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Essential Principles



Pascal W. Hasler, MD
Essential Principles of Phacoemulsification

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Essential Principles of Phacoemulsification

Pascal W. Hasler, MD

ISBN: 978-9962-678-61-8

Published for: Jaypee - Highlights Medical Publishers, Inc.

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Pascal W. Hasler, MD
Fellow of the European Board
of Ophthalmology (FEBO)
Department of Ophthalmology,
University Hospital of Basel,
Basel, Switzerland

Essential Principles of Phacoemulsification

First you have to know that I am a vitreoretinal surgeon and
I was really disappointed about my cataract surgery skills. I decided
to change that and found an excellent and very experienced cataract
surgeon and teacher from India, Nirav Patel. The initial idea was
to put down in writing the knowledge of Dr. Nirav Patel, in order to
remember all the important steps of phacoemulsification cataract
surgery during my time as a fellow at the Advanced Eye Care Clinic
in Vadodara, India. After coming back to Switzerland I started to draw
important steps and pitfalls of the procedure in order to visualize the
topic. Dr. Patel showed the first draft to his trainees and he realized
how they improved faster. It finally reached the size of the handbook
that you have in your hands now.
The question rises- why should there be another book on
cataract surgery? Well, this handbook is quite different than most of
the other ones. There are a lot of practical tips and tricks a cataract
surgeon beginner as well as a more experienced cataract surgeon can
benefit from. The idea was to make the topic straight forward and not
to oversize the content with information which is not of any practical
use. Most of the information taken for this handbook has been given by
Dr. Nirav Patel. Besides, I was able to compile additional information
on cataract surgery from other books, DVDs and homepages which
helped me to write this book. You will find the list of the references at
the end of the book.
The sentences are short and concise and may sometimes
sound even like a command. Some of this information is very important,
so I repeat it several times in order not to be forgotten. Dr. Patel and
I decided to offer this handbook to all fellows at the Advanced Eye
Care Clinic as a help and a guide for phacoemulsification surgery. I
really hope it will help you to improve your skills!
I want to thank Nirav Patel, MD who helped me to become a
better cataract surgeon and Frank Sens, who arranged the contact
with him. I do also want to thank my surgical teachers Christian
Prnte, Joergen Villumsen, Ole Mark Jensen, Sebastian Wolf, Selim
Orgl, Ulrike Schneider and Jrg Messerli. I want to thank also Josef
Flammer for the support of this advanced cataract surgery training
in India. Last but not least I dedicate the book to my family, my wife
Deborah and my children Sven and Mira.
Pascal W. Hasler, MD

I. Phaco Methods and Device Settings............................. 1

II. Positioning, Microscope, Phacodynamics and More.......7
III. Corneal Wounds..........................................................13
IV. Capsulorhexis...............................................................21
V. Hydrodissection and Hydrodelineation.........................35
VI. Grooving........................................................................45
VII. Divide & Conquer............................................................57
VIII. Chip & Flip.....................................................................65
IX. Stop & Chop...................................................................69
X. Phaco Chop...................................................................75
XI. Cortex Removal............................................................77
XII. Dealing with Vitreous in the Anterior Chamber.............85
XIII. Insertion of the IOL........................................................93
XIV. Decision Taking in Cataract Operations.......................105

Essential Principles of Phacoemulsification

Phaco Methods and
Device Settings

The main four phacoemulsification - methods / techniques you

will have to learn are:

1. Divide & Conquer

2. Stop & Chop
3. Chip & Flip
4. Phaco Chop

As a phaco-surgeon you first need to be able to handle the divide

and conquer technique, later the three other phaco-methods.
If you feel confortable with divide and conquer, then you may start
with the other techniques.
Use different phaco programs for different situations during phaco
surgery. Three phaco programs should actually be enough to
perform the 4 main phaco techniques.
You have to know very well your phaco machine in order to adapt
the device settings for yourself. Try while coming from the safe
Essential Principles of Phacoemulsification

3 Phaco-Program examples (for Whitestar Phaco Machine, AMO

(Abbott Medical Optics)):

PHACO-1 Ultrasound Vacuum Flow

(%) (mmH20) (ml/Min)
Very soft 30-35 60 45
Soft-G1 40-55 60 45
G2-G3 60-65 60 45
G4 75-80 60 45

PHACO-2 Ultrasound Vacuum Flow

(%) (mmH20) (ml/Min)
Very soft - G1 10-15 200 48
G2 20-25 200 48
G3 25-30 200 48
G4 45-50 200 48

PHACO-3 Ultrasound Vacuum Flow

(%) (mmH20) (ml/Min)
Very soft - G1 10-15 130 48
G2 20-25 130 48
G3 25-30 130 48
G4 45-50 130 48

You do not have to take over these settings. Use the safest settings
in your hands, but something must happen while you are working
in the eye. Too safe settings will increase your working time in the
Phaco-1 program: for grooving and sculpting the nucleus.
Continuous phaco power.
For chopping you need high vacuum power in order to hold the
lens. Therefore you may need to adapt the settings.
Phaco-2 program: for dealing with the smaller pieces of the
nucleus. Non-continuous phaco power.

Chapter I: Phaco Methods and Device Settings

Phaco-3 program: like Phaco-2, but safer Non-continuous phaco

To sculpt the nucleus you need low outflow rate and just little
High outflow rate does not increase the speed of nucleus removal,
but rather creates turbulence and high flow rate through the eye
and since you are not occluding the phaco tip, you can use low
vacuum while grooving.
If cataract surgeons talk about flow, they generally mean the
outflow rate while the pump is operating. This is measured in
ml per minutes.
The outflow rate is the flow rate at which the fluid leaves the eye
through the aspirating instrument (ml/Min).
Remember: the bottle height has no influence on the outflow rate
in peristaltic pumps (in Venturi pumps there is a relationship: the
higher the pump, the higher the flow).
The bottle height has to be adapted to the flow since the chamber
should stay stable during work.
A low bottle and a high flow will lead to a collapsed anterior
The outflow of fluid cools down the phaco tip while working. Using
only the phacoemulsification mode will create a corneal burn
While sculpting a hard nucleus you should increase the outflow
rate in order to cool down the phaco tip.
A decreasing IOP will manifest as a shallowing of the anterior
chamber, but there are of course other reasons for a shallow
anterior chamber (we will see that later)
The infusion bottle height will tell you the IOP if the incisions are
tight and you are not operating the pump. The 15 cm bottle height
corresponds to 11 mmHg, roughly 15 cm = 10 mmHg.
As soon as you use the operating pump, fluid will flow out of the
eye and the IOP will lower down. Look at the anterior chamber
depth while working in the eye. You may have to adapt the bottle

Essential Principles of Phacoemulsification

Vacuum is building up when the phaco tip is occluded. You do not

have a vacuum effect without occlusion (Figure 1).
Vacuum is not flow rate! The flow rate will just tell you how fast the
vacuum will build up in an occluded tip. The higher the flow, the
faster you will build up vacuum (Figure 1).

Figure 1

Vacuum is not important while sculpting the nucleus, but gets

important if you are eating the lens pieces. Thats why some
surgeons have two or more programs of vacuum and pump action
during one phaco.
For a given amount of ultrasound power per time unit, more
volume of nuclear material will be aspirated while the tip is
occluded. Therefore using occlusion during phaco is more time
and energy efficient then without occlusion.
To hold a piece of nucleus you need high vacuum. First grab it with
aspiration and create a short phaco power in order to get into the
piece and create tip occlusion for vacuum.
Ultrasound power creates a repulsive action meaning that the
aspirated piece is also pushed away during phaco action. This
repulsive phaco action has to be overcome by adequate vacuum
power in order to keep the piece at the tip.

Chapter I: Phaco Methods and Device Settings

If you want to attack a piece of nucleus, you have to turn the tips
opening towards the piece in order to rapidly create an occlusion.
Therefore you have to be aware of your tip angle (Figure 2).

Figure 2

Do not press with the phaco tip on the incision. Compression of the
incision lips with the working phaco tip will create a corneal burn.
Especially the anterior lip is in danger while sculpting deep.
As soon as you have vacuum building up, you know then that you
have occluded the tip. But be aware of the fact that you will then
not have flow cooling the phaco tip
Do not use phaco power for long time otherwise you have a corneal
If the anterior chamber is flattening during cataract operation,
then stop all maneuvers in the eye, calm down and think about
the reason. You may deal with a subchoroidal hemorrhage/
effusion, or an infusion misdirection syndrome (fluid passing
through the zonula or a capsular tear which then accumulates
in the retrocapsular space), or an instable anterior chamber
due to inadequate infusion pressure or leaky incisions, or fluid
misdirection under the iris plane in floppy iris syndrome or myopic
eyes. A lot of ors (Figure 3).
Essential Principles of Phacoemulsification

The term positive vitreous pressure is a descriptive and not

a diagnostic term. It just means that the anterior chamber is
flattening You will have to find out why (Figure 3).
If the anterior chamber is flattening during cataract operation
you have to pressurize the eye to normal or slightly elevated
intraocular pressure. If the anterior chamber remains shallow
you deal with either a subchoroidal hemorrhage/effusion or more
often an infusion misdirection syndrome. If the anterior chamber
deepens again check the infusion bottle, the infusion line and the
incisions (Figure 3).

Figure 3

A flat anterior chamber with normal IOP is usually due to an

infusion misdirection syndrome. If the media are clear and you
can exclude a subchoroidal hemorrhage/effusion, then continue
the cataract operation with lower infusion bottle. You may have to
convert to ECCE.
If you diagnose a subchoroidal hemorrhage/effusion during
cataract operation, immediately pressurize and close the eye.

Positioning, Microscope,
Phacodynamics and

A cataract operation success is depending on each step of the

procedure. If one step is not nicely performed, you will pay for it
later in the procedure.
Each step in cataract surgery is important and needs to be well
done. Most of the time you have problems during an operation
because an earlier step was not nicely performed.
Well-performed cataract operation steps, even if time consuming,
will help you to continue the operation safely.
A cataract operation success starts with a plan. You have to have
a plan how you want to operate the patient knowing the possible
problems of the patients eye.
Each step of the procedure has a lot of influence on the next steps.
A problem at the end of the operation may have the reason at the
beginning of the operation.
Perform each step of the cataract operation meticulous and
accurately. Dont be lazy!!!
Watch other cataract surgeon working. Watch also videos of
normal cataract operations and the complication management.
Talk with other surgeons about your problems during operation.
Thats the way to get better.

Essential Principles of Phacoemulsification

Ask an experienced surgeon watch your operation and then review

your steps. A good idea is also to tape/record your operations at the
beginning. Afterwards you always know it better, but sometimes
you are not aware of what you are doing wrong.
At the beginning better use the temporal approach. The deep
eyes are then not a problem anymore.
With a temporal approach you avoid the brow. You have a better
access to the eye.
You can also start with a superior approach, but this is a little more
difficult to start with. It is important to choose your patients and
not to start with these deep eyes.
Right foot for the phaco pedal and left for the microscope or the
other way round. Learn to use both feet! Adapt to the way it is done
at your clinic.
If possible take your dominant foot for the phaco pedal and the
non-dominant foot for the microscope footswitch.
Do not start cataract operations at your clinic with a lot of special
and new stuff only for you. You have to adapt to the situation and
watch others. Your co-workers will appreciate that.
First: check if the eye/the face are horizontal to the microscope.
Often you have to ask the patient to put his chin up.
Then check if the head is not tilted to the other eye. The fluid should
flow down away to the temporal side from the operation field and
not collecting around the operated eye and towards the nose.
You have to adjust your inter-pupillary distance and the corrections
at the microscope before you wear the operation gloves.
Check if you sit comfortable, the microscope image is centered
and sharp, and the foot pedals are in the right place.
You have to sit upright and comfortable during the operation.
A high magnification will give you a perfect view for details, but
you have also a small field of vision and a bad depth of field. With
a low magnification you will not see details. Choose the best
magnification for your work, but do not use too high magnification.

