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Contents i

Mastering the Art of

Bimanual Microincision
Phaco (Phakonit/MICS)
ii Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Contents iii

Mastering the Art of

Bimanual Microincision
Phaco (Phakonit/MICS)
Ashok Garg I Howard Fine MD FACS
MS, Ph.D, FIAO (Bel) FRSM, FAIMS, ADM, FICA Clinical Professor of Ophthalmology
International and National Gold Medalist Oregon Health and Science University
Medical Director Chief Consultant
Garg Eye Institute and Research Centre Drs Fine, Hoffman and Packer, LLC
235-Model Town, Dabra Chowk 1550-Oak St, Ste 5
Hisar-125005 (India) Eugene, OR 97401, USA

David F Chang MD Keiki R Mehta MS, DO, FRSH, FIOS

Clinical Professor of Ophthalmology Chairman and Medical Director
University of California, San Francisco Mehta International Eye Institute
Private Practice, 762, Altos Oaks Drive and Colaba Eye Hospital
Los Altos, CA-94024 (USA) Seaside
147, Shahid Bhagat Singh Road
Jerome Jean — Phillippe Bovet MD Mumbai-400005 (India)
Consultant Ophthalmic Surgeon FMH
Clinique de L’oeil Luis Felipe Vejarano MD
15, Avenyue Du Bois-de-law Chapelle Medical Director
CH-1213, Onex, Switzerland Fundacion Oftalmologica
Vejarano, Nacional Bascom Palmer Eye Institute
Suresh K Pandey MD Carrera: 3#5-54
Achievement Awardee, AAO Popayan - Colombia
Assistant Professor South America
John A Moran Eye Centre
Department of Ophthalmology and Visual Sciences Cyres K Mehta
University of Utah, 50 North Medicla Drive MS, FAGE, FSVH, FNRERF, FSEC
Salt Lake City, Utah-8413, USA Director and Consultant Ophthalmic Surgeon
Intraocular Implant Unit The Mehta International Eye Institute
Sydney Hospital and Sydney Eye Hospital and Colaba Eye Hospital
Scholar to University of Sydney Seaside
Save Sight Institute and Discipline of Ophthalmology 147, Shahid Bhagat Singh Road
Sydney, NSW, Australia-2001 Mumbai-400005 (India)

Foreword: Dr Richard L Lindstrom

New Delhi
iv Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
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Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

© 2005, Editors

All rights reserved. No part of this publication and interactive CD ROMs should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior
written permission of the editors and the publisher.

This book has been published in good faith that the material provided by contributors is original. Every effort is made to
ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s).
In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition : 2005

ISBN 81-8061-542-1
Typeset at JPBMP typesetting unit
Printed at Replika Press Pvt. Ltd.
Contents v
Dedicated to
My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings & motivation.
My Respected Parents, teachers, my wife Dr Aruna Garg, son Abhishek and daughter Anshul
for their constant support and patience during all these days of hard work.
My dear friend Dr Amar Agarwal who invented the technique of Phakonit (Bimanual Phaco)
for the first time in the world in 1998.
Ashok Garg

Our patients who entrust their vision to our Surgical intervention &
who stimulate us to continually seek improved technology and techniques.
I Howard Fine

My wife, Victoria and my children Courtney and Alex.

David F Chang

Zena the light of my life.

Keiki R Mehta

Yveric, Luc and Fanny Laure.

Silvio Korol, who was not only a teacher but also an intellectual guide and a friend.
Jerome Bovet

My wife and son who help me & support me in all my ophthalmology worse and also had been a lot of time
without me. They are reason of my life & the engine in my career, in my progress & in my personal development.
To thank my parents who always were in the right place in the right moment & always support my ideas.
To a very good friend of mine & colleague in the clinic Dr Alejandro Tello who push me to write & show to the
world all my techniques and new ideas and also help me invaluably with all my chapters & articles.
L Felipe Vejarano

My parents Shri Kameshwar Prasad Pandey and Smt Maya Devi Pandey,
for instilling values of sincerity, honesty and integrity.
My spouse, Dr Vidushi, for her love, and constant support.
Suresh K Pandey

My parents for everything.

To Vini my Best friend.
Cyres K Mehta
vi Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Contents vii

