capsulorhexis can be created with minimal stress to the zonules. Then vitreous gets trapped in the patient’s leaky incision. These can be issues such as an improperly constructed incision that leaks during surgery and causes anterior chamber instability and flattening. If we start with poor patient selection. We are then at much higher risk of a broken capsule and vitreous loss. the maximum pre-set vacuum level is not reached until the phaco tip is occluded. good exposure and draping of the eye. The rest of the procedure can be performed with much simpler instrumentation. In order to facilitate removal of the cataract nucleus with the phaco probe. Being in foot-pedal position 3 without having the 40 • WORLD REPORT CME SERIES Cataract Surgery Complication Pyramid The fluidic control of the phaco machine is used to draw the cataract pieces toward the phaco tip. With a well-formed anterior chamber. where each previous step provides the foundation upon which the next step is performed. Most surgeons start learning them in that order and eventually choose some form of phaco chop as their primary technique. Clearly. But these other steps of the surgery are critical. A common mistake novice surgeons make is trying to use ultrasound power to draw cataract pieces to the tip. The primary concept to remember is that we are performing ultrasound-assisted aspiration of the cataract. The phaco energy should only be applied when there is actual cataract material at the tip of the phaco needle. When everything goes well. ineffective anesthesia. phaco tip in cataract material will result in transmission of the ultrasound energy through the aqueous and to the corneal endothelium resulting in post-operative corneal edema. and quick-chop. These incisions will then seal very well and will be astigmatically neutral. when. good anesthesia. With all of this together. This makes the capsulorhexis difficult and irregular with stress placed on the zonules. and inadequate ex- Figure 1 Apply ultrasound energy when the nuclear pieces are at the tip.

Use a high pulse rate of between 60 and 120 pulses per second. For fluidics. however. the phaco settings should be optimized for sculpting. and then a second instrument is used to crack the nucleus into pieces. and a maximum power setting of 20-60% depending on the density of the nucleus. which can then be easily removed. If your phaco machine does not have the ability to do a high pulse rate and a variable duty cycle. To create the groove. which are more easily extracted. [ Figures 1. The traditional method of ‘one-handed’ phaco involves using the ultrasound energy to bowl out the nucleus. Use the phaco probe’s vacuum to bring the pieces out of the capsular bag and to the iris plane. Make sure to raise the bottle height to ensure that the inflow of fluid into the anterior chamber exceeds the outflow of fluid in order to maintain a stable chamber. TYPICAL BETTER Widen the Grooves Allows more room for placement of the phaco probe and second instrument. the vacuum level should be between 200 and 400 mmHg. the crack will be incomplete and the pieces will not separate. Using a method to mechanically disassemble the nucleus allows for easier removal. To crack the nucleus into quadrants. in which the phaco probe is first used to sculpt grooves into the nucleus. Continue to bring the quadrants to the iris incomplete crack complete crack plane and phaco-aspirate them. 2 ] Use the phaco probe and the second instrument to rotate the nucleus 90 degrees and make a second groove orthogonal to the first. a second instrument is placed into the groove along with the phaco probe tip. Figure 4 Start the groove as close to the sub-incisional area as possible so that the groove has the longest length possible. Be aware that the continuous phaco energy mode will put more energy into the eye and may lead to a high rate of corneal endothelial cell loss. The Deep placement allows for comlete phaco power settings can be changed to a lower pulse cracking and separation of the nuclear pieces rate. For fluidics. and a lower maximum DEEP SHALLOW power setting of approximately half of what was used for grooving. a somewhat lower duty cycle of 30-50%. a duty cycle of 50% or more. and the flow rate should be between 30 and 50cc/min.LESSON 18 Divide-andConquer Technique of Nucleus Removal To facilitate removal of the cataract nucleus with the phaco probe. This will result in a complete crack with separation of the nucleus into distinct pieces. You should create grooves that are at least half the depth of the nucleus in order to facilitate cracking. as it is far from and the BADboth the corneal endothelium GOOD capsular bag. the goal is to simply keep the anterior chamber deep and well formed while providing a small amount of flow and vacuum to aspirate the sculpted cataract material. Depending on the phaco needle size. The proper method is to place the instruments deep within the grooves then pull apart. between 10 and 30 pulses per second. this requires a lot of energy and is rather slow and cumbersome. The average lens is approximaately 4mm deep centrally and shallows peripherally. it is important to have more holding power. and continue to sculpt the grooves deeper into the lens material. A simple and effective approach to nucleus removal is the divide-and-conquer technique. If the instruments are placed too shallow. [ Figures 3. 