Chapter II: Positioning, Microscope, Phacodynamics and more

Start phaco training with retrobulbar or parabulbar anesthesia

(for example with Lidocain 2%). A moving eye is terrible for a
phaco beginner.
Do not perform surgery in case of retrobulbar hemorrhage due to
anesthesia. Better wait two weeks.
Do not open the eyelids too much with the lid speculum. You
produce too much pressure from behind.
Whenever you realize that the eye presents with too much pressure
from behind then check first the lid speculum position.
Draping the eye is very important and should be performed
correctly. If you have had problems during the draping, you will
have problems later.
You have to take away the lashes from the operation field since
they are a major source of bacteria.
Take the lashes out of the operation field!
Start the irrigation for the phaco tip or I/A-tip before you enter the
eye (kick the pedal first horizontally to the left or the way you have
programmed your phaco device).
Enter the eye always with infusion on. First, because you will have
less air bubbles in the anterior chamber and second, because the
anterior chamber will fill more controlled.
You can program your foot pedal as you want. Here is an example
with four positions: Position 0 - everything is off, Position 1 -
irrigation is on (remember to start the infusion before you enter
the eye!), no pump, no ultrasound. Position 2 - irrigation is on,
pump is on, no ultrasound. Position 3 - irrigation is on, pump is on,
and ultrasound is on.
You may also program your phaco device differently, but you have
to know exactly what is going on while you are pressing the foot
In G4 or white cataract better operate in retrobulbar anesthesia.
The eye is not moving and it is easier to convert in ECCE or even
pars plana vitrectomy.

Essential Principles of Phacoemulsification

Assess the difficulty factors of the operation as soon as you look at

the eye: is there a risk of zonular laxity (due to Pseudoexfoliation
(PEX) syndrome, history of trauma or Marfans syndrome)? Is it
a deep eye with big brow limiting the superior access? Narrow
angle with little space in the anterior chamber? Is the cornea
clear (cornea guttata, other dystrophy, scar)? Do you have a poor
red reflex (due to white or black cataract, vitreous bleeding)?
Small pupil size (due to PEX-syndrome, long-term use of miotics,
posterior synechias, diabetes after laser treatment)? Is the patient
claustrophobic / nystagmus / monocular / cannot lie flat, etc.?
Be critical!!! Are you the right surgeon to operate on that eye?
It is not a sign of weakness if you feel not being the right surgeon
for this eye. Better be lore before the operation than be stumped
during and after the operation.
The goal of phacoemulsification is to remove lens with minimal
ultrasound power to reduce damage to the cornea, but safe phaco
does not mean low power. Appropriate phaco power is demanded.
Stop phaco power if you are not working close to the lens!
It is forbidden to use the phaco tip close to the endothelium, the
iris or the incisions!
A phaco tip does not look like a weapon, but it is
Readjust the microscope and the patients head position during
If visualization gets poor during cataract surgery something is
wrong. You have to analyze the problem. Stop, look, analyze and
If visualization is getting worse due to corneal epithelium edema,
you may use a topical hyperosmolaric solution, like glycol. This
will give you better vision for about 5 minutes. If this doesnt work
you may even perform a corneal abrasion. You really need to see
something during phacoemulsification procedure.
If you do not have red reflex then check the microscope parameters.
If you still not have a red reflex then you have a white or black
cataract, a vitreous hemorrhage or a total retinal detachment, a
large retinal tumor or a large retinal hemorrhage. Better color
the lens capsule before doing capsulorhexis in these cases.
Chapter II: Positioning, Microscope, Phacodynamics and more

As a beginner it is easier to color the lens capsule with a dye. You

really see the anterior capsule better and can concentrate on your
movements in the eye.
A small pupil is nothing for a cataract surgeon beginner. You have
to dilate this pupil or if not possible ask an experienced surgeon to
take over (Figure 4).

Figure 4
If the pupil is small you are in trouble, since it may not get bigger
during the whole procedure. First try to dilate it with OVD and
additional topical mydriatic drops. You may also put adrenalin in
the anterior chamber. Wait for several minutes until you see an
effect. If the pupil is still too small you need mechanical enlargers
like iris hooks or a Malyugin ring.
For cataract surgery you need to have a plan. This plan may change
during the procedure, but do not change the plan too fast. You may
have to try more than one time to be successful.
If you tremble too much with your hands during the cataract
surgery, better remove the instruments of the eye and try to calm
down for several minutes and then continue. Dont let you be
stressed by others! You may also drink coffee after the operation
instead of before.
Essential Principles of Phacoemulsification

Time should not matter for a beginner in cataract surgery. Better

perform a slow, but safe procedure than a fast and dangerous one.
The speed of operation will come after more experience.
Dont be too much proud of yourself. It is better to ask for help in
certain situations.
If you are in trouble, then ask for help. If you know that you will be
in trouble even before the operation, then ask a college that you
may need his help.

Corneal Wounds

To create a paracentesis wound you should enter the cornea close

to the limbus and parallel to the iris plane. This is safer for a
beginner. You will have less probability to touch the lens and due
to small hemorrhage at the entry site you will have less problems
to find the entrance later (Figure 5).
You may go more and more to a clear corneal approach for
paracentesis as soon as you are getting more experienced. The
risk of iris prolapse is less then since the distance from the iris to
the cornea increases.
A little bleeding from the limbal vessels created during
paracentesis creation doesnt matter and will help you to find the
access later (Figure 5).

Figure 5

Essential Principles of Phacoemulsification

Dont make a too long or too short tunnel! (Figure 6).

Figure 6

As a beginner you have a high risk of destroying the wound

architecture during manipulations in the paracentesis wounds.
This is a problem in short tunnels since the wound may stay open
at the end of the surgery.
You need to pass through the total thickness of the cornea while
creating the paracentesis or the tunnel. Especially you should pass
the largest part of the blade through the endothelium (Figure 7).

Figure 7
Chapter III: Corneal Wounds

A very tight paracentesis will always make problems when you

want to enter the eye. If you finally have entered the eye you
probably also have destroyed the wound morphology and it will
not be watertight any more. Enlarge it or make a new one at the
beginning of the procedure
If you perform your paracentesis sclera-corneal, you will always
have problems to enter the eye because of the conjunctiva. You
may even have conjunctival ballooning
Think about the best location before putting the paracentesis You
will have to work with these incisions later (Figure 8).
Do not put the paracentesis close to the tunnel. You will have
problems manipulating with your hands close together (Figure 8).

Figure 8

Avoid extreme elevation of the phaco tip or the I/A hand piece
during intraocular maneuvers. You are stretching the wound and
it may not be self-sealing any more

Essential Principles of Phacoemulsification

Perform the clear corneal incision as peripheral as possible. You

will have less astigmatism thereafter and will be able to work in
the eye with better visualization (Figure 9).

Figure 9

A superior main incision will create a flattening of the vertical

meridian. The more central you put the clear corneal incision the
more you have astigmatism.
A superior incision creates about twice more flattening of the
cornea than a temporal incision.
You need an adequate size of the main incision in order to work
properly in the anterior chamber with the phaco tip. A snug
and therefore tight incision will help you to reduce intraocular
turbulences and iris prolapse. You will be able to elevate the
infusion bottle and work in a stable and deep anterior chamber.
Better stabilize the eye with a second instrument during
paracentesis and tunnel preparation. This instrument should hold
the eye 180 from where you want to work (Figure 10).

Chapter III: Corneal Wounds

Stabilize the eye while performing the incisions, but dont press
too much on the globe. Better hold it with a forceps for example
(Figure 10).
Fixating the eye during clear corneal incision is safer. You can
use a cotton tip, a fixation ring or even the finger opposite to the
incision side (Figure 10).

Figure 10

Do not use extensive pressure to hold the eye with the second
instrument. It is better to hold it with a forceps then.
Take care not to create the paracentesis or the tunnel too flat. You
may hit the endothelium after coming into the eye.
First make two paracenteses and then fill the anterior chamber
with Ophthalmic Viscosurgical Device (OVD) prior to tunnel
preparation (Figure 11).

Essential Principles of Phacoemulsification

Figure 11

If you loose a cannula from the syringe while injecting OVD or BSS,
then remember to tighten it better next time
If you nick the lens capsule during paracentesis or tunnel
preparation, then remember to include the nick during
capsulorhexis, Use it as the starting point of the rhexis
If you nick the iris, do not worry. This is usually not a big deal.
If you put the paracentesis at the wrong place, then make another
one (Figure 8).
If the paracentesis is too small, then enlarge it or make a new one.
If too big/large, then you may suture it later.
If you start the tunnel sclerocorneal (through the conjunctiva) then
open the conjunctiva parallel to the limbus in this area. You can
avoid conjunctival ballooning (Figure 12).
If the main incision is performed through the conjunctiva and the
wound does not seal well during manipulation you will experience
a ballooning of the conjunctiva (Figure 12).
In case of ballooning of the conjunctiva, you have to perform a
conjunctival incision close to the conjunctival opening or enlarge
the conjunctival opening in order to create a passage for the fluid.
You have to open the Tenon too to push out the water. Press out
the water firmly (Figure 12).
Chapter III: Corneal Wounds

Figure 12

Conjunctival ballooning will decrease the visibility for the cataract

procedure since water will collect in front of the cornea.
If you know that you have to deal with a rock-hard cataract then
put the phaco tunnel backwards, meaning that you do not perform
a clear cornea incision, but a sclero-corneal incision. The cornea
will benefit from this position since corneal burns may occur due
to excessive phaco power.
A sclerocorneal approach is normally also safer, brings less
corneal burns, is self-sealing and induces less astigmatism.
Check the eye pressure before you enter the eye! Especially after
having performed a retrobulbar injection or in eyes with known
high intraocular pressure. If the IOP is too high then first press
on the eye for 1-2 minutes. If still too high then do it again. If still
too high you may even use intravenous mannitol to lower down
the pressure ((not working well in vitrectomized eyes), and check
with anesthesiologist, if patient is able to take mannitol).
If you know that you have a high intraocular pressure before the
operation, give carboanhydrase inhibitors preoperatively. This
is also a good idea if you have a patient with shallow anterior
Essential Principles of Phacoemulsification


Consider it as one of the most important steps in phaco cataract

Since it is a very important step: take your time!
You should exercise the procedure on an aluminium film, a tomato
skin or other tissues before trying it on a human eye.
You may have the opportunity to use preformed cystotomes or
cystotomes bended by your operation staff. If not, then you need to
practice the bending.
If the needle is not bended correctly, you need another one.
If you do not want to work with the cystotome, you may pinch
the capsule on purpose during the paracentesis or tunneling
procedure. It is easier then to grab the border with the forceps.
As a beginner you should start with a colored anterior capsule.
Use a dye (Vision Blue for example) in order to concentrate on your
maneuvers in the eye.
You may directly inject the dye through the paracentesis (before
OVD!) or you may first inject an air bubble in the anterior chamber
and then put in the dye. Afterwards you need to flush the anterior
chamber several times until you have a clear view.
Capsulorhexis must be around 5mm, not too big and not too small,
but better a little too big then too small.
Essential Principles of Phacoemulsification

The size of the rhexis should not be bigger than the lens optic you
plan to put in.
In a large pupil stay always 1.5 mm away from the border of the
pupil. This will give you a nice rhexis.
Stay always within the central 8 mm. This will avoid that you get
into the zonules (Figure 13).