Ahmed Galal MD, Ph.D. Athiya Agarwal MD, DO, FRSH E John Milverton DO, FRANZCO,
Vissum/Instituto Oftalmologico Consultant FRC Ophth
De Alicante, Alicante, Spain Dr Agarwal’s Eye Hospital Chairman, Intraocular Implant Unit
19, Cathedral Road Sydney Hospital and
Alberto Vejarano MD Chennai-600086, India Sydney Eye Hospital
Fundacion Oftalmologica Vejarano Macquarie Street
Popayan, Cauca, Colombia Barbara Kusa MD Sydney - Australia
Centre Microchirurgia
Alejandro Tello MD Ambulatoriale Elizabeth A Davis MD
Fundacion Oftalmologica Vejarano Via Donizetti, 24 Minnesota Eye Consultants
Popayan, Cauca, Colombia 20052 - Monza, Italy 9117, Lyndale Aves, Bloomington
MN 55420, USA
Amar Agarwal MS, FRCS, FRC Ophth. Clement K Chan MD
Consultant Medical Director Ezequiel Campos - Mollo MD
Dr. Agarwal’s Eye Hospital Southern California Desert Retina Hospital General
19, Cathedral Road Consultants, MC Universitario de Alicante
Chennai-600086, India Inland Retina Consultants Alicante, Spain
Palm Springs
Anthony J Maloof MD, FRANZCO, FRACS California, USA Fabrizio I Camesasca MD
Director of Ophthalmic Surgery Deptt. of Ophthalmology
Western Sydney Eye Hospital Cyres K Mehta MS, FAGE, FSVH, Istituto Clinico Humanitas
Westmead Hospital FNRERF, FSEC Rozzano, Milano, Italy
Howkesbury Road Director and Consultant
Westmead, New South Wales (NSW) Mehta International Eye Institute Francisco J Gutiérrez—Carmona
2145, Australia Seaside, 147, Colaba Road MD, Ph.D
Mumbai-400005, India Associate Professor, Ophthalmologic
Arif Adenwala MS Research Institute Ramón Castroviejo
Consultant David F Chang MD Complutense University of Madrid
Aditya Jyot Eye Hospital Pvt. Ltd. Clinical Professor of Ophthalmology Spain
Plot No. 153, Road No. 9 University of California Anterior Segment Surgery Specialist
Major Parmeshwaran Road San Francisco Private Practice Department of Ophthalmology
Wadala, Mumbai-400031 762, Altos Oaks Drive (Cornea and Lens Unit)
Los Altos, CA 94024 Hospital Ramón y Cajal
Arturo Pérez - Arteaga MD USA Carretera de Colmenar Km. 9.100
Medical Director 28034-Madrid, Spain
Centro Oftalmologico Tlalnepantla David J Apple MD
Dr Pérez - Arteaga Vallarta No. 42 Director and Professor of Frederic Hehn MD
Tlalnepantla, Centro, Estado de Mexico Ophthalmology Centre de La Vision
54000, Mexico John A Moran Eye Centre Nations - Vision
Department of Ophthalmology and 23, Boulevard de l’europe
Ashok Garg Visual Sciences 54500, Vandoeuvre, France
MS, Ph.D, FIAO (Bel) FRSM, FAIMS, ADM, FICA 5th Floor, University of Utah
International and National 50, North Medical Drive Gaurav Shah MS, DNB
Gold Medalist Salt Lake City Consultant
Medical Director Utah-84132, USA Gaurav Laser Academy
Garg Eye Institute and Research Centre 105-A, Patel Shopping Centre
235-Model Town, Dabra Chowk Dipan Desai MS Chandavarkar Road
Hisar-125005 (India) Director Borivli (W)
Desai Eye Hospital and Laser Center Mumbai-400092
Ashok Grover MD, MNAMS, FRCS 2nd Floor, Anand Complex
Chairman Opp Shilp, CG Road Gilles Lesieur MD
Deptt. of Ophthalmology Near Navrang Pura 32, Place Jean Jaures
Sir Ganga Ram Hospital Ahmedabad 81000 Albi-France
Rajinder Nagar, New Delhi-110060 India-380009 060-9706266
viii Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Harinder Singh Sethi MD, FRCS Jose - Luis Rodriguez Prats MD, Ph.D Melania Cigales MD
Senior Research Officer Instituto Oftalmologico De Alicante Instituto Oftalmologico Hoyos
Dr RP Centre for Ophthalmic Alicante, Spain Sabadell (Barcelona) Spain
Sciences, AIIMS, Ansari Nagar
New Delhi-110029 Keiki R Mehta MS, DO, FIOS Minas T Coroneo MS, MD, FRACS
Chairman and Medical Director FRANZCO
Hiroshi Tsuneoka MD Mehta International Eye Institute Deptt. of Ophthalmology
Associate Professor 147, Shahid Bhagat Singh Road University of New South Wales
Deptt of Ophthalmology Colaba Road Prince of Wales Hospital, High Street
Jikei University Daisan Hospital Mumbai-400005, India Randwick NSW 2031, Australia
4-11-1, Izumihoncho, Komae
Tokyo, 201-8601, Japan Kirit Mody MS, FRCS, FRCO Narender Seshadri MS, DOMS
Consulting Eye Surgeon Doctor Eye Institute
I Howard Fine MD, FACS Salil Eye Clinic and Contact Lens Centre Spenta Mansion, SV Road
Clinical Professor of Ophthalmology 506, Om Chambers, Kemps Corner Andheri (West), Mumbai-400058, India
Oregon Health and Science University 123, August Kranti Marg
Chief Consultant Mumbai-400036, India Nick Mamalis MD
Drs Fine, Hoffman and Packer, LLC Professor of Ophthalmology
1550-Oak St, Ste 5 Kumar J Doctor MS, DNB Director, Ocular Pathology and
Eugene, OR 97401, USA Director Intermountain Ocular Research Centre
Doctor Eye Institute John A Moran Eye Center
J Agarwal MS Spenta Mansion, SV Road Deptt of Ophthalmology and Visual
Dr Agarwal’s Eye Hospital Andheri (West), Mumbai-400058, India Sciences, University of Utah
19, Cathedral Road 50, North Medical Drive
Chennai-600086, India Liliana Werner MD, Ph.D Salt Lake City, Utah, USA-84132
Assistant Professor
Jairo E Hoyos MD, Ph.D John A Moran Eye Centre Pandelis A Papadopoulos MD
Instituto Oftalmologico Hoyos University of Utah Director Ophthalmological
Rambla de Sabadell 62 10 50, North Medical Drive Diagnostic and Therapeutic Centre
08201 Sabadell Salt Lake City Ophthalmo Check Ltd.
Barcelona, Spain Utah 84132, USA 42, Poseidon Avenue, Paleo Faliro
Athens, Hellas, Greece
Jairo Hoyos - Chacón MD L Felipe Vejarano MD
Instituto Oftalmologico Hoyos Medico Oftalmologo Rajamani Muralidhar MD
Rambla de Sabadell 62 10 Fundacion Oftalmologica Vejarano Sr Registrar
08201 Sabadell Nacional Bascom Palmer Eye Institute Dr RP Centre for Ophthalmic
Barcelona, Spain Carrera 3, No. 5-54 Sciences, AIIMS, Ansari Nagar
Popayan, Cauca - Colombia New Delhi-110029
Jerome Jean - Phillippe Bovet MD South America
Consultant Ophthalmic Surgeon FMH 572-8241926 Randall J Olson MD
Clinique de L’oeil Director
15, Avenyue Du Bois-de-law Chapelle Mahendra D Dive MS, DNB John A Moran Eye Centre
CH-1213 Onex, Switzerland Doctor Eye Institute Deptt of Ophthalmology and Visual
Spenta Mansion, SV Road Sciences
John McAvoy Ph.D Andheri (West), Mumbai-400058, India University of Utah
Professor of Exp. Ophthalmology 50-N, Medical Drive, Salt Lake City
Director Mahipal S Sachdev MD Utah 84132, USA
Save Sight Institute Research Chairman and Medical Director
Laboratories Centre Foresight Ranjit H Maniar MS
Save Sight Institute A-23, Green Park 17, Vithal Court, 6th Floor
The University of Sydney Arovindo Marg 151, August Kranti Marg
Sydney, NSW-Australia New Delhi-110016, India Mumbai-400036 (India)

Jorge L Alio MD, Ph.D Matteo Piovella MD Richard L Lindstrom MD

Instituto Oftalmologico De Alicante Centro Microchirurgia Ambulatoriale Minnesota Eye Consultants, PA
Avda. Denia 111, 03015 Via Donizetti 24 710 East, 24th Street, Suite 106
Alicante, Spain 20052, Monza, Italy Minneapolis, MN 55404, USA

José J Martinez - Toldos MD, Ph.D Mark Packer MD Richard S Hoffman

Head of the Ophthalmology Unit in the Oregon Eye Surgery Centre Oregon Eye Surgery Centre
Hospital General Universitario de Elche 1550, Oak Street 1550, Oak Street, # 5 Eugene
Alicante - Spain # 5, Eugene, OR- 97401, USA OR- 97401, USA
Contents ix
Richard Packard MD, DO, FRCS, FRC Ophth Suresh K Pandey MD T Agarwal FORCE, DO, FICS
HRH Princess Christians Hospital Achievement Awardee, AAO Director
Windsor, UK Assistant Professor Dr Agarwal’s Eye Hospital
John A Moran Eye Centre 19, Cathedral Road
SK Das DOMS, MS Deptt of Ophthalmology and Chennai-600086
P-1, CIT Maniktalla, Main Road Visual Sciences India
Houesinskin-12, Skin No. 7M University of Utah
Near Kankurgachi Railway Bridge 50, North Medical Drive, Salt Lake City Yogesh Shah MS, FCPS, DOMS
Kolkata-54, India Utah-84132 (USA) Medical Director
Intraocular Implant Unit Gaurav Laser Academy
S Natarajan MS Sydney Hospital and 105-A, Patel Shopping Centre
Chairman and Medical Director Sydney Eye Hospital Chandavarkar Road
Aditya Jyot Eye Hospital Pvt Ltd Schlor to University of Sydney Borivli (W)
Plot No. 153, Road No. 9 Save Sight Institute and Mumbai-400092
Major Parmeshwaran Road Discipline of Ophthalmology India
Opp SIWS College GPO Box 1614
Gate No. 3, Wadala Sydney, NSW, Australia Zia Chaudhuri MS, MNAMS,FRCS
Mumbai-400031, India Consultant
Susmita Shah MS, DNB, FICO Deptt of Ophthalmology
Soosan Jacob MD, DNB, FERC Consultant Sir Ganga Ram Hospital
Dr Agarwal’s Eye Hospital Gaurav Laser Academy Rajinder Nagar
19, Cathedral Road 105-A, Patel Shopping Centre New Delhi-110060
Chennai-600086 (India) Chandavarkar Road, Borivli (W) India
Sunita Agarwal MS, DO, PSVH
Dr Agarwal’s Eye Hospital Tanuj Dada MD
19, Cathedral Road Asstt. Professor
Chennai-600086, India Dr RP Centre for Ophthalmic Sciences
15, Eagle Street, Langford Town AIIMS, Ansari Nagar
Bangalore, India New Delhi-1100029
x Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Contents xi