2 HALVES 4 QUADRANTS BAD incomplete crack GOOD complete crack phaco fundamentals • 43 . 3 Starting the Grooves Start the groove as close to the incision as possible for a longer groove length TYPICAL BETTER Widen the Grooves Allows more room for placement of the phaco probe and second instrument. thein phaco should be changed. 2. which means more vacuum. Once completed. it is helpful to divide it into quadrants or segments. 4 ] Starting the Grooves Start the groove as close to the incision as possible for a longer groove length NARROW WIDER GROOVE GROOVE Place Instruments Deep in the Groove Deep placement allows for comlete cracking and separation of the nuclear pieces SHALLOW DEEP Rotate & Create 4 Quadrants Maintain the Squared Grooves to facilitate cracking of the nucleus into quadrants. 42 • WORLD REPORT CME SERIES Figures 1. then it is acceptable to use continuous phaco energy. Be careful not to hit the edge of the capsulorhexis with the phaco probe. the two intersecting grooves will form a + sign and will segment the nucleus into four quadrants. This is the technique of Divide-and-Conquer for nucleus removal. Instruments OncePlace the nucleus is fully cracked and separated into four Deep thesettings Groove quadrants. This is the ideal location to phaco-aspirate the nuclear fragments.

we need to change the phaco and fluidic settings: here a burst mode is my preference as it affords using very little energy. 30-50% duty cycle. A short burst width of 4-20 milliseconds and a power of 10-40% works well. try 10-20 PPS (pulses per second). it is still helpful to have Stop-and-Chop as a back-up plan for nucleus removal. towards the left and right to separate the chopped segment. pull the instruments apart. 44 • WORLD REPORT CME SERIES Step 1. For those surgeons preferring a pulse mode. It’s a technique that can be mastered by all surgeons. and a maximum power of 20-50%. To chop each half. regardless of their level of prior experience. it is important to make a sufficiently long trench that extends from the sub-incisional region to the area under the anterior capsular rim. This is an easier transition for most surgeons and results in more efficient surgery. and then chops each half further. MD. Figure 1 T he technique of Stop-and-Chop uses a grooving technique to make a single linear trench in the cataract nucleus. Make a Groove Crack into Halves The fluidics must also be changed to increase the holding power of the nucleus. To hold the nucleus in place. so Paul Koch. The surgeon then stops. Making the jump from divide-and-conquer to a full chop technique is not simple for many surgeons. The width of the groove should be sufficient to allow placement of both the phaco tip as well as the chopping instrument deep within the trench. Stop-and-Chop is an important step on the road to performing phaco chop. divides it into two halves. Now that the nuclear half is stuck on the phaco tip. it does tend to require more phaco energy since the creation of the grooves and disassembly of the nucleus is accomplished with ultrasound energy. and opposing forces can be gently applied so that the nuclear halves are separated. If division is incomplete. Try using a higher vacuum level (200-400 mmHg depending on your phaco needle size). many surgeons feel more comfortable transitioning to a full chop technique. Once the technique of Stop-and-Chop is mastered. the phaco probe should be embedded into the nuclear half using ultrasound energy. When sculpting the initial groove into the nucleus. The initial phaco settings here should be a high pulse mode (80 PPS or more). Make a groove & crack Allows more room for placement of the phaco probe and second instrument Once the instruments are placed deep within the trench. due to the natural shape of the cataractous lens. The fluidics should allow for a low vacuum and low flow setting to simply evacuate any emulsified cataract bits from the excavated trench. For those surgeons who eventually transition to a pure phaco chop technique. Once the chopper has cut through the nuclear half and is in close proximity to the phaco tip. and a higher flow rate (30-50 cc/min) with a corresponding higher bottle height to ensure that the in- flow is greater than the outflow. then the individual nuclear halves will not be easily chopped. bring it up to the iris plane. The first chopped segment can be phaco-aspirated and the chopping steps repeated to further break both remaining nuclear halves into pieces. Now Chop Each Half While divide-and-conquer is an effective technique for nucleus removal. Care should be taken to separate centrally as well as peripherally in the groove in order to get complete separation of the two halves.Crack into Halves LESSON 19 Stop-and-Chop Technique of Nucleus Removal Figure 2 Step 2. phaco fundamentals • 45 . and then the foot pedal returned to position 2 with just vacuum. and a maximum phaco power of 40-60%. The groove is deeper centrally than peripherally. place the chopper around the edge of the piece. with a 40-60% duty cycle. and bring the two instruments together. invented Stop-and-Chop.