Figure 13

Must be curvilinear and round. The correct name for the good
capsulorhexis is CCC for continuous curvilinear capsulorhexis.
Just do it like the name says (Figure 14).

Chapter IV: Capsulorhexis

Figure 14

As a beginner you better start the capsular incision in the center

or paracentral. This gives you a certain security margin. You will
then be able to create a flap and curve the rhexis before it reaches
the periphery (Figure 15).

Figure 15
Essential Principles of Phacoemulsification

As a beginner, use two hands during this procedure. The dominant

hand is holding the rhexis instrument and the other one helps to
guide it.
Since the cataract wound acts as a pivot (especially the small
paracentesis wounds), pivot your hands in the opposite direction
that you want to have your instrument tip to move. If you want to
have your tip moving downwards, then your hands must move
upwards (Figure 16).

Figure 16

You can perform capsulorhexis through all corneal incision (main

incision and small paracentesis). The paracentesis approach
will help you to keep a deep anterior chamber, but you have less
mobility of the instrument. The main incision approach gives you
more space to move, but OVD can also come out easier and flatten
the anterior chamber.
The cystotome can be used through all corneal incisions, the
forceps not
Do not push too much down on the corneal wound while doing the
rhexis. OVD may come out and the chamber will flatten and you
may also experience folds in the cornea with reduced visibility.
Capsulorhexis procedure can be performed either by a shearing
technique or a ripping technique. You may use both techniques
during one operation (Figure 17).
Chapter IV: Capsulorhexis

Figure 17

The shearing technique consists in pulling the created flap in the

direction of the wanted direction (Figure 18).

Figure 18

Essential Principles of Phacoemulsification

The ripping technique consists in pulling the flap more towards

the center of the capsule. You have to pull the flap at a point much
closer to the tear than with the shearing technique (Figure 19).
With the ripping technique you pull the tear more towards the
center of the pupil (Figure 19).

Figure 19

You have to train these two capsulorhexis methods first. Use an

aluminium film, a tomato skin, other films or skins, or try it in a pig
eye. You will be more confident to approach a human eye.
Watch always the direction of your tear. If it is going straight
outwards (radial), then it will keep on going out until you react. If it
is circular, then it will normally stay in a circular path (Figure 20).

Chapter IV: Capsulorhexis

Figure 20

If you find your rhexis heading straight out, then stop immediately,
inject OVD over the tear, and then use the forceps to make a sharp
turn inwards to prevent radialization: grab the end of the flap right
where the rhexis is heading out and then pull inwards, somehow in
the direction in between radial towards the center and tangential!
And stay always on the surface of the lens! (Figure 21).
To redirect the tear you have to act on the flap close to the
evaluating tear (Figure 21).

Figure 21

Essential Principles of Phacoemulsification

If you are unable to redirect the tear since it extended peripherally

then begin a new tear on the opposite side with cystotome, with
capsular scissors or change to electro-capsulorhexis procedure.
Do not move the cystotome or the forceps in the anterior cortex.
You will have difficulties to distinguish the border of the flap.
If you have difficulties to identify the border of the flap then inject
OVD towards the probable direction of the running flap. If you still
cannot see the flap margin then use capsular scissors to create a
new tear or use the electro-capsulorhexis device.
Avoid doing a discontinuity of the rhexis. Therefore do not hit the
capsule during paracentesis or tunnel preparation and finish the
rhexis from outside in and not the other way round.
If you have a discontinuity in the rhexis, then repair it if possible.
Beginners should colour the anterior capsule with dye. It is easier
to see the rhexis margin and safer. Flush out the dye just after dye
injection with BSS (you have to go in the anterior chamber with the
tip of the cannula to flush out all the dye). But do not mix up the dye
with OVD, otherwise you will get a blue mass and bad visualization.
PEX-syndrome, uveitis and retinitis pigmentosa will increase the
difficulty to perform a capsulorhexis due to thickened anterior
capsule (be prepared, but not scared!!!). Create an adequate rhexis
size in these eyes, since shrinkage occurs more often here over
time and you should not end with a capsular shrinkage syndrome
/ capsular phimosis here.
Atypical CCC behavior also in children and juveniles. In these
cases do not perform a large rhexis, since the rhexis will enlarge
0.5-1 mm after completion of the rhexis due do elastic behavior of
the anterior capsule.
Put OVD with the blunt needle tip starting at the other side of where
you enter the eye. This will push away all bubbles back through the
main incision. Press the inferior lip of the tunnel a little down- the
bubble will come out easier (Figure 11).
A shallow anterior chamber indicates that the vitreous pressure
is higher than the anterior chamber pressure. Of course there
are some eyes with anatomically shallow anterior chamber
Whatever, you need to deepen this anterior chamber in order to
work safe in the eye (Figure 22).
Chapter IV: Capsulorhexis

Figure 22
A shallowing anterior chamber results in an anterior displacement
of the lens and therefore zonular stress. These forces are creating
tension on the anterior lens capsule. Performing capsulorhexis
under these circumstances will lead to peripheral propagation of
the tear (Figure 22).
You need always OVD ready to inject while performing the rhexis
(Figure 23).
Always deepen the anterior chamber!!! In doubt / if the rhexis is
going outwards / if the chamber flattens / if the flap is not seen
clearly, then refill the anterior chamber for safety (Figure 23).

Figure 23

Essential Principles of Phacoemulsification

If the rhexis situation is unclear or a large tear was created

towards the periphery, then never ever let the anterior chamber
flatten. Put Viscoelastic even before exiting the chamber with the
irrigation instrument (phaco tip or I/A-tip).
Always perform the rhexis with an OVD like Viscoelastic or Healon.
The rhexis is easier performed with OVD since the anterior
chamber is more stable.
If the iris is protruding through the wounds, you have a major
problem. But you will have to deal with it. Remember, that if the
iris protrudes once, it will come again and again The problem
is that the iris is very mobile and the pupillary margin is located
central to the inner corneal wound opening. Try to get the iris out
from the paracentesis with a spatula. Reduce the flow in the eye
(put the bottle down) and deal with minimal OVD for the rhexis.
Eventually you have to perform another tunnel.
Iris will protrude through the wound in eyes having had pupillary
stretching due to small pupils, posterior synechias, etc. and in
floppy iris syndrome. In these cases do initially not fill the chamber
from the other side with OVD, but start directly at the tunnel,
eventually start even through a paracentesis and put OVD under
the tunnel. This will give you some space. And do not overinflate
the anterior chamber.
OVDs are classified in cohesive (like Healon, Healon GV, Provisc,
etc.) and dispersive (like Viscoat,). Special products like Healon
5, Duovisc and Discovisc include both behaviors, cohesive and
adaptive. Cohesive describes the physical pattern that the fluid
wants to stay together (best to maintain space and create space).
Dispersive means that it provides good tissue protection (best to
seal off and to coat).
Remove air bubbles in placing OVD distal from the entry site and
force them out. Then put BSS or Methylcellulose or Viscoat on the
cornea before doing capsulorhexis. Adjust the microscope to have
the anterior capsule sharply visualized. You should have a perfect
vision while performing the rhexis.
Enlarge the image of the microscope, but not too much.
Take your time doing the rhexis, but be quick in white and/or
intumescent cataracts.

Chapter IV: Capsulorhexis

Use needle first, as long as possible. If rhexis is going out, then

refill the anterior chamber and then use the forceps. Pull the
rhexis margin directly at its end, flat on the surface of the lens,
towards the center and a little in the direction the flap should go.
This will redirect the flap (Figure 21).
In very soft cataracts, fluid cataracts and dislocated lens, first
pinch the anterior capsule with the cystotome (or even directly
with the forceps) and then continue with forceps.
In forceps rhexis stay always close to the lens surface while tearing
the flap, otherwise your rhexis will run out (Figure 24).

Figure 24

Do not go too much in the periphery, especially in widely dilated

pupils. You may get into the zonules and will be in trouble
(Figure 13).
The most difficult part of the rhexis is the 12 oclock position (if
you work with the main incision approach) since corneal striae are
often produced by wound distortion. You can avoid this difficulty by
changing from the main incision to a paracentesis.

Essential Principles of Phacoemulsification

If a rhexis is trying to run out all the time from the beginning
although the chamber is deep, then use forceps and be quick!!!
The target is then to make a small rhexis, but CCC-type. Even
when the rhexis is small, it is still better than a rhexis running
out. You can always enlarge the rhexis, but a tear will stay a tear
Performing the rhexis through the paracenteses will provide you a
stable chamber and the rhexis can be performed safely.
If the rhexis is too small, then enlarge it. The area of enlargement
is not the most important, but if it is too small it has to be enlarged,
where it is easier to access. Use scissors and come through the
main port. Use them in a horizontal manner, meaning that you do
not have to cut the anterior rhexis vertical like you cut paper. Just
put one scissor end under the anterior capsule and cut fast (only
A too small rhexis will lead to problems during all the following
steps. Therefore better enlarge it in the capsulorhexis procedure:
after 360 degree just pass outside of the initial beginning of the
rhexis and continue the rhexis there as much as possible (called
spiral enlargement). If this does not work, then use scissors and
enlarge with forceps.
If a rhexis is just a little too small then enlarge it after placing the
If the rhexis is too big, then forget about it. This is not a serious
issueYou may have the lens coming out of the bag during
hydrodissection and you will have to put it back in the back
afterwards. At the end of the surgery you will then have to be sure
that the haptics are both in the bag. If the IOL shows a tendency to
pull forward, use a miotic agent in order to keep the IOL where it
should stay.
In white cataract: first pinch the central capsule with the needle.
If fluid is coming out of the bag, continue with the forceps (since
there is a fluid filled bag, the needle has no contra-pressure and
needle rhexis does not work properly). Try to perform a very small
(the rhexis will always try to run out!) and quickly performed
forceps rhexis. This will give you a normal sized rhexis. If, after
initial puncture of the capsule, there is no fluid coming out, then
needle rhexis is possible, but perform it quick and always fill the
chamber with OVD.

Chapter IV: Capsulorhexis

In white cataract or cataract under tension try to perform a

small rhexis (do it quick!), even if it is too small at the beginning. It
is easier to enlarge it with scissors and then with the forceps than
having a capsulorhexis tear going out.
Remember: in a tense bag the rhexis will always try to run out.
Always deepen the anterior chamber and be quick!!! If you are to
slow, the rhexis may run out without doing anything I think you
remember the Argentinean flag sign
If there is evidence of zonular laxity during the case, then consider
placing iris hooks to stabilize the capsular bag. You do not have
to place 4 iris hooks, but just enough to hold the bag at the place
where zonula support is gone.
If you expect a posterior capsular defect like in congenital posterior
cataract then make a smaller capsulorhexis. If the posterior
capsule is defective you place the IOL in the sulcus and capture
the optic within the anterior capsulotomy.
Cataract surgery through small pupils is dangerous! This is
nothing for beginners
Do not overinflate the anterior chamber with OVD while putting the
iris retractors. You will have problems to reach the pupil margin
since it is way back.
In eyes with small pupils try first to enlarge the pupil
pharmacologically with dilating drops or intracameral with
epinephrine 1%. If this does not work, try to slightly overinflate
the anterior chamber with OVD (OVD-dilatation) and stretch the
pupil mechanically with two instruments and release posterior
synechiae. If the pupil is still too small then use 3-4 iris retractors
90 degrees from each other or a Malyugin ring.