Minimally invasive surgery is a worthy goal for all surgical fields. Our patients
and society demand that we surgeons and the industry that supports us
develop procedures that are equally effective to the classic approaches but
safer and capable of being performed on a same day discharge basis in an
ambulatory surgery center. Such minimally invasive procedures must allow
the individual patient a shorter and more comfortable recovery with less
morbidity and a lower incidence of complications. They should also enhance
efficiency and reduce the cost per procedure, an important factor in a global
economy severely stretched to meet the health care needs of its citizens.
In most surgical fields, a smaller incision is the sinequanon of minimally invasive surgery. For example,
the modern knee reconstruction by arthroscopy or cholecystectomy through a laparoscopic incision.
Ophthalmology is no different.
Ophthalmology has been a leader in the development of minimally invasive surgery. During my 30-year
career we have evolved from an 11-12 mm incision for intracapsular cataract surgery to the current state-of-
the-art cataract removal and lens implantation through a 2.5-3.5 millimeter incision. Yet, our patients still
occasionally suffer from wound related complication such as wound leak and sight-threatening
endophthalmitis, prompting cataract surgeon innovators to continue their quest for yet smaller incision and
less invasive procedures.
Under several banners, including microincision cataract surgery, microphaco, and phakonit a global
consortium of surgeons and industry leaders have developed the capability to remove a cataract through two
or three 1.0.-2.0 millimeter incisions. These techniques, while continuously evolving, are now robust enough
to teach to every ophthalmic surgeon.
This book, Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS) written by
Internationally renowned Dr Ashok Garg and his co-editors summarize the current art and science of
minimally invasive cataract surgery. Accompanied by two interactive CD ROMs, this book provides the
interested surgeon a quality base of knowledge to expand their cataract surgery and lens implantation skills.

Dr Richard L Lindstrom
Minnesota Eye Consultants, PA
710 East 24th Street, Suite 106
Minneapolis, MN 55404,USA
Ph. 612-813-3633
E-mail :
xii Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Contents xiii


Cataract surgery has undergone rapid advancements in last 2 decades. From simple intra to ECCE-IOL
implantation-Phacoemulsification and now to Bimanual Microincision phaco. Indeed cataract surgery is
Elective and outdoor procedure now. There is no indoor stay for the patient in high tech Microphaco
surgery—a major revolution. There is need to master this technique and all related issues by all
Our book on Microphaco in its most advanced presentation, is a sincere effort to spread knowledge and to
provide finer details of this technique. A number of leading International Microphaco Surgeons serving the
people in different parts of the world have shared their skills and experiences about bimanual phaco in this
book for the benefit of readers.
56 chapters of this book cover all aspects of Microphaco from Anatomy of lens to various operative
techniques, complications management, recent advances and future technologies. Two interactive CD ROMs
are also being provided with the book showing various Microphaco operative techniques being done by
leading International Microphaco surgeons.
Our special thanks to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (General
Manager [Publishing]) and all staff members of M/s Jaypee Brothers Medical Publishers (P) Ltd. who took
active interest in this project and never ruffled to prepare this high quality International Microphaco book.
Each author in this book had made every effort to shape this book as an indispensable companion to our
It gives us great pleasure to present this book to ophthalmologists with the hope it shall enrich them with
comprehensive and complete up-to-date information about Bimanual Microphaco.

xiv Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Contents xv




1. Evolution of Cataract Surgery ........................................................................................................................... 3

SK Das (India)
2. Human Crystalline Lens Anatomy and its Relevance to Microphaco .................................................... 26
Suresh K Pandey (Australia), David J Apple (USA)
3. Introduction and Evolution of Microincision Phaco .................................................................................. 34
Kirit Mody (India)
4. Clinical Significance of Bimanual Phaco in Modern Cataract Surgery and its Learning Curve ....... 37
Ranjit H Maniar (India)
5. Pearls for Transitioning to Bimanual Microincision Phaco ...................................................................... 43
David F Chang (USA)
6. Transition to Microincision Phaco .................................................................................................................. 50
Kumar J Doctor, Mahendra D Dive, Narender Seshadri (India)
7. Ocular Biometry and Intraocular Lens Power Calculations in Microphaco .......................................... 69
Arif Adenwala, S Natarajan (India)
8. Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL ........................................................ 77
Amar Agarwal, Soosan Jacob, Athiya Agarwal, Sunita Agarwal, Ashok Garg (India)
9. Sterilization ........................................................................................................................................................ 82
Sunita Agarwal (India)
10. Anesthesia in Microphaco ............................................................................................................................. 113
Ashok Garg (India), Francisco J Gutiérrez-Carmona (Spain)
11. Preoperative Assessment of the Patient in Bimanual Phaco ................................................................... 124
Ashok Garg (India)
12. Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco ................................................................... 128
Ashok Garg (India)
13. Bimanual Microincision Phacoemulsification : Instrumentation and Techniques ............................ 139
I Howard Fine, Richard S Hoffman, Mark Packer (USA)
14. Air Pump in Phakonit ..................................................................................................................................... 147
Amar Agarwal, Sunita Agarwal, Athiya Agarwal, Ashok Garg (India)
15. Internal Forced Infusion for Phakonit ........................................................................................................ 153
Arturo Pérez - Arteaga (Mexico)
xvi Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

16. Phakodynamics of Microincision Phako .................................................................................................... 161

Dipan Desai (India)
17. Fluidics in Phakonit ........................................................................................................................................ 169
L Felipe Vejarano, Alberto Vejarano, Alejandro Tello (Colombia)


18. Anterior Capsule Staining During Microphaco ........................................................................................ 183