With the vacuum setting high. it is very easy to place the chopper around the lens equator or even behind the nucleus. well within the confines of the capsulorhexis. the vacuum level should be between 250 and 400mmHg. and if 46 • WORLD REPORT CME SERIES you are using a peristaltic fluid pump. The phaco probe is embedded into the nucleus and the chopper is passed under the capsulorhexis and towards the lens equator. The tilt and chop technique is my preferred technique for very dense cataracts. with the phaco probe in front of it. I am able to exert a powerful chopping force while still being very gentle to the zonules and other intra-ocular structures. thereby separating the two nuclear halves. The phaco tip is embedded into the nucleus and a high vacuum level is used to fixate it securely.LESSON 20 Quick Chop Techniques of Nucleus Removal The most efficient technique of nucleus disassembly is a purely mechanical one where the nucleus can be chopped into segments within a few seconds. [ Figure 2 ] Tilt and Chop To minimize the stress on the capsular bag. 3 Horizontal Chop Vertical Chop Tilt & Chop phaco tip together that does the chopping. whereas a chop technique is similar to using an axe to chop and split the firewood along the grain. bury the phaco tip into the nucleus using phaco power (foot pedal position 3). These segments can then be easily removed with relatively little phaco energy. Similarly. A high vacuum level is required to achieve the holding power that we desire for chopping. Compare this to the divide and conquer technique. 2. the nucleus can be tilted out of the capsular bag. the phaco probe must achieve a high enough vacuum level to firmly fixate the nucleus so that the chopper can do the mechanical splitting of the cataract. These nuclear halves can then be further chopped into smaller segments and emulsified. then once you have full occlusion of the tip. phaco fundamentals • 47 . this means bringing the chopper towards the left. Now the cataract is well-fixated and we are ready to employ a chop technique. T he basic concept of chopping is holding the nucleus with the phaco probe while the chopping instrument splits it into pieces. Horizontal Chopping The original technique of chopping described by Nagahara is a horizontal chop. the pieces need to be separated by pulling the two instruments apart. While the technical skill required for chopping is high. A relatively large capsulorhexis of 5 mm or more. The chopper is then placed vertically into the center of the nucleus. [ Figure 1 ] Vertical Chopping In a dense nucleus. The most common difficulty that beginning surgeons encounter when attempting chopping techniques is failure to adequately fixate the nucleus so that it can be chopped. By placing the chopper behind the nucleus. Depending on the phaco needle size that you are using. combined with hydrodissection or viscodissection. [ Figure 3 ] Chopping techniques are quickly becoming the preferred method for cataract surgery due to their inherent efficiency and greater safety. It is this action of moving the chopper and the Figures 1. If you’re going to use a fork and knife to cut a piece of meat. A complete separation of the two pieces is required for complete mobilization of the halves and for further chopping into segments. where a tremendous amount of ultrasonic energy is required to create the grooves that are used to create the quadrants. Once at the lens equator. the chopper is brought towards the phaco tip. The chopper is brought towards the phaco tip and the two instruments are pulled apart to create the two nuclear halves. remember that total occlusion of the phaco tip is required to achieve the maximum preset vacuum level. which is particularly helpful in cases of pseudoexfoliation or trauma where there is zonular weakness. will aid in partially prolapsing the nucleus out of the capsular bag. For most surgeons. the great majority of ophthalmologists can master with practice. When this is accomplished. A simple analogy is the splitting of firewood: a grooving technique is similar to using a saw to cut through the piece of wood. where a significant amount of force is required to propagate the chop through the nucleus. the two instruments are pulled apart: the chopper to the left and the phaco probe to the right. With the nucleus tilted out of the capsular bag. back off the pedal into position 2 so that the nucleus is being held by the high vacuum level. Once the chopper and phaco tip are both fully buried in the center of the nucleus. vertical chopping is a very effective and safe technique. hence the name Quick Chop. while the phaco probe is pushed towards the right. you must first hold and immobilize the meat with the fork so that the knife can do the cutting.