Essential Principles of Phacoemulsification

Hydrodissection /

The goal of hydrodissection/hydrodelineation is to free the lens

from the adhesion to the capsule. The applied forces during
phacoemulsification and manipulation will be less forwarded to
the zonules.
If the lens turns/spin in the capsule, the hydrodissection was
successful. You can check that with the injection cannula or
another instrument.
Before you perform a hydrodissection or a hydrodelineation, you
should know how the lens is built. From outside you have first the
lens capsule, then the cortex, the epinucleus and last the nucleus.
You have to understand the anatomy in order to realize what you
are doing (Figure 25).

Figure 25

Essential Principles of Phacoemulsificationy

Always perform a hydrodissection !!! But be careful in posterior

polar cataract, perforating lens trauma or post vitrectomy cataract.
In congenital posterior cataract you have to be careful since a lot
of these cases do have a posterior capsular defect. A good way to
deal with that is to perform first a hydrodelineation and to remove
the nucleus. Afterwards you may perform a hydrodissection and
remove the cortex.
If you drop a piece of nucleus into the posterior chamber you may
probably have to ask a vitreoretinal (VR) surgeon to remove it from
there. A cortex loss is usually less of a problem. Therefore it is
safer first to perform hydrodelineation in cases where you expect
to have a posterior capsular weakness in order to remove the
Put the infusion cannula between lens capsule and cortex 1mm
from the border of the rhexis towards outside and flush relatively
quick (Figure 26).

Figure 26

A good advice is also to slightly push the tip of the cannula up to

the capsule before you are injecting. The water will find the way
easier like that (Figure 27).

Chapter V: Hydrodissection / Hydrodelineation

Figure 27

Do not push the syringe aggressively during hydrodissection. You

may blowout the posterior capsule But if you push the syringe
too little, nothing will happen (Figure 28).

Figure 28

Essential Principles of Phacoemulsificationy

You may start to inject fluid just before entering the subcapsular
space during hydrodissection. Push then the cannula forward and
continue to inject fluid until you see the wave passing to the other
Remember to inject continuously during hydrodissection/
hydrodelineation and not to withdraw the cannula during injection.
As soon as you move the cannula backwards the water may found
an easier way to get out of the subcapsular area instead of passing
behind the lens.
Overinflating the capsular bag during hydrodissection can produce
a shallowing of the anterior chamber or a capsular rupture.
Depress the nucleus several times during hydrodissection in order
to push to fluid back in the anterior chamber (Figure 29).

Figure 29

Push the lens back in the back after every injection phase. First,
to avoid prolapse of the lens in the anterior chamber, especially
in large capsulorhexis. Second, to avoid high pressure in the
posterior between lens and bag due to compartment syndrome
(you may break the posterior capsule) (Figure 30).
Hydrodissection at one position may be enough to loosen the
capsular-cortex connections, but better perform it at two positions.
With hydrodissection you cleave the cortex from capsule. Look for
a fluid wave. Dont stop till the wave is passing to the opposite
side! (Figure 30).
Chapter V: Hydrodissection / Hydrodelineation

Figure 30

Hydrodelineation (cleaving the epinucleus from the nucleus) is

certainly not always mandatory for cataract surgery, but it is a good
help in case of zonular laxity and congenital posterior cataract.
In congenital posterior cataract you have to look at the water wave
as it passes the posterior pole. If it behaves strange, then perform
hydrodelineation. A good advice is also to avoid turning the lens in
the bag in these cases. These cataracts are normally very soft and
can be removed mainly by suction.
Hydrodissection in an OVD-overfilled anterior chamber can be
dangerous since it may cause a posterior capsular rupture.
You may release some OVD through the main injection prior to
Use the main incision (tunnel) for hydrodissection and
hydrodelineation. You push in fluid and if you would go through the
paracentesis wounds, the pressure in the anterior chamber would
increase and help to rupture the posterior capsular bag. Working
through the main incision will permit water to come out of the eye
and compensating for the fluid you are flushing in (Figure 31).
Essential Principles of Phacoemulsificationy

Figure 31

For hydrodelineation, point the cannula a little downwards and

forward in the lens until you see the lens moving slightly. You will
be then at the right position to inject fluid. Look for the golden ring
sign creation during fluid injection (Figure 32).

Figure 32

Chapter V: Hydrodissection / Hydrodelineation

Point the cannula towards downwards and forward in the lens

until you see the lens
Always check after hydrodissection, whether lens is turning in
the bag! Rotating the lens ensures that the job is done. If the lens
does not rotate then you will not be able to perform the cataract
extraction nicely (Figure 33).
A lens that dropped out of the bag during hydrodissection should
be pushed back if possible. You do not have to rotate it thereafter
since it is already free
The lens should spin freely in the bag!!! (Figure 33).

Figure 33

Always perform hydrodissection through the main incision. You

put fluid in the eye and the fluid should have no problems to get
out of the eye (Figure 31).
Look for a fluid wave passing behind the lens. Do not stop injecting
as soon you can see it. Continue until it reaches the other side
(Figure 30).

Essential Principles of Phacoemulsificationy

After each try, push the lens back into his bag. With this maneuver
you break the firm equatorial cortico-capsular adhesions and
the lens gets free. Otherwise you just push more BSS behind the
lens creating high pressure there and risking a posterior capsular
rupture (Figure 28).
Hydrodissection is more difficult to perform in very large rhexis.
With a very soft cataract it is difficult or even impossible to put the
lens back in the bag. Therefore do not overdue the dissection.
If hydrodissection fails, then try again at a different spot, increase
force, or use bursts and gently push on nucleus between bursts.
But remember: be careful in posterior polar cataract, perforating
lens trauma or early post vitrectomy cataract. If it does not work
in the first attempts in these cases then skip it and perform
Hydrodelineation is separating the outer epinuclear shell from the
compact mass of the harder inner nuclear material (endonucleus).
To perform hydrodelineation point the cannula in the lens until it
moves (you reached the harder endonucleus) and now gentle
inject BSS until you see a golden ring or a dark circle (Figure 29).
Hydrodelineation is difficult to see in hard cataracts.
If Hydrodissection still fails, then perform hydrodelineation.
If the rhexis is too small or not curvilinear due to a tear towards
the equator, then flush slowly. Soft hydrodissection is used also
in a very soft cataract (the lens will otherwise be expelled to the
anterior chamber and you will not be able to put it back in the bag)
and in posterior polar cataract.
In case of a posterior polar cataract or extended rhexis do not
persist in doing Hydrodissection. If it does not work in a soft
manner or if you cannot turn the lens in the bag, skip it and
perform hydrodelineation.

Chapter V: Hydrodissection / Hydrodelineation

The Hydrodissection often fails in cheesy cataracts.

The sign of nicely performed hydrodelineation is the golden ring
sign (in hydrodissection you see only the fluid wave passing).
If the lens is not turning after hydrodissection, then perform the
hydrodissection again. If still not working (even if you have seen
the waterfront passing behind the lens), then dont try hard (there
may be a peripheral or posterior cortical-bag adhesion / scar,
which does not loosen). Make a hydrodelineation and then one
central groove with phaco. Crack directly and then try to turn the
nucleus just a little while holding the phaco tip towards the wall
of the nucleus (called oblique chopping). Plant the phaco tip in the
nucleus and then chop one piece and eat it directly. Continue this
procedure and finish the lens like this.
In mature white cataract there is not much cortex left. Perform
hydrodissection, but slowly. Even when you are not able to see the
waterfront turning behind the lens try to turn the lens in the bag.
Normally it works quite well. If not then hydrodissection is used
again and try to turn again. If the lens is not turning, then leave it
and start phaco with one central groove.
Turn the lens in the bag with the chopper (it is easier to perform
than with the cannula). You should clearly see that the lens is
turning (Figure 33).
In pseudoexfoliation syndrome you need a good capsulorhexis and
a perfect hydrodissection. Do not try to rotate the nucleus until
you are certain that the hydrodissection is well done and rotate it
with as little stress for the zonula as possible, eventually use two
instruments for rotation.

Essential Principles of Phacoemulsificationy


If you do not use the phaco tip properly, it is more a weapon in the
eye than a help for you (Figure 34).

Figure 34

Essential Principles of Phacoemulsification

Use the phaco tip correctly and you will have a safe
phacoemulsification procedure (Figure 35).
Increase your chamber depth during phacoemulsification. You can
use the phaco tip through a small incision and thereafter enlarge it
for IOL implantation. But be careful because of the corneal burns
since the sleeve can easier be occluded in small wounds. And you
can elevate the infusion bottle if you have performed a good and
tight incision. A leaky incision will otherwise increase the flow in
the eye and create turbulences.
Phacoemulsification is easier to perform in an eye with a good or
slightly increased intraocular pressure. You will encounter less
corneal folds and therefore have better visibility. The eye is more
rigid and the manipulations are getting easier. The ability to attract
lens fragments is also increased.
You have to adapt the phaco power to the situation.
Be careful with phaco power and aspiration if you move your tip
close to the rhexis rim, close to the iris, close to the endothelium,
or close to the posterior capsule and at the inferior nuclear rim
(Figure 35).

Figure 35

Do not press or create distortion on the main incision as the

phaco tip moves in the eye. Learn to use the incision as a fulcrum.
Otherwise you will encounter corneal striae with a bad visualization
and a leaky wound (Figure 36).

Chapter VI: Grooving

Figure 36
Always full speed at the beginning in the safe zone!!! Like if you
want to make a race and the lights turn green: full power with
Phaco-1 program (Figure 37).
From the border of the proximal rhexis to the other one. Thats
your race distance (Figure 37).

Figure 37
Essential Principles of Phacoemulsification

Be careful with the phaco power whenever you leave the central
safe zone! (Figure 35).
Go deep centrally, but not too deep peripheral!!! The lens is
spherical and not like a brick (Figure 38).

Figure 38

The groove will be deeper opposite to the tunnel. But do not forget
to groove the proximal part also
If the globe is moving downward during grooving for example,
then insert a spatula through a paracentesis to counteract this
If the lens is moving downward during grooving and you have
enough phaco power, you have lax zonules. You may counteract
the force by using a second instrument on the lens.
In a lax zonule situation you should not pull or push on the lens.
You may have to increase the phaco power and then let the tip
of the phaco work on the lens without pushing the lens forward
(Figure 39).
In lax zonule situation some surgeons are holding the capsular
bag with iris retractors hooked at the capsulorhexis margin.

Chapter VI: Grooving

Figure 39

Do not perform a groove with minimum width in a hard nucleus.

You may occlude the sleeve the deeper you groove and will then
have reduced irrigation (Figure 40).

Figure 40

Essential Principles of Phacoemulsification

Do not perform a large groove width in a soft nucleus. You will

have problems to crack it and end up in a lens bowl.
The deeper you get, the more you have red reflex. The red reflex
should shine like a down going sun. Then you are deep enough
(Figure 41).

Figure 41

As soon as the groove gets quite deep, you should not go full
power any more
If you have to attack the central deep fibers, then dividing is easier.
But remember to stay always on the safe side. Too deep is too
You have to consider the grooving to the posterior pole as a polar
expedition. Go all the way down until you reach a thin layer of
epinuclear material. You have to get there!!! Thats a key of success
(Figure 42).