Suresh K Pandey (Australia), Liliana Werner, David J Apple (USA)
19. Dynamics of Temperature Control in Microphaco with New Insulated Phako Tip .......................... 193
Dipan Desai (India)
20. Ultrasmall Incision Intraocular Lenses ....................................................................................................... 196
Suresh K Pandey (Australia), Randall J Olson, Liliana Werner, Nick Mamalis (USA)
21. Implantation Techniques in Microphaco : Vejarano’s Safe Chop in Phakonit .................................... 205
L Felipe Vejarano, Alberto Vejarano, Alejandro Tello (Colombia)
22. Phakonit ............................................................................................................................................................ 215
Amar Agarwal, Athiya Agarwal, Sunita Agarwal, Ashok Garg (India)
23. Phakonit with Acri.Tec IOL ........................................................................................................................... 228
Sunita Agarwal, Athiya Agarwal, Amar Agarwal, Ashok Garg (India)
24. Bimanual Microincision Phacoemulsification ........................................................................................... 236
I Howard Fine, Mark Packer, Richard S Hoffman (USA)
25. Microincision Cataract Surgery (MICS) ...................................................................................................... 240
Jorge L Alio, Jose-Luis Rodriguez Prats, Ahmed Galal (Spain)
26. Minimally Invasive Bimanual Phaco Surgery and Foldable IOL .......................................................... 250
Hiroshi Tsuneoka (Japan)
27. Microphaco : The Aqualase Way .................................................................................................................. 261
Keiki R Mehta, Cyres K Mehta (India)
28. Lens Salute Microphaco: A Tilt Above ........................................................................................................ 270
Cyres K Mehta, Keiki R Mehta (India)
29. Microlenses – Sometimes Small is Better ................................................................................................... 278
Cyres K Mehta, Keiki R Mehta (India)
30. Microincision Bimanual Phaco and Thin IOL Implantation .................................................................. 287
Matteo Piovella, Fabrizio I Camesasca, Barbara Kusa (Italy)
31. Laser Phakonit .................................................................................................................................................. 293
Sunita Agarwal, J Agarwal, T Agarwal, Ashok Garg (India)
32. Multifocal IOLs and Microincision Cataract Surgery .............................................................................. 301
Ashok Grover, Zia Chaudhuri (India)
Contents xvii
33. Microincision Cataract Surgery of Mature Lenses .................................................................................... 307
Richard Packard (UK)
34. MICS Lenses ..................................................................................................................................................... 313
Gilles Lesieur (France)
35. Three Port Phakectomy .................................................................................................................................. 320
Dipan Desai (India)
36. ThinOptX Rollable IOL .................................................................................................................................. 323
Jairo E Hoyos, Melania Cigales, Jairo Hoyos - Chacón (Spain)
37. Bimanual Nucleus Fracture in MICS Surgery ........................................................................................... 330
José J Martinez – Toldos, Melania Cigales, Jairo Hoyos – Chacón,
Jairo E Hoyos, Ezequiel Campos – Mollo (Spain)
38. No Irrigating Chopper Phakonit Technique (NIC-Phakonit) ................................................................. 339
Arturo Pérez-Arteaga (Mexico)
39. Microincision Cataract Surgery (MICS) Combined with Trabeculectomy .......................................... 346
Tanuj Dada, Rajamani Murlidhar, Harinder Singh Sethi (India)
40. Ocular Pharmacotherapeutics in Bimanual Phaco .................................................................................... 355
Ashok Garg (India)



41. Bimanual Microincisional Phaco for Complicated Cases ........................................................................ 363

David F Chang (USA)
42. Complications of Phakonit ............................................................................................................................ 369
Amar Agarwal, Mahipal S Sachdev (India), Clement K Chan (USA)
43. Management of Complications in Microphaco ......................................................................................... 380
Jerome Jean Bovet (Switzerland)
44. PCO Prevention and Management in Microphaco ................................................................................... 385
Frederic Hehn (France)
45. FAVIT—A Technique for Removing Dropped Nucleus During Phakonit .......................................... 391
Amar Agarwal, Sunita Agarwal, Athiya Agarwal, Suresh K Pandey (Australia),
Clement K Chan (USA), Ashok Garg (India)
46. Posterior Capsule Opacification (After Cataract) :
Surgical and Implant Related Factors for Prevention .............................................................................. 396
Suresh K Pandey (Australia), David J Apple (USA), John McAvoy,
Anthony J Maloof, E John Milverton (Australia)
xviii Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

47. Intraocular Lens Opacification : Clinicopathological Correlation,

Prevention and Management ........................................................................................................................ 423
Suresh K Pandey (Australia), Liliana Werner, David J Apple (USA)



48. Functional Vision, Wave-front Sensing and Cataract Surgery ............................................................... 441
Mark Packer, I Howard Fine, Richard S Hoffman (USA)
49. NeoSoniX Microphaco : A New Technique ................................................................................................ 446
Keiki R Mehta, Cyres K Mehta, (India)
50. Sealed Capsule Irrigation Device and Phakonit ....................................................................................... 453
Amar Agarwal (India), Anthony J Maloof (Australia),
Sunita Agarwal, Athiya Agarwal, Ashok Garg (India)
51. Refractive Microincision Cataract Surgery ................................................................................................. 458
Pandelis A Papadopoulos (Greece)
52. Refractive Lens Exchange in Microphaco ................................................................................................... 469
I Howard Fine, Richard S Hoffman, Mark Packer (USA)
53. Catarex: Endocapsular Vortex Emulsification for Cataract Removal ..................................................... 475
Elizabeth A Davis, Richard L Lindstrom (USA)
54. Microphaco and Beyond ................................................................................................................................ 479
Yogesh Shah, Gaurav Shah, Susmita Shah (India)
55. Catarefractive Surgery : The Next Step to Phakonit ................................................................................. 484
Jerome Jean Bovet (Switzerland)
56. Futuristic IOLs for Bimanual Microincision Phaco .................................................................................. 490
I Howard Fine, Richard S Hoffman, Mark Packer (USA)
Index .................................................................................................................................................................... 493
Evolution of Cataract Surgery 3

Evolution of Cataract
1 Surgery

SK Das (India)

Evolution, which is a state of perpetual change when applied to any disciplines and techniques, is necessary
for advancement. We should always seek to evolve our methods in the direction of eliminating the shortcomings

Section 11
and enhancing the benefits (Fig. 1.1).

Fig. 1.1: Evolution of Cataract Surgery: From ancient to modern

Cataracts are the main cause of curable blindness. About 1. Cataract surgery in antiquity-from 1000 BC to 1700
17 million people worldwide are blind due to cataract AD
alone. The only known treatment is surgical removal 2. Cataract surgery in the 18th century-from 1701 AD
of the lens. Indeed, cataract surgery is one of mankind’s to 1800 AD
greatest achievements in the last millennium. 3. Cataract surgery in the 19th century-from 1801 AD
to 1900 AD
4. Cataract surgery in the 20th century-from 1901 AD
to 2000 AD
The history of cataract surgery can be broadly categorized 5. Cataract surgery in the 21st century-from 2001 AD
under the following headings: to till date.
4 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Cataract Surgery in Antiquity keeping his hair and beard short, his nails and hands
The history of cataract surgery goes back some 4000 clean and wearing a sweet smelling dress and apparently
years and probably even further back. The disease and using some kind of inhalation anesthetic (Fig. 1.3).
its treatment were well-known to the Sumerians of
Mesopotamia and also known in ancient Egypt.
The eye is one of surgery’s oldest interests.
There are numerous references to cataracts and their
treatment in the literature of many ancient civilizations.
Perhaps the first is in the code of Hammurabi (1750
BC). This includes a schedule of payment for the surgeon,
should sight be restored, along with the penalty removal
of the surgeon’s finger should the paor loose his or her
vision (Fig. 1.2). Fig. 1.3: Susruta

It seems obvious that this extremely detailed account,

probably written before the Hippocratic era, was the
outcome of previous knowledge and experience
accumulated over a long period in the rich civilizations
Section 1

of early Hindustan.
“It is interesting that while in Hindu medicine cataract
was defined by Susruta as opacity due to derangement
of the intraocular fluid, subsequent history is full of
fantasies and prejudices concerning its nature” (Fig. 1.4).