and is a mechanical means to force the nuclear chips into the small I/A suction port. Spider-like radial lines indicate Our goal dangerous at the end of cortex removal is to have a clean and clear bag. If that does not release the capsule.LESSON 21 Cortex Removal Once the nucleus is removed. 3 and is less likely to result in residual cortical material in the capsular bag. Care should be taken to remove as much cortex as possible so that post-op inflammation and posterior capsule opacification are minimized. stray nuclear fragments can be removed by using the I/A tip in combination with a second instrument. via the paracentesis. blocked by the iris tissue. T he amount of cortex adherent to the capsular bag is proportional to the effectiveness of the hydrodissection performed prior to nucleus removal. For cortex removal. residual cortex fragments are left on the posterior capsule. the I/A probe is placed under the edge of the capsulorhexis and the cortex is grabbed from within the capsule. care should be taken to stop and release it. phaco fundamentals • 49 . The action is similar to using a fork to mash potatoes. the I/A tip can be positioned so that it is facing inferiorly. near the lens equator [ Figure 1 ]. a gentler irrigation and aspiration setting can be programmed into the phaco machine. such as posterior capsule or iris that was inadvertently grabbed. If spider-like wrinkles [ Figure 3 ] appear on the posterior capsule. either a chopper or a spatula. Aspirate 3 clock hours of cortexin a circumferential manner Aspirate 3 clock hours of cortexin a circumferential manner When small. When it comes to the sub-incisional cortex. move the probe towards the center of the anterior chamber and bring the port upwards to complete the aspiration. Spider-like radial lines indicate dangerous aspiration of the capsule In small pupil cases. The key for efficient cortex removal is to move in a circumferential manner. It is not acceptable to leave a significant amount of lens cortex in the eye at the end of the cataract surgery since it will induce inflammation and may affect the patient’s quality of vision and level of comfort. If the posterior capsule is inadvertently suctioned during the removal of the lens cortex. When the small nuclear chips become stuck at the I/A tip opening. The goal is to remove a few large sheets of cortex material instead of pulling many small strips of cortex. the remaining lens cortical material must be thoroughly cleaned from the capsular bag. Any small. ready to accept our intra-ocular aspirationcapsular of the capsule lens implant. remember that the cortex needs to be removed from the equatorial region of the capsular bag. Once the cortical piece is held via the suction of the I/A tip. go to reflux position. The foot pedal has a position called ‘reflux’ where the vacuum is stopped and the fluid pump is reversed to release any trapped material. Use of the new siliconecoated soft irrigation/aspiration tips allows a higher margin of safety since no metal will come in contact with the posterior capsule. You should aim to grab at least a few clock hours of cortex by moving circumferentially prior to bringing the probe radially towards the center of the anterior chamber. This reflux position is typically used to reverse the aspiration of fluid and to release the tissue. simply use the second instrument to push them into the port. towards the underlying capsular bag. which allows for more control and a higher vacuum level while maintaining the stability of the anterior chamber. Removing a large sheet of cortex allows for safer and more efficient cortical clean-up 48 • WORLD REPORT CME SERIES Figure 1 Grab cortex from within the capsule Figures 2. Using a setting such as ‘capsule polish’ or ‘capsule vacuum’. the cause is most likely aspiration of the capsule and you should immediately release the vacuum by going to foot-position 1. we can use low flow and low vacuum to remove these last few bits of cortex while being very careful not to damage the posterior capsule. Grab cortex from My preferred technique is to remove about three clock within capsule hours of cortex atthe a time with the circumferential tech- nique [ Figure 2 ]. The I/A hand-piece has a much smaller opening as compared to the phaco needle. As much of the nucleus and epi-nucleus as possible should be removed with the phaco probe prior to switching to the irrigation/aspiration (I/A) hand-piece. which may be out of view. Cortex removal requires a delicate touch since we are working in direct proximity to the fragile capsular bag.