Chapter VI: Grooving

Figure 42

Only by this polar expedition you will obtain the mechanical

advantage required to fracture the entire lens (Figure 43).

Figure 43

Essential Principles of Phacoemulsification

If the center of the nucleus is not thin enough you will not be
successful in dividing (Figure 42).
Remember: a very soft cataract will be grooved with just one or
two full power races.
Dont push the nucleus to hard downwards or towards inferior
while grooving, especially in hard cataracts. The zonules may not
forgive you that increase the phaco power and let the tip make
the work. In between the races you should let the phaco tip cool
down with a pause. The cornea will benefit from this pause
(Figure 44).

Figure 44

Grooving a hard nucleus stresses the zonules. You may use a

second instrument to counterforce the forward movement of the
phaco tip and stabilize the nucleus.
If the zonules are extremely lax, then convert to ECCE or elevate
the nucleus and perform phaco in the anterior chamber. You can
also put iris hooks and stabilize the lens capsule at the rhexis.
A hard nucleus must be sculpted very deeply before cracking and
you may still not see the red reflex Shiny reflective and fasery
lens material will indicate you that you are deep enough
(Figure 41).
Chapter VI: Grooving

A hard nucleus is difficult to crack, especially the central portion.

You still may be not deep enough. In these cases after having
performed one central groove, you can try to crack the nucleus
first in two hemi-nuclei. Thereafter you groove the two parts to
prepare for cracking too.
The lens should not move much during grooving. Optimal grooving
is achieved when the lens nearly does not move. This implicates
that in hard nucleus you have to increase the phaco power. If the
lens still moves then go full power, but slowly. If the lens still
moves, then do not groove with the tip completely embedded in
the nucleus (Figure 39).
As a beginner try the divide and conquer technique first. You will of
course have to learn all four techniques at the end to be a complete
cataract surgeon.
Turn the nucleus either with the second instrument or with the
phaco tip until you have it in the optimal position. Use the wall of
the groove as a counter bearing to turn (Figure 45).

Figure 45

Essential Principles of Phacoemulsification

But, if the rhexis is not curvilinear / in very soft cataract / in bad

hydrodissection: perform first one groove and then divide. If
dividing is not possible then try to chop or change to chip & flip,
especially in a very soft cataract.
There is a kind of rule regarding the hardness of the nucleus: in a
G1 cataract you may have to groove once or twice with full power
to be through the nucleus, in G2 twice or three times, in G3 and G4
more than three times.
A special situation is the cheesy cataract. It is difficult to divide.
Try, if not working then you have to stop & chop or even chip & flip.
Adapt to the situation!!!
The more bubble you get during phaco power application the
harder the cataract Sometimes you have to get these bubbles
out for better visualization!!!
During grooving the visibility may get bad. Often it is due to
fragments of phacoemulsificated nucleus, cortex or epinucleus
pieces, and air bubbles. Get rid of these and then continue. You
have to see what you are doing!
If you have an instable anterior chamber, first check that you are
not pushing on the posterior wall of the tunnel. You are creating a
lot of outflow while pushing on the wound (Figure 46).

Figure 46

Chapter VI: Grooving

In instable anterior chamber during phacoemulsification check

that you are not pressing on any wound. You may even have to
remove the other instrument and stay in the eye only with the
phaco tip (Figure 47).

Figure 47

If you have an instable anterior chamber and you are not pushing
on the wounds, then increase the bottle height, check the tubing
and fluid level and decrease the flow. If the corneal wounds are
leaking then consider suturing the leaky wound or just one end of
the wound.

Essential Principles of Phacoemulsification

Divide & Conquer

A good starting technique/method for beginners. A good method

at all!!!
Easy: first make two large and deep grooves in the nucleus and
then divide into 4 pieces (Figure 41).
After 2 deep grooves in the nucleus put the phaco tip deep in the
center and the Nagahara chopper in front of it (not beside!), push
first down and then to the side to divide (Figure 43).
Put the instruments as deep as possible within the groove!
If you try to divide the lens in his center or above, you compress the
floor of the lens instead of dividing it (Figure 48).

Figure 48
Essential Principles of Phacoemulsification

Push the lens first down and then to the side! (Figure 43).
It does not matter to which side you push each instrument
(chopper or phaco-stick), but push first down and then opposite to
each other to the side!!!
To divide the nucleus you need walls on each side of the
instruments. Dividing in a cup is quite difficult
Do not destroy your walls while sculpting not precisely.
If you try to crack the nucleus but you act not deep enough then
you may separate the two walls of the nucleus, but the posterior
part of the nucleus will be more compressed instead of being
cracked (Figure 48).
Be sure that the cracking is complete. You may have to crack
several times Well, the central part or the very peripheral part is
sometimes not well cracking (Figure 49).

Figure 49

Crack the nucleus completely!!! (Figure 50).

Chapter VII: Divide & Conquer

Figure 50

If a nucleus piece is coming out of the bag, then eat it! If the
nucleus piece in the anterior chamber is too big to be eaten fast,
then chop it.
You have to feel/see the weakness of each cataract and cataract
piece. Attack it at his weakest point, but remember: always be
safe! (Figure 51).

Figure 51
Essential Principles of Phacoemulsification

If dividing is not possible and you still have nice walls of the
grooving then groove deeper, especially in the center and try again
If dividing is not possible any more due to bowling/cupping of the
nucleus (no walls any more from the grooving), then change to the
chip and flip strategy. Take one half out of the bag into the anterior
chamber and then chop it vertically.
Take the pieces out of the bag one by one with phaco opening
towards the pieces. This will create a faster occlusion (Figure 52).

Figure 52

During eating lens fragments in the anterior chamber put the

phaco opening to the side or downwards (the cornea will look
better the next day).
For the last piece do not put the phaco opening downwards (you
may bite the posterior capsule) (Figure 53).

Chapter VII: Divide & Conquer

Figure 53

After dividing, take out the second instrument. So unnecessary

leakage will be prevented and the chamber stability will be
excellent (an easy way to prevent surge).
For the last pieces: take care of the bag and never attack these
last pieces too aggressively with phaco power towards the capsule
(Figure 54).

Figure 54

Essential Principles of Phacoemulsification

For the last pieces: try to create occlusion at his thickest point
and then lift it up in the aspiration mode towards a safer zone for
phacoemulsification (Figure 55).

Figure 55
Stay in the center of the anterior chamber with the phaco tip
while eating the pieces. Do not pull out the tip while doing phaco
power or aspiration, otherwise the anterior will collapse since the
infusion is located behind the tip opening and may get out of the
eye (the posterior capsule is in danger)
If you are able to perform a crack in soft to very soft cataract, then
continue in divide and conquer (groove deeper and try also the 90
groove). If still not possible to crack, then skip to chip and flip.
Remember. It is still easier to deal with the grooved nucleus or
even better with half of the nucleus than with the whole lens
Try first to get the small pieces out in the anterior chamber after
cracking. It is easier thereafter to get out the bigger one
If there are some nuclear fragments that want to come out. So let
them come out of the capsular bag and eat them! Take the easier
one first. The others will then come easier
To take the nucleus fragments out you have to adjust the phaco tip
opening to the piece. Turn the opening to the side or tilt it a little

Chapter VII: Divide & Conquer

down in order to create a good occlusion at the tip. You have to

learn to play that game. It will get easier with time and less time
As soon as you have one piece of nucleus left in the bag, you may
change the phaco machine settings from phaco-2 into phaco-1.
You reduce the vacuum and therefore are in safer settings for the
posterior capsule.
If you get out a quite big piece in relatively soft cataract then try to
hold it on one side (not in the center). You will probably be able to
eat it up easier like that. In harder cataract you take them out in
the center and then chop them.
If one piece is too big and lies in the anterior chamber, then make
it smaller, especially in hard cataracts, meaning that you have to
chop it horizontally. Otherwise the corneal endothelium suffers.
To avoid corneal burns, do not use phaco for more then 3-5
seconds, especially during conquering of hard nucleus pieces. Let
the phaco instrument cool down and then re-use phaco power.
To keep the nucleus fragment close to the tip during phaco
pauses (cooling pauses), use just aspiration. The piece will
have time to readjust towards the phaco tip.
Remember: vacuum without phaco power is much stronger then
with phaco power!!!
Use high vacuum for a soft nucleus. It will help you to bring the
peripheral nucleus towards the safe zone.
If the chamber is unstable, then watch out for the reason. There may
be too much flow coming out from the cornea wounds. Especially
look for the paracentesis wound of the second instrument. Taking
out the second instrument while finishing with the quadrants, may
stabilize the anterior chamber and make the surgery safer
If you plan to do divide & conquer, or what technique ever, then
do it. Do not change the technique too fast, just because it did not
work in the first attempt. You may end in trouble since no technique
will finally help you to get the lens out of the eye...

Essential Principles of Phacoemulsification

If you know that there must be a hidden nuclear fragment,

then search it! They are often difficult to find in eyes with well-
established arcus senilis or with small pupils. You may flush the
side ports and the main incision to find them (Figure 56).

Figure 56
Never leave a nucleus piece in the eye! You will have problems after
the surgery with prolonged inflammation and high intraocular
If you have an epinucleus cup left after taking out the nucleus, try
to aspirate it on side and flip it. Otherwise use a blunt instrument
to push it towards your phaco tip and eat it, while taking care of the
posterior capsule (Figure 57).

Figure 57

Chip &

Use it in very soft cataract or in every situation, where dividing

is not possible any more due to cupping of the nucleus or soft
cataract (Phaco-3 program).
First you perform a hydrodissection, otherwise too much stress is
exerted towards the zonules.
There are two ways of chip & flip.
The first way of chip & flip is the classic one, where you make first
one groove central and then make grooves paracentral in each
direction to bowl out the nucleus (Figure 58).

Figure 58
Essential Principles of Phacoemulsification

The second way of chip & flip is the alternative way. You make a
deep groove central and then divide the nucleus like in divide &
conquer, thereafter you bowl out the nucleus (Figure 59).

Figure 59

Groove out the nucleus like a cup and then chip the epinucleus/
cortex with vacuum (do not use phaco power if possible) at
different places in the periphery until the lens will flip, then phaco
(Figure 60).

Figure 60

Chapter VIII: Chip & Flip

Take care of the capsule while chipping (Figure 61).

Figure 61

You have to turn the epinucleus while chipping. Suddenly it will

flip. Then you have to hold it with the phaco tip. Use just little
phaco power to emulsify the nucleus.
Chip and flip technique is easier handled with the nucleus divided
in two pieces (alternative way of chip & flip).
If you are able to divide the nucleus once in soft cataracts, you can
also chip one half out of the bag and finishing it and then the other
one. It is really a nice method to deal with softer cataracts.
The chip & lip method is a nice method safety variant if you
destroyed your walls in divide & conquer method and you are not
able to crack the nucleus any more. Changing to the classical chip
& flip is a perfect way to complete your cataract operation in these
Take care of the endothelium

Essential Principles of Phacoemulsification

Stop &
A good method to avoid stress towards the zonules.
In case of zonular dehiscence you better chop than groove. You
produce less stress towards the zonules while chopping.
A fast method, but for advanced cataract surgeons. (Phaco-2
Stop & chop is a nice way to learn chopping.
For moderate to hard cataracts. Not ideal for soft cataracts
Stop means that you start with a normal divide & conquer method.
You perform one deep groove and then divide the nucleus in two
pieces by cracking it. You stop the divide & conquer method at this
point and start chopping (Figure 62).