Fig. 1.2: Code of Hammurabi

The authentic records of cataract surgery come from

ancient Hindu medicine long before the Christian era.
In this amazingly advanced community the occurrence
of cataract was recognized as an opacity in the “eye
apple” long before the acceptance of this view in Europe
and its treatment by couching was widely practiced in
Susruta is said to be the first surgeon in the world
to remove cataract by couching (some 800 BC), and
taught the foundations of surgery based on anatomical
dissections. Fig. 1.4: Duke Elder

He pierced the sclera with a sharp lancet, then “All in all Susruta must be considered the greatest
inserted a blunt instrument which depressed the lens in surgeon of the premedical period”. AO Whipple
the vitreous cavity (In Susruta Samhita). Although there is no record of cataract operation in
He practiced aseptic surgery by having the operating ancient Egyptian or Greek medicine-Roman writers
room fumigated with sweet vapors and the surgeon Celsus (25 BC-50 AD) and Galen (AD 131-201)
Evolution of Cataract Surgery 5
indicated that cataract surgery was practiced in the This tradition of couching was maintained in Arabian
Alexandrian school probably because Susruta’s teaching Ophthalmology also, which was essentially an
reached Alexandria during or after the Indian expedition interpretation of Alexandrian and Romanian teaching.
of Alexander the great. Most probably the Hindus filtered Later on the Susruta Samhita was translated into
westward to Alexandria (Fig. 1.5). Arabic before the end of the eighth century AD and was
named “Kitab-I-Susrud” by Abillasiabil (Fig. 1.7).

Section 11
Fig. 1.5: Alexander the great
Fig. 1.7: Kitab-I-Susrud
Recent excavations in Iraq, Greece and Egypt have
uncovered bronze instruments that would have been Arab surgeons performed couching by the safer
used for cataract surgery. Celsus documented the Hindu technique with two instruments instead of one
procedure of couching in the oldest known medical as Celsus had done except Rhazes in 925 AD - and
treatise in the world ‘De medicina’ -where the material Ammar in 1015 AD who operated by tearing the cataract
dispersed is not the lens but an inspissated humor lying to pieces with a needle and sucking out the soft lens
in an empty space between the lens and the pupil. He matter through a hollow glass tube or needle. Probably
used only one sharp instrument whereby the capsule Rhazes and Ammar were motivated by the knowledge
was often ruptured and complications developed (Fig. of the relief of cataract among the ancients derived from
1.6). the fable that wild goats with this disease practised self-
surgery by charging into a thorny bush and puncturing
the eye (Fig. 1.8).

Fig. 1.6: Instruments used by Celsus Fig. 1.8: Rhazes

6 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

In 1575-Ambroise Pare of France introduced ocular In medieval Europe couching prevailed until the
speculum which we are still using today (Fig. 1.9). middle of the 17th century-but there was strong
controversy of opinion regarding the morphology of the
cataract as a corrupt inspissated humor as documented
by Celsus (25 BC - 50 AD) and Galen (AD 131- 210).
The same opinion of corrupt inspissated humor was also
adopted in Arabian writings and largely because of the
immense authority of Galen, it was maintained
throughout Europe for centuries (Fig. 1.12).

Fig. 1.9: Ocular speculum

In 1585-Jacques Guillemeau of France was the first

to recognize that the disintegration and dissolution of
a soft cataract could occur and he deliberately practiced
the operation of discission (Fig. 1.10).
Section 1

Fig. 1.12: Galen

Fig. 1.10: Jacques Guillemeau From the middle of the 17th century, dissenting
In 1622, Richard Banister of London also used to opinions started particularly in France when Francois
do discission. They all introduced the needle posteriorly Quarre taught that the cataract is an opacity of the lens
through the sclera (Fig. 1.11). and not a corrupt humor. Werner Rolfinck—the
anatomist who dissected executed criminals at Jena—
demonstrated in 1656 that cataract is the opacity of the
lens. Their revolutionary opinions were not published.
In 1685, French surgeon Antoine Maitre-Jan on couching
two patients noted the rounded lens and not an
inspissated membrane appear in the anterior chamber
which he confirmed after dissection on dead patients
whose eyes he had previously couched. He also did not
publish his findings at that time. While this controversy
raged throughout Europe Stephan Blaukaart, the Dutch
surgeon, removed cataract through a corneal incision
Fig. 1.11: Richard B-nister
in 1668 and ruled out the existence of inspissated humor.
Evolution of Cataract Surgery 7
Cataract Surgery in the 18th Century Evolution of Cataract Surgery
In the later part of the 17th century though many In 1752, George de la Faye, who became Vice Director
notable surgeons and anatomists announced that of the Royal Academy of Surgery in Paris, simplified the
cataract is an opacity of the lens, they did not publish operation by using two instruments only, a single knife
this in any scientific forum. On 17th November 1705, (bistoury) to make the incision and cystitome to incise
French physician Michel Pierre Brisseau demonstrated the lens capsule. George De la Faye practiced this on
to the Academy of Royal Science in Paris that cataract cadavers. Anticipating the clinical application of de la
is an opacity of the lens and not an inspissated humor. Faye’s technique, in 1753 Samuel Sharp of London first
For a considerable time the controversy raged throughout made a puncture and counter puncture and cut
Europe, sometimes with much acrimony. Shortly after downwards through the lower limbus and then delivered
Michel Pierre’s demonstration opaque lens was delivered the lens with its capsule by thumb pressure. By this
from a living eye by French ophthalmologist Charles procedure he introduced the concept of intracapsular
Saint-Yves in 1707 and Jean Louis Petit in 1708 in Paris. surgery.
In 1745, Jacques Daviel of France (made a planned In 1759 three dramatic advances were made by
extraction of cataract from its natural position behind Pierre-Francois Benezet Pamard of Avignon belonging
the iris) while operating failed to couch the lens and then to the Pamard family having seven generations of eye
based on his extensive dissection on cadavers during surgeons (Fig. 1.14). These were:

Section 11
the plague epidemic-he incised the lower-half of the 1. Supine position-instead of sitting.
cornea and removed the lens. That started a revolution 2. Fixing the eyeball which we are still doing today.
in ophthalmic surgery. After that debate over the merits 3. Incising the upper part of cornea-instead of lower.
of couching and extraction raged into the next century.
Daviel’s technique was by no means easy and for some
considerable time couching remained the standard
method of treatment (Fig. 1.13).

Fig. 1.14: Pierre-Francois

The last innovation was hearty welcomed by Benjamin

Bell (1785 in Edinburgh).
In 1766 Tadini, an itinerate eye doctor of the French
Court was the first person who mentioned the possibility
of lens implantation. Tadini came from an old and
distinguished Milanese medical family. His imagination
Fig. 1.13: Jacques Daviel has come true today (Fig. 1.15).
8 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Thus, creative imagination is more important than anterior approach through the cornea. In the 16th and
knowledge. 17th centuries the same operation was performed
through the posterior route from the sclera.
Cataract Surgery in the 19th Century
In 1801 Carl Himly Gottingen of Germany
introduced mydriasis before cataract surgery (Fig. 1.17).