Inject viscoelastic as you insert the canula into the eye so that there is never any direct contact of the canula with the posterior capsule. In some situations. with care taken to tilt the IOL to the sides to remove any viscoelastic that is sequestered behind the IOL optic. it opens up and resumes its full size and shape. and the future trends will be to move towards smaller and smaller incisions and less invasive surgery. At this point the anterior chamber can be filled with balanced salt solution.0mm or so has only a into Capsular Bag The technique for inserting all of these IOLs is similar: the leading haptic is placed into the capsular bag. T he recent advances in IOL technology have been a tremendous benefit to surgeons and patients alike—with better optics and improved bio-compatibility. pass the canula under the capsulorhexis edge and completely fill the capsular bag. Once the anterior chamber is inflated.0mm to be inserted through an inci50 • WORLD REPORT CME SERIES Injectable IOLs are also made of acrylic or silicone. Note that IOLs have a proper front and back surface. the IOL may be intentionally placed with the ciliary sulcus – the space between the posterior surface of the iris and the anterior lens capsule. [ Figure 1 ] You want the eye to be firm and ready to accept its new lens implant.0mm capsulorhexis. [ Figure 2 shows the proper “Z” orientation of the haptics. the viscoelastic should be aspirated. due to their rigid nature. and not in the “S” formation. ] Once the IOL is completely within the capsular bag. the IOL is released. they require a larger incision for insertion.5mm.0-3. it can be gently rotated with a second instrument to ensure that it is well-positioned. An incision of 3. These smaller incisions have the least astigmatic effect and tend to seal the best. Each is inserted differently. the forceps are opened. then finally the trailing haptic is also placed into the bag. and are designed to work with a specific IOL injector system. it should be filled with viscoelastic. Rigid IOLs are typically made of polymethyl methacrylate (PMMA) which is a well-tolerated non-flexible plastic. foldable IOLs. With the lens completely within the capsular bag. followed by the optic. Figure 1 Inject Viscoelastic in Capsular Bag mild to moderate astigmatic effect. An incision as large as this should not routinely be made in the cornea. and injectable IOLs. This allows an IOL with an optic size of 6. [ Figure 3 ] Using high flow and high vacuum.LESSON 22 IOL Insertion Figure 2 Insert IOL into Capsular Bag Figure 3 Remove All Viscoelastic Once the capsular bag is clean and clear. the viscoelastic needs to be removed from the eye. and the incisions can be sealed. Once the IOL is inserted within the eye. which can often be lessened by proper closure with sutures. sion of about 3. The three main IOL classifications for insertion are: rigid IOLs. These IOLs tend to be single piece.5mm incision. Foldable IOLs are often made of acrylic or silicone. the PMMA IOLs tend to be used rarely in most modern practices. and. With a typical 5. and then placed within the eye.0mm optic will be held in place by the edge of the anterior capsule for 360 degrees. and the forceps IOL canInsert be removed. This allows the IOL to be completely shielded from contacting the ocular surface during insertion. made entirely of PMMA. and the injector can be removed from the incision.0mm. Most 6. a scleral tunnel incision should be created. Due to the large incision size. held with forceps.5mm greater than the optic size. rather. and it can be closed without sutures. This larger incision will cause a long-term astigmatic effect. and sometimes even less than 2. a 6. and they should not be placed into Remove the eye upside down. and the long-term stability of the IOL is ensured. and with the introduction of new lens materials that permit insertion through smaller and smaller incisions. and are designed to be folded in half. which can be made safely in the cornea. The normal configuration is with the haptics in the same orientation as the letter “Z”.0mm optic PMMA IOLs can be passed through a 6. such as with a compromised posterior capsule. Once the IOL is injected into the eye. All Viscoelastic phaco fundamentals • 51 . and it allows for smaller incisions of less than 3.0mm. typically 0.