Figure 62

Essential Principles of Phacoemulsification

First perform a deep groove. You may eventually turn the lens 180
to groove also in the other direction. Then crack it and turn 90 and
let the phaco tip work his way in the central nucleus with some
power. Then hold the nucleus half with vacuum and chop either
horizontal or vertical.
To attack the nucleus with the chopper it is better to remove the
epinucleus first.
Removing the epinucleus in the area of the opened capsule will
allow you to get directly in contact with the nucleus.
Horizontal chopping is when you come around the nucleus from
behind towards the phaco tip. In vertical chopping you plant the
chopper into the nucleus from upwards and then chop towards the
phaco tip.
Chopping in the bag is normally done in a horizontal way, but as
you get more experienced you can chop vertical in the bag.
Chopping out of the bag is either horizontal or oblique. You cannot
chop vertical out of the bag.
Not all chop instruments are adequate to perform all types of
chopping. The Nagahara Karate Chopper for example is able to
perform vertical, horizontal and oblique chopping.
The chopping is performed with the chopper in left hand and the
phaco tip in the right. Chopping movement is (after correctly placed
the instruments) chopper towards left side. Crossover movements
are not well working in chopping (in contrast to cracking the
nucleus in divide and conquer).
Stop the nucleus from moving with planting the phaco tip deep in
the nucleus (first give a little phaco power, then hold the nucleus
with vacuum).
Remember: you cannot hold the nucleus while you are using phaco
power! The phaco power is to get deep in the nucleus.
To prepare for chopping you have to bring the phaco tip at least in
the middle of the nucleus and keep it there. You may impale the
tip into the nucleus with first a little phaco action and then hold it
with aspiration, but you dont need always to hold the phaco tip in
aspiration mode. Adapt to the situation!

Chapter IX: Stop & Chop

Horizontal chopping can be performed in- or outside of the bag.

The second instrument is getting behind the nucleus and is driven
towards the phaco tip. You can perform it in the bag, but take care
of the bag(only for advanced phaco surgeons) (Figure 63).

Figure 63

Horizontal chopping is sometimes difficult since you have to pass

the chopper behind the nucleus without damaging the capsule
A safe way to get at the nucleus equator is to slip the chopper
between the epinucleus and the nucleus while still being in contact
with the nucleus. It is easier to reach the periphery if you tilt your
instrument parallel to the iris plane and rotate it back as you reach
the equator (Figure 64).
In horizontal chopping be aware that you have to stay deep in the
nucleus while you are moving the chopper towards the phaco tip.
Towards the center the lens is getting bigger (Figure 64).

Essential Principles of Phacoemulsification

Figure 64

Vertical chopping is performed in the bag, where the phaco tip is

holding the nucleus with vacuum and the second instrument is
planted deep in front of it and pulled to the side (Figure 65).

Figure 65

Chapter IX: Stop & Chop

If the cataract is too hard then vertical chopping is difficult. During

planting the chopper in the lens you may push the lens backwards
while stressing the zonules. Better go under the capsulorhexis
and try to chop horizontally in the bag.
Oblique chopping is for special situations where the rhexis situation
is unclear and therefore hydrodissection is not or incompletely
performed and the nucleus is already divided into two half pieces.
Then turn the nucleus just a little and attack the nucleus (half
piece) in the center with the phaco tip opening turned towards the
nucleus half piece. First give a little phaco and then hold the piece
with vacuum. Now chop from the periphery in an oblique manner
towards the phaco tip. Take the first chopped nucleus part and eat
it directly. Repeat that maneuver as much as possible.
In very hard cataract you may start with one groove and then chop.
You may also directly start with chopping in G2 to G3 cataracts.
Since you will need a lot of phaco power in hard cataracts, better
use the phaco tip opening downwards or to the side while eating
the pieces.
If the lens turns in the bag, then start with one central groove and
then crack. Turn 90 degrees and plant the phaco tip deep in the
nucleus and chop horizontally.
Do a lot of chopping. Small pieces of hard material are easier to
eat then large ones.

Essential Principles of Phacoemulsification

Phaco Chop

Describes the technique, where you directly attack the nucleus

with the phaco tip and then chop as much as you can.
Like in stop & chop you better remove the epinucleus in order to
get a direct access to the nucleus.
Regarding chopping techniques see also chapter IX. Stop & Chop.
Probably the fastest method (in the hand of an experienced
surgeon- you really have to know a lot about cataracts before you
can deal with it).
Only for G2-G3 cataract, sometimes even for G4. But it should at
least not be soft.
Full power with phaco program 1 towards the center of the
nucleus, then plant the chopper in front of it and chop vertically, or
chop horizontally, but take care of the rhexis (Figures 66 and 67).
Good for weak zonules or even subluxated lenses.

Essential Principles of Phacoemulsification

Figure 66

Figure 67

Phaco chop is a nice way for moderately dense or dense nuclei,

but you will have problems to chop a rock hard nucleus or a soft
Phaco chop is a persistent threat to the anterior capsule integrity.
Be sure not to hit the capsule while chopping!!!
Cortex Removal

There are one hand and two hand I/A tips. Both are useful, but
both have to be used a little different.
Stay always in the middle of the capsule with the irrigation tip in
two hand I/A (Figure 68).

Figure 68

Essential Principles of Phacoemulsification

The opening of the aspiration tip should be upwards and go deep

into the bag towards the periphery (Figure 69).

Figure 69
Move the tip in the periphery of the bag under aspiration from
side to side (this will loosen the cortex there) and then pull under
aspiration towards the center (Figure 70).

Figure 70
Always look for the rhexis margins and posterior capsular folds.
In doubt immediately stop aspirating and wait (stay at the same
place but stop aspiration!!!). Do not remove the tip until you
Chapter XI: Cortex Removal

are sure that you did not have caught the rhexis margin or the
posterior capsule. Eventually you have to pull out the I/A content
(Figure 71).

Figure 71
Sticky cortex needs patience
The most difficult part of cortex to remove is the subincisional one,
meaning the temporal or superior one
The most difficult part of lens cortex removal is the superior
subincisional area. An angulated one hand I/A tip helps to get to
this area. In two hand I/A instruments you may have to perform
a third paracentesis at 6 oclock to reach the area or remove the
cortex with bimanual I/A (Figure 72).

Figure 72
Essential Principles of Phacoemulsification

Take care not to aspirate the capsule during cortex removal in

loose zonules. Use lower aspiration flow rate there.
To access the subincisional cortex move the one hand I/A tip in a
rotational movement from left to right (or the other way round)
and turn during that movement the opening first downwards and
then upwards again.
Another point regarding subincisional cortex removal for the two
hand tips is that the paracentesis should not be too close to the
phaco tunnel. You better access the cortex if the paracenteses are
positioned away from the main incision.
Full power aspiration with I/A never with the opening downward
Always watch for wrinkles of the capsule during I/A and always
be sure that you have not engaged the rhexis border. In doubt,
stop the suction immediately and leave the I/A tip where it was. To
panic now is not the right moment
If you are confronted to a capsular star fold during aspiration of
the cortex you have engaged the posterior capsule in the tip. You
are now tearing on the capsule and the zonules Stay calm, stop
aspirating and leave the tip there. Dont move! Now you can use
reflux or the capsule will be free since you stopped aspiration
(Figure 73).

Figure 73
Chapter XI: Cortex Removal

If you move the aspiration tip while you have engaged the posterior
capsule, you will create a tear (Figure 74).

Figure 74
Inadvertent capsular aspirations are usually harmless as long as
you are not moving the tip! Therefore release the foot pedal and
even push the reflux (Figure 71).
Some cataract surgeons are using a capsular polishing program
in order to safely clean the posterior capsule. This program has
very low flow and very low vacuum parameters.
If you encounter large star folds during cortical removal, be aware
of possible zonular rupture. If you are attacking the peripheral
cortex in this area you may even create more ruptures (Figure 75).

Figure 75
Essential Principles of Phacoemulsification

If you have created a hole in the posterior capsule then dont go

out with the instruments. Be sure that the aspiration tip is free
of vitreous and then take it out while leaving the infusion in. Then
fill the anterior chamber with dispersive OVD. Now you can go
out with the irrigation and you have time to think If no vitreous
is present and the hole is small then put the lens in the bag. Do
not use too much aspiration while taking out the OVD Check for
vitreous in the corneal wounds. If you have vitreous in the anterior
chamber prolapsing from the hole then you have to perform
anterior vitrectomy. But remember: never try to pull the vitreous.
You may pull the retina with it Vitreous has to be cut away or
released from the corneal wounds (Figure 76).

Figure 76

Vitreous in the anterior chamber has to be cut or vitrectomized!!!

Never ever pull on the vitreous!
If you encounter pieces of nucleus or epinucleus, you have to help
the I/A opening eating the cortex with a second instrument. You
just move it over the opening and/or push it in.
If the nucleus or epinucleus remnants are too big /hard, you can
either try to get them out by the tunnel in aspiration mode or take
the phaco tip again. Do not chase the remnants, just wait until it
will come to the tip. You may have to go in and out of the eye again
to create turbulences (Figure 77).
Chapter XI: Cortex Removal

Figure 77

If you still have problems to remove the subincisional cortex, then

perform another paracentesis at 6 oclock. You will be able to
access this cortex easier. Remember: dont be lazy. Just do it after
some unsuccessful trying. Stay on the safe side (Figure 72).
If you have a rhexis tear or in very thin and mobile capsule, then try
to get out as much cortex as possible and eventually leave small
cortex amounts. You can either take them out while the lens is
in the bag or leave it there. A YAG-capsulotomy is safer than a
ruptured posterior capsule during phaco surgery
A flaccid posterior capsule is difficult and dangerous to polish.
Put some pressure with a finger on the sclera in order to increase
the pressure from the posterior segment and you will have a taut
posterior capsule that is easier to polish
Do not overdo the posterior capsule polishing. A YAG-capsulotomy
later is still better than a capsular tear
Do not polish the posterior capsule too much. You may polish
vitreous at the end

Essential Principles of Phacoemulsification

Dealing with Vitreous in
the Anterior Chamber

If you deal with vitreous in the anterior chamber then you have to
think about the cause. This may guide your surgical way of treating
the problem and may help you to decide where to put the IOL later
(Figure 78).
So, why do you have vitreous prolapse? Most common it is an
anterior capsular tear extending posteriorly or a primary posterior
tear from your instruments. Besides tears zonular dialysis can
also lead to vitreous prolapse. You may have used too much
force while rotation or pushing / pulling the lens or the capsule
(Figure 78).

Figure 78

Basics of Phacoemulsification Cataract Surgery

If you realize that the chamber suddenly deepens, the pupil widens,
the residual lens material is no longer centered or does not move
normally, that lens particles no longer come to the phaco needle,
then you are into trouble These are signs of vitreous prolapse in
the anterior chamber (Figure 79).

Figure 79
If lens pieces sink to the back of the eye you definitively know that
you are in trouble
Before the lens particle sinks, better use an instrument, for
example a spatula, to prevent it from falling back (Figure 80).