Fig. 1.15: Tadini

Fig. 1.17: Mydriasis before cataract surgery
In 1786, Wenzel was the first eye surgeon who made
an incision in the upper part of cornea by keratomea In 1811, John Cunningham Saunders of Moorfields
Section 1

method frequently used today (Fig. 1.16). Eye Hospital, London established discission as an
operation for cataract in children. He introduced the
needle by anterior approach through the cornea. Three
years later in 1814 Benzamin Travers of the same Hospital
established curette evacuation for soft cataract in children
(Fig. 1.18).

Fig. 1.16: Wenzel’s keratome

In 1795, thirty years after the Tadini’s imagination

regarding the possibility of lens implantation in the eye,
Casamata, the court eye doctor of Dresden was the first
surgeon who did cataract operation and implanted an
artificial lens. Casamata performed the procedure by
inserting a glass lens through the wound of the cornea
into the eye. Later on he realized that the glass lens could
not be the substitute for the natural lens because during
this experiment the glass fell into the bottom of the eye.
Fig. 1.18: John Cunningham Saunders
Another milestone in the development of cataract
surgery was in 1797, when George Conradi of Gottingen The aspiration method, resembling the suction technique
was the first surgeon who performed discission by the of the Arabian surgeons, was reintroduced by Blanchet
Evolution of Cataract Surgery 9
and Laugier in 1847 in Paris and Teale in 1864 in complications to 2 percent. In 1866 Albrecht Von Graefe
London. But it was regarded as an accessory and not of Germany introduced the technique of combined
adopted in general practice. The only decisive innovation “Linear extraction” where the incision is through the sclera
which has since been made has been the concept of in the plane of largest possible circle of limbus with
S Lewis Ziegler (1921) of Boston who practised a iridectomy at the time of operation of extracapsular
“Complete discission” wherein a V-shaped incision is surgery. The idea of peripheral iridectomy was strongly
made deeply into the lens (Fig. 1.19). supported by Bajardi in 1895 and also enthusiastically
advocated by Elschnig (Fig. 1.21).

Section 11
Fig. 1.21: Von Graefe

In 1866 to 1871-A and H Pagenstecher of Paris

Fig. 1.19: Complete discission established the procedure of lifting the cataract out with
In 1862-Preliminary iridectomy was introduced by a spoon or loop (vectis), a dangerous technique but
Albert Mooren of Dusseldorf of Germany (Fig. 1.20). sometimes of great value even today in case of
subluxation of lens (Fig. 1.22).

Fig. 1.20: Albert Mooren Fig. 1.22: Lifting the cataract with a spoon or loop

Originally the section used for removal of lens was In 1867 Henry Williams of New England for first time
corneal in location. But in 1863 Julius Jacobson of Berlin introduced the suture as a safety method for wound
introduced the limbal incision which reduced closure (Fig. 1.23).
10 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

operations by 1884. However general anesthesia was

not welcomed by ophthalmologists. Though Thomas
Morenay Maiz of Peru suggested the medicinal use of
Cocaine - in 1884 Dr. Koller of Vienna and Dr. Sigmund
Freud were the first to use cocaine as local anesthesia
(Figs 1.26 and 1.27).

Fig. 1.23: Henry Williams

During the second-half of the 19th century surgeons

became interested in the complete removal of the lens
with its capsule. All the previous techniques involved
pressure on the globe leading to loss of vitreous. Cataract
Section 1

was then removed by ‘Traction’, not by pressure or thrust

on the globe.
In 1970, Terson was the first surgeon who grapsed Fig. 1.26: Dr. Koller
the capsule with a tooth forcep and removed the cataract
with its capsule. In 1978 Landesberg used an iris forcep
for ICCE. In both the above cases while grasping the
capsule it ruptured and ICCE was not achieved (Figs
1.24 and 1.25).

Fig. 1.27: Dr, Sigmund Freud

In 1884, H. Knapp introduced the technique of

retrobulbar anesthesia where the anesthetic is injected
Fig. 1.24: Terson Fig. 1.25: Grasping the
into the muscle cone directly behind the eye (Fig. 1.28).
capsule with a tooth forcep
In 1894, Eugene Kalt of Paris devised a smooth forcep
The introduction of general anesthesia was widely especially for intracapsular extraction of lens and he
accepted since 1846 and patients wanted it for all successfully delivered the lens with its capsule (Fig. 1.29).
Evolution of Cataract Surgery 11

Fig. 1.30: Intracapsular cataract extraction

Fig. 1.28: Technique of retrobulbar anesthesia

Section 11
Fig. 1.31: Suction cup

Motor akinesia was initially introduced by Van Lint

Fig. 1.29: Eugene Kalt of Brussels in 1914. He paralysed the orbicularis muscle,
a technique modified by R. E. Wright of Madras in 1921,
Cataract Operation in the 20th Century who injected the trunk of the facial nerve as it emerged
In the early part of this century ICCE was the operation from the stylomastoid foramen, and simplied by 0' Brien
of choice and the ophthalmologists tried to deliver the of Iowa in 1920 who injected the temporofacial division
lens with its capsule by different means or ways. Instead of the nerve as it crossed over the condyle of the
of traction by instruments ICCE was performed by mandible (Fig. 1.32).
traction through suction.
In 1902, Stoewer was the first person who used a
suction cup for intracapsular cataract extraction. Later
on Hulen did it in 1910 (Figs 1.30 and 1.31).
In 1910, Colonel Henry Smith of India popularized
the technique of intracapsular cataract extraction by
pressure on the globe by curette or strabismus hook.
He did operations on an incredible number of patients
at Madras in India. His technique is very suitable for
hypermature Morgagnian cataracts and is popularly Fig. 1.32: Akinesia by injecting the trunk
known as “Smith’s technique” today. of the facial nerve
12 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

In 1917, ICCE was done by traction through was was very popular and useful for intumescent hypermature
very popular and useful for intumescent and Erysophake Morgagnian cataracts (Fig. 1.36).
controlled by electric pump and popularized
hypermature Morgagnian cataracts (Fig. 1.36) by Ignacio
Barraquer of Barcelona (Fig. 1.33).

Fig. 1.35: Arruga’s forcep

Fig. 1.33: Ignacio Barraquer

In 1922, Anton Elschnig of Prague introduced the Fig. 1.36: Stiff rubber bulb for suction
famous Elschnig intracapsular forcep for intracapsular
Section 1

In the same year (1948) the operating microscope

surgery by traction which we are still using (Fig. 1.34). was first used by Dr Ken Swann of Portland, Oregaon,
The modern lens implantation was introduced in
ophthalmology by Harold Ridley of London. In 1949,
at the end of a cataract operation, Ridley was asked by
a medical student why he did not replace the sick lens
with a new one. That question gave Ridley the impetus
to explore the possibility of lens implantation. The first
intraocular lens was implanted in the capsular bag
following extracapsular cataract extraction at St. Thomas
Fig. 1.34: Anton Elschnig Hospital in London on November 29,1949. The second
In 1930, though Knapp had introduced the technique was on August 23, 1950. Both these two patients
of retrobulbar injection in 1884, Procaine was used for developed high refractive power and postoperatively had
the first time in that year. 20.0 and 15.0 dioptre myopia. Ridley recalculated the
In 1932, Lacarrere of Madrid innovated diathermo- power of the IOL and again implanted. Even after that
coagulation with a double pronged needle for ICCE by patients developed high refractive error and ultimately
traction. he abandoned the implantation of lens in posterior
In 1933, H Arruga introduced his famous Arruga’s chamber (Fig. 1.37).
forcep for removing the cataract with its capsule by Failure of posterior chamber lens implantation lead
traction (Fig. 1.35). to the development of anterior chamber lens implantation
In 1948, AE Bell introduced a stiff rubber bulb for and in 1951 anterior chamber lens implantation was
suction in removing the cataract. It was very simple and performed by Strampelli of Italy and Daneheim of
Evolution of Cataract Surgery 13

Fig. 1.39: J Barraquer

In 1960, ICCE done by cryosurgical probe through

Fig. 1.37: Harold Ridley
traction was introduced by T Krwawicz of Lubin of Poland
Germany. Later on one after another anterior chamber and AmoHs of South Africa (Figs 1.40 and 1.41).