size. symmetry. and obtuse angles of more than 90 degrees result in deeper passes. Incision / Wound Figure 5. spacing. [ Figure 1 ] Sutures should be placed symmetrically so that an even amount of tissue on either side of the incision is captured by the suture. . The holding power is strongest under the suture and Suture Holding Power the it decreases as you move futher away. it is customary to tie interrupted sutures with three knots in a 3-1-1 manner: the first knot should be three throws. equal to the radius of the needle. B. Figure 1. acute angles of less than 90 degrees result in shallow passes. Any leakage will cause the sponge to swell and absorb the fluid. This is an indication of insufficient wound closure. better long term stability. The needle should be grasped at about one-third the distance from the swaged end to the point. and. (A) and Figure 2. too loose and the incision will leak. the movement is like turning a screwdriver in circular motion. distributing forces in a diamond shape. B. This may be helpful in situations where higher strength closure of the wound is required. which aids in patient comfort while helping to prevent unraveling of the knots. (A) Acute angles result in shallower sutures. These tiny sutures. Acute Angle < 90˚ Shallow Depth B. (B) Right angles result in nomal depth. 5 Figure 4. Figures 4. phaco fundamentals • 53 C. they must be at the same tension. and additional sutures may be needed. and the needle-holder A. and therefore more sutures are required to close the incision or wound. B. Right Angle = 90˚ Nomal Depth Incision / Wound Suture C. as a result. (C) Obtuse angle result may result in excessively deep suture passes. Obtuse Angle > 90˚ Excessive Depth The entry angle of the needle will determine the depth of the suture placement. Entry Angle Determines Depth A. and this diminishes as you move further away. Placing a suture with good depth. equal to the radius of the needle. When tying nylon monofilament sutures. Figure 4. C. then the circular path of the needle will result in a depth equal to the radius of curvature of the needle. where the Suture Length andincision. Entry Angle Determines Depth T he sutures typically come with semi-circular needles. Overly long sutures tend to distribute the closure force over too broad an area. [ Figure 3 ] 52 • WORLD REPORT CME SERIES The suture holding power is greatest directly under the suture itself. There should be no linear pushing with these needles. Since needle creates a circular path. 90˚ (A) Obtuse Angle > 90˚ Nomal Depth Excessive Depth The entry angle of the needle will determine the depth of the suture placement. Note that if two or more sutures are placed in the same incision. they may give less effective holding power for the incision. 3needle. and tensile force is an art and an integral part of ophthalmic surgical technique. This results in optimum holding power of the incision. Finding the right balance only comes with practice and experience. (C) Obtuse angle result may result in excessively deep suture passes. (B) Right angles result in nomal depth. Suture placement in clear corneal incisions should be radial.to close the incision. Spacing forces provide good holding power for the entire (C) An overly long suture may distribute the forces over too large an area and therefore give less effective holding power A. otherwise they will bend and distort the tissues. (A) Short sutures distribute their force over a smaller area. and it gives the surgeon an opportunity to enhance the fine motor skills that Symmetrical suture placement (B) results in optimal power (C) do not provide the same security. The balance in throwing a suture to close a corneal incision is: too tight and there is a lot of induced astigmatism. Sutures placed in the cornea can then typically be rotated so that the knots are buried within the corneal stroma. Circular Path of the Needle Figure 2. which create circular paths when they are passed through tissue.bend and the tissues to distort. Suture The holding power is strongest under the sutur it decreases as you move futher away. and therefore more suturesFigure are requird 5. Right Angle =closure. Excessive pushing in a linear A. [ Figure 5 ]. 2. manner will the end of the surgery. typically 10-0 inand wound closure. This gives better sealing of the incisions. Acute Angle < 90˚ Shallow Depth C. [ Figure 2 ] The entry angle of the suture plays a large role in determining the depth of the suture. (B) The ideal balance of suture length and spacing. [ Figure 4 ] Shorter sutures distribute their force over a smaller area. and a lower likelihood of cheesewiring through the tissues. Rather. short C. Suture Length and Spacing A. B. length. I recommend suturing the incisions at turning a screwdriver in circular motion.Circular Path of the Needle LESSON 23 Incision Closure & Dressings To pass a suture with aFigures semi-circular 1. B. (A) Acute angles result in shallower sutures. cause the needle toC. Only when the tight suture is removed will the tension on the other sutures appear normal again. Excessive pushing in a linear manner will cause the needle to bend and the tissues to distort. much like the spokes of a bicycle wheel. Suture Holding Power Figure 3. (B) results in optimal power Symmetrical suture placement and wound and (C) do not provide the same security. the movement is like For beginning phaco surgeons. Sutures that are placed at a more ideal length will provide good holding power at the incision while minimizing the number of sutures required for a given length of incision. for the incision. These three knots are placed in alternating directions in order to create square knots. The incisions can now be checked for leakage by using a small sponge and pressing on the lip of the wound. Figure 3. If there are normal tension sutures on either side of a tight suture. A. should be unlocked before passing the suture. The resulting forces from the suture result in a diamond-like distribution pattern. can be challenging to use given their low tensile strength and the Symmetrical Suture Placement small circular needles. Symmetrical Suture Placement To pass a suture with a semi-circular needle. are involved in microscopic suturing. distributi long forcesideal in a diamond shape. then these normal tension sutures will appear to be loose. and the second and third knots should be one throw. If the needle entry angle is 90 degrees. the movement used to pass these sutures is similar to turning a screwdriver in a circular motion.