Figure 80

Chapter XII: Dealing with Vitreous in the Anterior Chamber

If you have a posterior capsular tear and no vitreous is seen in

the anterior chamber, then you may be lucky, or do not see the
vitreous If there is really no vitreous, seal the capsular wound
with OVD and continue the phacoemulsification or the I/A or
wherever you are. But do it in a slow manner, reduce the flow and
work away from the tear, thats safer (Figure 76).
If you perform phacoemulsification in the presence of a posterior
capsular tear, then try to create always a complete occlusion of
the phaco tip. This will avoid suction to the vitreous.
If you have a small posterior capsular tear, no vitreous prolapsing
through and still need to remove the cortex, then use I/A with little
flow. Take first the cortex out away from the tear and at the end
the one close to the tear. Eventually, when it seems too dangerous,
leave it and put first the IOL in the bag (or if the tear enlarged, put
it in the sulcus).
If you deal with vitreous in the anterior chamber, then it is important
to take into consideration in what stage of the cataract operation
you are. If vitreous presents early in cataract operation, while you
still have a lot of nuclear material in the eye then clean up is the
most difficult. The vitreous is often around the nuclear pieces and
it can be very difficult to get posterior enough with the cutter to cut
off the vitreous at its source. The risk of losing pieces through the
capsular tear is quite highIt is time to make the decision whether
you convert to ECCE or not. In hard nuclei and in nearly untouched
nuclei better go for ECCE.
Sometimes even with an early loss of vitreous with the
remaining nuclear material you can carefully continue with
phacoemulsification. The most important is to create some
separation between the space with vitreous and the area of
phacoemulsification. You use OVD to create more distance between
these two. And you have to slow down the working pace with a
low bottle height and low vacuum, keeping the phaco tip occluded
in the lens as much as possible to avoid pulling on the vitreous,
working with one or two large pieces (rather than chopping into
many small bits that easily fall downwards). The right way to
continue is therefore slow motion phaco

Basics of Phacoemulsification Cataract Surgery

If you know that you have vitreous prolapse in the anterior chamber,
then first stop phaco / aspiration in I/A, but keep the instruments in
the eye!!! Use your other hand to put in dispersive (not cohesive!)
OVD in the anterior chamber and then you can come out. You will
seal the wound and press the vitreous back (Figure 76).
If you have a tear but no vitreous prolapse, then continue after
having applied OVD!!! If the anterior vitreous membrane is not
broken, then you may be lucky and will be able to finish the case
without dealing with vitreous.
Vitreous is like a bastard in phaco surgery. It is difficult to get rid
of it, but whatever, get rid of him.
Never ever pull too much on vitreous. You may pull the retina too
You have to cut the vitreous!!!. Use scissors or use a vitreous
cutter. While using the scissors you have to cut fast, several times.
Try first with the scissors. If a piece of nucleus is embedded in the
vitreous, then take it with phaco probe and cut below the piece
with the scissors. Cut fast, but controlled, since there are some
other important structures around
If you realize that it is not working alone with the scissors, then
use the cutter. But be careful, it is quite a weapon in the eye It
easily can eat up the iris, the capsule and the retina.
Take the cutter in your dominant hand and go with the infusion in
the other hand in the eye through the paracenteses wounds. The
chamber should then be deep.
Remember: you have to limit the amount of vitreous expression
and its risk of retinal detachment! If you encounter too much
flow outwards then suture the wound. The problematic wound is
usually the tunnel
Remember not to go out of the eye with the irrigation before having
put dispersive OVD (Figure 76).
Put the irrigation just in the eye and put the cutter deeper. You
create a pressure gradient downwards towards the cutter. If you
irrigate in the area of the cutter you may push the vitreous away
from the cutter and even worse more anterior toward the wound.

Chapter XII: Dealing with Vitreous in the Anterior Chamber

The typical time to have a vitreous prolapse is while removing the

last pieces of nuclear material or during cortical removal. The goal
is then to remove any residual nucleus. Small amounts of cortical
material clinging to the anterior chamber or in the posterior
chamber often present no difficulty.
Place the cutter into the posterior capsular rupture and perform
vitrectomy just in the neighborhood of the tear. Do not go too deep
and too much in the periphery. Remember also to preserve the
capsule for lens placement in the sulcus (Figure 81).

Figure 81

Go first out of the eye with the cutter, leaving the irrigation in the
eye. The cutter should be taken out of the eye in the fast cutting
mode and no aspiration. Put again some dispersive OVD and
check the wounds for vitreous prolapse (using a cotton tip or a
triangular tip). In doubt you have to check the wound from the
opposite paracentesis with a spatula instrument, especially look
for incarcerated vitreous in the tunnel (Figure 82).

Basics of Phacoemulsification Cataract Surgery

Figure 82

In doubt repeat the vitrectomy procedure. Dont be lazy

To visualize the vitreous, you can use triamcinolone. But this can
make the overview of the situation even worse, especially if you
put a lot of triamcinolone
If you are too much in trouble, then call a VR surgeon Well it is
even better to call for help at an earlier stage
If possible, meaning if you think it is stable enough, put in an IOL,
in the bag (if tear is central and not going to the periphery) or in
the sulcus (if the posterior capsule is still there in the periphery
at least). Otherwise do not put an IOL in the eye and let the VR
surgeon decide. A bad idea is to put as an initial step an iris-fixated
lens, since the dilatation will be bad and the vitrectomy difficult
If you take an instrument out of the eye with vitreous prolapse in
the anterior chamber, be sure that the vitreous will follow you out
to the wound (Figure 83).

Chapter XII: Dealing with Vitreous in the Anterior Chamber

Figure 83

Vitreous always follows pressure gradients (Figure 84).

Figure 84

Wherever fluid is coming out of the eye, vitreous will follow

(Figure 85).

Basics of Phacoemulsification Cataract Surgery

Figure 85
If you think that you have cleaned the anterior chamber of vitreous,
then perform one last step: create a miosis with topical drops or
better intracameral and look for unusual corners in the pupil. The
vitreous may still be around (Figure 86).

Figure 86

Insertion of the IOL

Eventually you may have to enlarge the tunnel with the blade. You
should know the size of you tunnel blade and then just check what
kind of lens you want to implant.
Before enlarging the tunnel, put in OVD It is safer regarding the
capsule (Figure 87).

Figure 87

Essential Principles of Phacoemulsification

During enlargement you have to be sure that you stay in the tunnel
and then go slowly under the anterior capsule (completely - the
largest diameter should pass the corneal endothelium).
While coming out with the blade, open a little more towards one
side of the port. This will make it easier to introduce the lens.
Remember: a nicely constructed wound that is large seals better
than a stretched small wound.
Deepen the anterior chamber before enlarging the tunnel.
Otherwise you may hurt the posterior capsule But you may also
pierce it with the blunt needle of the OVD (Figure 87).
Do not pierce the posterior capsule with the OVD-cannula or
while enlarging the tunnel with the blade. Start to fill the anterior
chamber with OVD as soon as you enter the tunnel.
If you pierced the posterior capsule then put dispersive (seals
better than cohesive) OVD in the post capsular hole and gently
place IOL into the bag.
In small capsular tears you still can put the IOL in the bag. In
larger tears better place it in the sulcus if you still have enough
support by the zonules (Figure 88).

Figure 88

Chapter XIII: Insertion of the IOL

If there is a small rupture of the posterior capsule, then put the

lens into the bag. With a larger rupture, first put it into the sulcus.
In case of a nice rhexis (CCC), which is also smaller than the optic,
then think about putting the optic in the bag and leaving the haptics
in the sulcus (called rhexis fixated IOL) (Figure 89).
A rhexis fixated IOL avoids decentering / rotation of the IOL. The
calculated power is similar to the bag localization and it prevents
vitreous prolapse and iris chafing (Figure 89).

Figure 89
Completely fill the anterior chamber and the bag with OVD before
putting in the IOL. Be sure that the tunnel is also filled with OVD.
Then, the IOL or the shooter slips better into the eye (Figure 90).

Figure 90
Essential Principles of Phacoemulsification

Always try to put the first entering haptic directly in the right place.
If you put it in the bag the first haptic should be in the bag from the
beginning (Figure 91).

Figure 91

Placing the IOL in the sulcus means between iris and zonules/
capsular bag (Figure 92).

Figure 92

If you plan to put the IOL in the sulcus, prepare the space for the
lens with OVD (Figure 93).

Chapter XIII: Insertion of the IOL

Figure 93

The IOL should go in forming a Z with the haptics side (not an

S which would mean stop, do not implant like that). Instead
of Z you may prefer another acronym like 7-O-L-even which
is the same This design is actually for right-handed surgeons
in order to easily rotate the haptics in the bag (clock-wise)
(Figure 94).

Figure 94

Essential Principles of Phacoemulsification

If you put in the lOL the wrong way, then you have three possibilities.
First flip it within the eye (better for more experienced surgeons),
second leave it as it is (it is not a catastrophe, but you may encounter
more posterior capsule opacification and the IOL power may not
be adequate) and third, you take out the lens and put it in correctly.
If you are not shooting the IOL, but inserting it with a large wound,
put the first haptic directly in the bag and the optic should have
passed the corneal endothelium with the larger diameter. Then
press the optic (with the Y-instrument) first down until half of the
optic is over the rhexis margin (and in the bag) and then turn the
haptic clockwise. This will put both haptics in the bag (Figure 95).

Figure 95

In large posterior capsular rupture be careful while placing the

IOL. Be sure that the first IOL haptic is going in the sulcus. If it
turns out to be in the bag and you still push the IOL in the eye, you
may need a vitreoretinal surgeon (Figure 96).

Chapter XIII: Insertion of the IOL

Figure 96

If you are in doubt whether the haptics are in the bag, then check
with Nagahara chopper or Y-instrument: push iris at the pupillary
margin out and look for the haptics. Eventually the lens has to be
turned in the bag to visualize both haptics.
Both haptics in the bag or both in the sulcus is OK, but never leave
one in and the other out. The IOL will decenter towards the haptic
in the sulcus. This by the way is the most common reason for IOL
Do not plan to leave a single-piece acryl IOL in the sulcus. It is too
small for the sulcus and will decenter If you know that you will
implant in the sulcus, choose a large optic IOL.
If the IOL centers by itself, then haptics and optic are very probably
in the bag.
If the IOL is just a little decentered, then leave it or rotate the IOL
carefully for better centering.
If the IOL doesnt center then check the haptics (located both in
the sulcus or in the bag? If so, then put them in correctly), look for
zonular dialysis (if so, then put a capsular tension ring if less than
5 clock hours dialysis, otherwise put lens in sulcus), check wounds
for vitreous (with cotton tip or miotic agent injection), check for
haptic damage (you may have to replace the IOL).

Essential Principles of Phacoemulsification

In case of rhexis tear / damage, put the haptics most peripheral

parts away from the tear.
If you have just a small posterior capsular tear in the center, then
put the lens in the bag. If the tear is going towards the periphery
then put the lens in the sulcus.
If you have a rupture of the zonules of less than 5 clock hours with
unstable capsule, then put a capsular ring, if you have more than
5 hours, then put the lens in the sulcus.
Even with the lens in the sulcus due to unstable zonules, a capsular
ring helps to stabilize the eye.
In zonular dialysis the lens should be implanted in the axis of
the dialysis, meaning that the lens haptic is pushing towards the
If you use a capsular ring then try to put it in the direction of the
dialysis. According to the position of the unstable zonules you may
use a paracentesis to inject it.
Put in the capsular ring with an injector or with two forceps. One
forceps guides the capsular ring and the other one pushes forward.
If you have to put the lens in the sulcus then decrease the IOL
power of about 0.75-1 dpt! (Placement in the sulcus creates about
a 0.75 D myopic shift in glasses).
If you have a rupture of the posterior capsule, then be sure that no
vitreous is in the anterior chamber or has connection to a corneal
wound. Remember: vitreous is very difficult to see!!! (Figure 86).
If you are looking for vitreous in the anterior chamber, then check
for indirect signs like pupil margin deformation, strange behavior
of OVD in the anterior chamber and stretched appearance of the
capsular rupture. Check the outside of the corneal wounds with
a cotton tip the presence of vitreous incarcerated in the wound.
Check the inside of the corneal wound with a spatula. In doubt, put
in some triamcinolone in the anterior chamber to help visualizing
the vitreous.
Remove the OVD over and behind the IOL (Figure 97).