Section 11
lens came in the market. Out of these notable are: CD
Binkhorst’s iris-clip lens and Edward Epstein’s collar
button lens (Figs 1.38A and B).


Fig. 1.40: Dr T Krwawicz


Figs 1.38A and B: Anterior chamber intraocular lenses

In 1958, J. Barraquer of Spain established ICCE by

an enzyme, alpha chymotrypsin, causing zonulolysis and
thereby helping in easy removal of the lens (Fig. 1.39). Fig. 1.41: Cryo probe
14 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

In the same year Atkinson advocated retrobulbar of lens into the chamber angle which often lead to
injection with hyaluronidase. corneal edema. Binkhorst introduced its four loop lens
For a perfect lens implantation, it is important that on 1st August 1958. Original Binkhorst lens had a large
the optimum power of the pseudophakos should be dislocation rate. The problem of fixation still remained.
calculated, for which the axial length of the eye is Mild iritis due to prolonged use of miotic and increasing
mandatory. In 1966, Weinstein et al developed corneal endothelial decompensation lead to
ultrasound which was better than formerly employed abandonment of 4 loop lens and in 1975 Binkhorst
X-rays. introduced the two loop lens (Fig. 1.43).
In 1967, Harmann Gernet of Germany was the first
to work with echometry. Later on several investigators,
first Gernet et al (1970), CD Binkhorst (1972),
Colenbrander (1973) and RD Binkhorst (1981)
developed useful formulas for calculation of IOL power
and presented the results in tables, nomograms and
computer programs (Fig. 1.42).
Section 1

Fig. 1.43: Dr CD Binkhorst

The Russian ophthalmologist Fyodorov modified the

Binkhorst lens and introduced this in the Soviet Union
in 1963 as Fyodorov I-Binkhorst lens. In 1965, Fyodorov
and Zakarov introduced a lens with three posterior loops
(Sputnik lens)-Fyodorov II. This lens was extremely light
weight and over the years did not cause any damage
to the sphincter of the pupil (Fig. 1.44).
Fig. 1.42: Harmann Gernet

Endothelium of the cornea has a great role in

regaining vision after cataract surgery. In 1968, Maurice
described a so-called specular microscope for the
observation of the endothelium. The instrument was later
modified by Laing et al (1975), and Bourne and
Kaufman (1976) so that one can examine the eyes of
a sitting patient.
The Dutch ophthalmologist CD Binkhorst visited
Ridley at the very early stage of implant history when
there was dissatisfaction among the ophthalmologists
Fig. 1.44: Dr. Fyodorov
regarding the failure of Ridley’s posterior chamber lens
implantation. Binkhorst realized that Ridley’s lens For safe intraocular surgery reduction of IOP (intra-
dislocated due to its weight, lack of fixation, extension ocular pressure) is very helpful. In 1967, D Vorosmarthy
Evolution of Cataract Surgery 15
invented oculocompression for lowering intraocular Phaco, many ideas can develop, with everyone
pressure. New mechanical techniques have been participating in the evolution.” The first operation was
developed to assure very soft eye having a deep anterior done in April 1967 and it took 76 minutes and that eye
chamber with a concave anterior vitreous surface. This ultimately turned into a painful blind eye. In 1970,
was done by Honan’s balloon in 1978. In 1979, Gills Kelman’s Cavitron Unit came into existence (Figs 1.47
introduced “Super Pinkie” which is very cheap and quite A and B).
safe for reducing lOP by the compression method. Outer
retinal ischemia or retinal artery occlusion may occur
on rare occasions. “Nerf ball” invented by Robert C
Drews in 1981 is safe because it is much softer and
impossible to induce high pressure on the orbit to occlude
the central retinal vessel (Figs 1.45 and 1.46).

Section 11
Fig. 1.45: Nerf ball

Figs 1.47A and B: Dr Charles Kelman

The ingenuinity and perseverance of Charles Kelman

led to the development of phacoemulsification which
in combination with advanced bioengineering science
Fig. 1.46: Dr Robert C Drews and improved surgical technology, transformed the
In 1967, Kelman introduced ECCE by phacoemulsifi- procedure from a fringe concept into a most useful and
cation, a technique which emulsifies the lens content using viable procedure for cataract surgery today. Dr Kelman’s
ultrasonic vibrations and aspirating the emulsified method is to prolapse the nucleus into the anterior
cataract. Kelman himself said. “Although I invented chamber for emulsification. He created a large anterior
16 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

capsulotomy by a cystitome in a “Christmas tree” or Since 1980, with the advent of viscoelastic materials,
triangular fashion and impaled the nucleus and brought capsulorhexis and with advanced technology of
it into the anterior chamber by the same cystitome under operative surgery, more and more surgeons are inclined
air. At that time, he used a one handed technique to to phacoemulsification as the cornea is protected by
emulsify the nucleus in the anterior chamber. viscoelastic materials and the circular capsulorhexis traps
In 1970, early propagators of phacoemulsification the nucleus within the capsular bag where emulsification
found marked corneal edema following surgery as most is done. The difficulty of elevating the entire lens nucleus
of the ophthalmologists were not fully aware of the, out of the capsular bag led the surgeons to develop
corneal endothelial physiology and they did not methods for dividing the nucleus and moving the pieces
appreciate the fact that corneal clarity depends on healthy from the capsular bag for safe emulsification.
corneal endothelium which once insulted or injured will Ophthalmologists devised a nuclear subqivision method
not regenerate. Moreover, viscoelastic materials and in linear, circumferential, or combined forms.
present vitrectomy techniques did not exist at that time. Additionally, hydrodissection evolved as a means of
They also frequently experienced difficulty in moving and rotating the nucleus within the capsular bag,
maneuvering the lens nucleus into the anterior chamber. and thereby facilitating the subdivision process.
Pioneers such as Richard Kratz, and Robert Sinskey Howard Gimbel described linear division as
relocated the emulsification action away from the nucleofractis.
Section 1