This 24 part series can serve as a good foundation for the principles of phacoemulsification surgery for ophthalmologists. While the steroids are efficacious at reducing the inflammation. NSAIDs are also a useful adjunct to steroids since they can help reduce inflammation further. On post-op day 1. which are dosed for at least 2 weeks after surgery. and sometimes for as long as 8 week after more complex cases. The vision on post-op day 1 is dependent on the clarity of the cornea—the less ultrasound energy that was placed in the eye. 54 • WORLD REPORT CME SERIES The routine post-op care of phacoemulsification patients involves seeing them the day after surgery to monitor the initial healing response. The patient’s comfort and return of sharp vision are also dependent on a successful post-op course and recovery. such as the case with fluoroquinolones. the clearer the cornea and the better the vision. and the IOL should be in good position. The next visit will be at approximately 4-6 weeks after surgery. The intra-ocular pressure should be normal to mildly elevated. and I hope that we can spread it to future generations – to the people who will one day perform cataract surgery on our eyes.Uday Devgan. I encourage you to pursue further training. To ensure optimum patient recovery of good. and help to prevent the development of cystoid macular edema.LESSON 24 Post-op Medications & Follow-up After routine phacoemulsification surgery. MD. and they are administered before surgery and then for the first week or so after surgery. offer pain relief. Course Summary We are truly fortunate to be ophthalmologists —it’s rewarding and challenging to perform complex microsurgery to restore the gift of sight to our patients. where the retina can be checked for any macular or peripheral lesions. clear vision. studies. topical antibiotics are often prescribed during the immediate post-op period. and mentoring in cataract surgery and to truly enjoy the process. they can induce a glaucomatous state as a side effect. the two primary concerns are resolution of the surgically induced inflammation and prevention of infection. The intra-ocular pressures should be monitored in post-op patients to ensure that this does not happen. at which point the vision should be better. the inflammation must be controlled with potent topical medications such as corticosteroids and NSAIDs (non-steroidal anti-inflammatory drugs). IOP is monitored to make sure that it is within normal range. I’m sure that many others share my passion and pride. phaco fundamentals • 55 . A high intraocular pressure typically indicates that some residual viscoelastic was left in the eye at the end of the case and should be treated with topical or oral IOP-lowering medications. and the other important people behind the scenes that have made this idea a success. . and the patient should be happy with the surgical result. The most commonly prescribed corticosteroids are prednisolone acetate and dexamethasone. California. T o prevent the dreaded complication of endophthalmitis. the incisions should be sealed and water-tight. and it’s a pleasure to put the technical art and science of surgery into practice. the inflammation should be less. The most commonly used topical antibiotics have broad-spectrum coverage. FACS Los Angeles. I would like to thank the people who have worked so hard to put this project together. Bausch & Lomb for their support. and the antibiotic medication can be stopped. USA The patients are typically seen again at post-op week 1 or 2. and a lifetime to truly master it. the anterior chamber should be deep and formed. including Mridula Chettri Singh and her team. Most cases of corneal edema will resolve within a few weeks. It takes years of practice and scores of cases to become proficient at phaco.

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