Chapter XIII: Insertion of the IOL

Figure 97

In larger tunnel incision (for example more than 5 mm) you may
have to suture the cornea with 1 to 3 stitches (Nylon 10-0). But
remember that a nicely performed tunnel will be tight even if
larger than 5 mm.
Better suture the tunnel if you think that it is not tight or the patient
will rub his eyes after surgery.
A corneal burn (due to too much phaco power, e.g. in a hard
nucleus G4), will often need a suture, since it represents a tissue
shrinkage and the tunnel will not be tight.
You may put a little air bubble in the anterior chamber. The
chamber will stay deep and the cornea will benefit (Figure 98).

Figure 98

Essential Principles of Phacoemulsification

Do not over-hydrate the corneal wounds. Postoperative you will

have more Descemet folds and remember: a corneal wound will
not get much more closed if you are overhydrating it. If you are not
getting the tunnel or a large corneal wound tight, then suture with
Nylon 10-0 and remove the suture after 7-10 days.
Take out the OVD after having placed the lens. The dispersive OVD is
harder to remove (short molecules dont stick together during I/A,
but short molecules create less post op IOP spike). The cohesive
OVD is easier to remove (longer molecules stick together), but
these longer molecules block the trabecular meshwork resulting
in big IOP spikes.
Use intracameral antibiotics after cataract operation, but avoid
giving aminoglycoside antibiotics in the eye since they are

Postoperative Care
Tell the patient that he shouldnt rub or put pressure on the eye
after cataract operation.
The patient should wear a protective eye shield during the night
for one to two weeks after cataract operation.
Instruct the patient that he should avoid splashing water directly
in the operated eye during the first days after operation.
Body bath, meaning washing below the neck, is allowed, but the
patient should not take a bath or go in the swimming pool for two
Instruct your patient to show up if he has pain, after a trauma to
the eye, decreasing vision or if he sees new flashes/dark spots.
The patient should avoid situations where he might get a hit
towards the eye and keep physical activities light.
Instruct the patient that slight redness, mild watering and
irritation, glare and little conjunctival bleedings are normal after
cataract operation.
Antibiotic and steroid drops combination 4x daily.

Chapter XIII: Insertion of the IOL

Remember the known allergies of the patient in order to adapt the

Instruct your patient how to put the eye drops.
Instruct the patient to wash his hands before applying the eye
Starting the antibiotic and steroid drops the day of the operation
will give you faster a calm eye.
In posterior capsular rupture start giving NSAIDs drops and keep
them for 8 to 12 weeks postoperatively. The risk of postoperative
cystoid macular edema is higher in these eyes.
Eventually a tropicamid drop just before going to bed the day of
the operation.
Eventually acetazolamide tablets 250 mg after the operation and
for the first night.
Corneal sutures can be removed 7-14 days after the operation.
The cornea is not healed, but the IOL is more stable in the eye after
some days.
Control the patient the day after the operation, after 3 to 7 days
and after 3-4 weeks.
The first postoperative day you can expect corneal edema,
especially at the tunnel site and proportional to the ultrasound
time, and cells (1 to 2+) and flare in the anterior chamber. The
pupil should be round and the IOL in place.
The eye pressure should always be measured at the postoperative
A clear cornea the first day after surgery, i.e. a cornea with only
a little amount of edema/endothelial folds, is a good sign after
Be always aware of endophthalmitis. Tell the patient that he
should see an ophthalmologist if he has pain in the eye some days
after the operation.

Essential Principles of Phacoemulsification

Decision Taking in
Cataract Operations

1. Stage the cataract: G1-G3: normal clear cornea incision, G4 or

white cataract: sclero-corneal incision + dying the anterior lens
capsule + in white cataract just pinch the center, if fluid is coming
out then forceps rhexis.
2. Capsulorhexis? Normal: continue classic procedure, tear: careful
hydrodissection, if lens not turning then hydrodelineation, no
stress to capsule, repeated OVD insertion during all steps, S&C or
D&C if lens turning, oblique chopping if lens is not turning. Small
rhexis: enlarge. Too large rhexis: take care while putting the lens
in the bag.
3. Hydrodissection? Good: push lens back and turn the lens in the
bag. Incomplete: repeat at another point, if not working then
hydrodelineation (see 2.).
4. Grooving: Very soft cataract: try cracking, if not working then
C&F. If very hard: after first groove (grooved from both sides) try
to crack then S&C. If lens not turning: crack after first groove
(without turning 180) and then oblique chopping. If not nicely
grooving but more cupping: change to C&F.
5. Cracking: Good: be sure that the cracking is complete. Continue
normal procedures. Not possible: groove deeper and try again, if
not working then chop in harder cataracts or C&F in softer.

Essential Principles of Phacoemulsification

6. Cortex removal: Complete: check, if really every cortex is out

and if the capsule is not injured. Continue normal procedures.
Incomplete: try bimanual I/A, EV. make another paracentesis on
the opposite side of the remaining cortex. If very adherent then let
it be.
7. IOL insertion: Good: are you sure the lens is in the bag, in doubt
check In sulcus: then put it in the bag Is it centered?: If not
then check for IOL location. If both haptics in the bag then turn the
lens in the bag. If still de-centered, then check for weak zonulas
8. OVD removal and finishing: Complete: are you sure that there
is no OVD behind the lens? Eventually press a little on the lens
or go behind the lens. Then check the wounds. Tight wounds?:
If not then hydrate the paracentesis or suture the wound with
Nylon 10-0.


Nirav Patel. Personal Communications, 2011.

Phacodynamics, fourth edition. By Barry S. Seibel. Slack
incorporated, 2005.
Surgical Techniques in Ophthalmology. Cataract Surgery. By Garg
and Alio. Jaypee Brothers Medical Publisher, 2010.
Essentials of Cataract Surgery, By Jae Young, Slack incorporated,
Phako Chop: Mastering Techniques, Optimizing Technology, and
Avoiding Complications. By David Chang, Slack incorporated, 2004
Cataract Surgery: Expert Consult- Online and Print, 3e. By Roger
F. Steinert, Saunders Elsevier, 2009
Cataract Surgery from Routine to Complex: A Practical Guide. By
Randall J. Olson, Slack incorporated, 2011
Premium Cataract Surgery: A Step-By-Step Guide. By John
Havanesian, Slack incorporated, 2012
Cataract Surgery And Ist Complications, 6e. By Norman S. Jaffe,
Mosby, 1997
Phacoemulsification, 3rd Edition, Volume 1. By Robert H. Osher,
Kindle edition, 2009

Essential Principles of Phacoemulsification

A Practical Guide to Phacoemulsification. By Mahipal Singh

Sachdev, Alpha Science Intl Ltd., 2003
Phacoemulsification Made Easy. By Aaheet H. Desai, Anshan Ltd.,
Video Atlas of Eye Surgery International Edition.
Phacoemulsification. 1. Basic Techniques (DVD). Eye Movies Ltd,
Complications During Cataract Surgery. Anterior Capsule (DVD).
By David Osher. American Academy of Ophthalmology, 2009.
Videos from and


Anesthesia 9
Antibiotics 102
Astigmatism 16, 19

Balanced salt solution (see BSS)

Ballooning (see conjunctival ballooning)
BSS (balanced salt solution) 18, 28, 30, 4
Burn (see corneal burn)
Bottle height 3, 55, 87

Capsular ring 99, 100

CCC (continuous curvilinear capsulorhexis) 22, 28, 32, 95
Chip & Flip 1, 54, 60, 62, 65, 66, 67
Cohesive OVD 30, 88, 94, 102
Conjunctival ballooning 15, 18, 19
Continuous curvilinear capsulorhexis (see CCC)
Cornea guttata 10
Corneal burn 3, 5, 19, 46, 63, 101
Cup 58, 60, 64, 65, 66, 105
Cutter 87, 88, 89
Cystotome 21, 24, 28, 31

Dialysis (see zonular dialysis)

Dispersive OVD 30, 82, 88, 89, 94, 102
Essential Principles of Phacoemulsification

Divide 1, 46, 49, 53, 57, 62, 63, 66, 67, 69, 70, 73
Draping 9
Dye 11, 21, 28

ECCE (extracapsular cataract extraction) 6, 9, 52, 87

Endonucleus 42
Endophthalmitis 103
Endothelium 10, 14, 17, 46, 63, 67, 94, 98
Exfoliation syndrome (see PEX)

Flow 2, 3, 4, 5, 8, 30, 46, 54, 55, 63, 80, 81, 87, 88

Forceps 17, 21, 24, 27, 28, 31, 32, 33, 100, 105
Fulcrum 46


Golden ring sign 20, 42, 43

Guttata (see cornea guttata)

Haptic 32, 95, 96, 97, 98, 99, 100, 106

Hemorrhage 5, 6, 9, 10, 13
Hooks (see iris hooks)

IOP (intraocular pressure) 3, 6, 19, 102

Infusion misdirection syndrome 5, 6
Iris hooks/retractors 11, 33, 48, 52
Iris retractors (see iris hooks)


Lid speculum 9

Magnification 8
Mannitol 19
Marfans syndrome 10
Misdirection syndrome (see infusion misdirection syndrome)

Nagahara Chopper 57, 70, 99

OVD (ophthalmic viscosurgical device) 11, 17, 18, 21, 24, 27, 28, 29,
30, 32, 33, 39, 82, 87, 88, 89,
93, 94, 95, 96, 100, 102, 105

Paracentesis 13, 14, 15, 16, 17, 18, 21, 24, 28, 30, 31, 39, 48, 63, 79,
80, 83, 89, 100, 106
Pedal 8, 9, 81
PEX 10, 28, 43
Pseudoexfoliation syndrome (see PEX)
Pupil 8, 10, 11, 22, 26, 30, 31, 33, 64, 86, 92, 100, 103

Retinitis pigmentosa 28
Ring (see capsular ring or ring sign)
Ring sign (see golden ring sign)
Rupture 38, 39, 42, 81, 83, 89, 95, 98, 100, 103

Essential Principles of Phacoemulsification

Scissors 28, 32, 33, 88

Settings 1, 2, 63
Shearing 24, 25, 26
Spatula 30, 48, 86, 89, 100
Speculum (see lid speculum)
Subchoroidal hemorrhage 5, 6
Sulcus 33, 87, 89, 90, 94, 95, 96, 98, 99, 100, 106
Suture 18, 88, 101, 102, 103, 106

Tenon 18
Trauma 10, 36, 42, 102
Triamcinolon 90, 100

Ultrasound 2, 4, 9, 10, 103

Uveitis 28

Vaccum 2, 3, 4, 5, 63, 66, 70, 72, 73, 81, 87

Vitreous 6, 10, 28, 82, 83, 85, 86, 87, 88, 89, 90, 91, 92, 95, 99, 100
Vitreous cutter (see cutter or vitrectomy)
Vitrectomy 9, 36, 42, 82, 89, 90

Zonular dialysis 85, 99, 100

Zonule 22, 31, 35, 43, 52, 65, 69, 73, 75, 80, 94, 96, 100