endothelium for protection of the cornea. John Shepherd developed four quadrant divide and
conquer technique.
Sinskey’s Method: After creating a large can-opener Howard Fine developed chip and flip nucleus removal
capsulotomy, he gently shaved or sculpted the nucleus technique.
within the posterior chamber. After sufficient debulking Paul Koch developed a hybrid method which is
of the lens, he could remove the softer posterior plate known as “stop and chop”, where the surgeon uses
from the posterior capsule and bring it forward through ultrasound to divide the lens nucleus into two pieces
the large capsulotomy without endangering the posterior and then chop the heminuclei bimanually.
capsule. Sinskey’s method did not eliminate the risk of After establishing the maintenance of corneal
tear to the posterior capsule as the anterior capsulotomy endothelium by retentive viscoelastic and circular
could easily extend peripherally and posteriorly. capsulorhexis, more attention was given in this latter part
of the century to low amount of ultrasonic energy to
Richard Kratz developed the concept of iris plane the cornea, so that clear cornea will be achieved on the
phacoemulsification. After creating a large size can-opener first postoperative day with any variety of nuclear
anterior capsulotomy, he sculpted a small crater in the densities. The results were achieved partly by the
central nucleus, and using a spatula as a lever in the modulation of emulsification energy in the form of bursts
crater, he steered the nucleus forward by discontinuing or pulses, high vacuum aspiration and chopping the
the fluid inflow. By manipulating the phacotip with one nucleus.
hand and using the spatula in the other hand, Dr Kratz Kunihoro Nagahara described nuclear chopping by
freed the superior pole of the nucleus from the capsular using high vacuum ultrasound to impale the lens nucleus
bag and brought it to the iris plane-rotated it and by emulsification tip which is firmly attached to the
ultrasonically chiseled the nucleus-while holding the nucleus. The surgeon simultaneously places a sharpened
nuclear remnant above the capsule with the spatula and chopper near the equator of the lens and draws it
using ultrasound to remove the materials. towards the phacotip in order to chop the lens into
Evolution of Cataract Surgery 17
portions before emulsifying and aspirating. This technique
reduces the total amount of ultrasonic energy to which
the anterior segment structures are exposed.

Manual Nucleus Expression Through a

Small Incision
Michael Blumenthal introduced manual nuclear
expression (extracapsular cataract extraction) which is
at present the most common cataract surgical procedure Fig. 1.49: Dr Keiki R Mehta
utilized worldwide. This surgery is best achieved if the
In the same year 1978, GF Worst of Netherlands
operation is performed throughout under positive
designed iris claw lens or Lobster claw lens based on
intraocular pressure with the utilization of an anterior
the recognition that it is possible to prepare a sheet of
chamber maintenance system that provides continuous
PMMA in such a way that it forms an elastic claw into
flow from the inside of the eye to the outside. The surgery
which the iris can be incarcerated without loosing its
is best performed through a sclerocorneal tunnel, the
physical properties of coherence and tensile strength
major portion of which is in the cornea. The nucleus
except for the points of the tissue directly squeezed
is separated by hydrodissection and is manipulated
between the branches of the claw. Iris claw lens can be

Section 11
manually in part or as a whole into the anterior chamber.
implanted after both intra or extracapsular cataract
Thereafter, nucleus expression is effected by the
surgery and as a primary or secondary procedure (Fig.
application of hydrostatic and external pressure which
enables lens implantation under the same condition. A
smaller incision than used in conventional nuclear
expression can be made and no sutures are required.
Rehabilitation is rapid and the procedure is cost-effective
(Fig. 1.48).

Fig. 1.50: Dr GF Worst

In 1982, iris claw lens was modified by Dr Daljit Singh

Fig. 1.48: Dr Michael Blumenthal of Amritsar, India and introduced as Worst-Singh’s claw
In 1978, Dr Keiki Mehta, Mumbai, India introduced lens. Dr Daljit Singh is the pioneer in the World who
HEMA and silicon lens with excellent results. Later on used steel sutures for wound closure (Fig. 1.51).
silicon lenses were used by Blumenthal in 1983, Cataract surgery reached its peak with the
Fyodorov and Epstein also in 1984 (Fig. 1.49). development of viscoelastic materials. In 1983, the
18 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 1.53: Dr Epstein

Fig. 1.51: Dr Daljit Singh

development of Healon, a hyaluronic acid polymer was

used as a viscoelastic material in implant surgery by Dr
Section 1

Endre Balazs of Columbia University. In 1935, the

discovery of hyaluronic acid and its molecular structure
had been done by Dr Karl Meyer in the Department
of Ophthalmology in the same Hospital. Later on many
viscoelastic materials were available (Fig. 1.52).
Fig. 1.54: Peri bulbar anesthesia

Capsular Surgery
It adds a new dimension and safety in IOL implantation
and phacoemulsification. There were several techniques
of capsular surgery.
1. Triangular or Christmas tree shape-advocated by
Kelman but the majority of extracapsular surgeons
preferred a circular anterior capsulectomy.
2. Beer Can technique.
3. Envelope technique.
Fig. 1.52: Dr Karl Meyer 4. CCC-Continuous Curvilinear Capsulorhexis.
In 1984, foldable lens was introduced by Mazzocco Continuous curvilinear capsulorhexis: Round
of USA and Epstein of South Africa (Fig. 1.53). capsulorhexis is suitable for ECCE. It is amazing that
In 1986, David B Davis II and Mark R Mandel of three doctors staying in three different countries in the
Medical Surgical Eye Centre, Hayward California startled world were thinking on the same lines at the same time.
the ophthalmic world with their publication of peribulbar In 1985, Gimbel gave the nomenclature of
anesthesia (Fig. 1.54). continuous capsulotomy (Fig. 1.55).
Evolution of Cataract Surgery 19

Fig. 1.55: Dr Gimbel Fig. 1.57: Dr Daniel Eichenbaum

In 1986, Neuhann gave the nomenclature of titanium tip. There is no sleeve-groove and crack
capsulorhexis (Fig. 1.56). technique. It is suitable for 1 to 3 grade nuclear
In 1987, Kimiya Shimizu gave the nomenclature of sclerosis (Fig. 1.58).
circular capsulectomy. One word from each inventor

Section 11
comes to ‘continuous circular capsulorhexis’.

Fig. 1.56: Dr Neuhann Fig. 1.58: Jack Dodick

3. Dr Michel Colvard used Erbium laser. The principle

Laser Assisted Cataract Surgery
is doing phacolase by Erbium YAG laser which
Today, one of the latest development in ophthalmology produces cavitation bubbles that collapse in water.
is the laser cataract surgical system. Three top ophthal- Pulse energy 5 to 50 mg—which has direct concussive
mologists were working of this. effect with bi-directional foot switch (Fig. 1.59).
1. Dr Daniel Eichenbaum, USA developed a machine
called laser photo which uses YAG laser for cataract
removal (Fig. 1.57).
2. In 1991, Dr Jack Oodick introduced the use of YAG;
YLF laser for surgical cataract removal. He gave the
nomenclature of Oodick photolysis NO-YAG Laser.
1.25 mm incision is required and the principle is
plasma formation and shock wave formation at the Fig. 1.59: Dr Michel Colvard
20 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

In 1991, cataract refractive surgery was introduced How the idea came in the mind of the inventor :
in the USA. Basically he is a vitreo-retinal surgeon and used to do
In October 1993, Richard A Fichman performed all his lensectomies with the phaco hand piece as he did
cataract surgery first under topical anesthesia. not have a fragmatome. He removed the infusion sleeve
In 1997, Cumming Kammon of Europe introduced and passed the phaco needle into the lens through the
accommodation IOL prototype. pars plana. Infusion was done through the infusion
At the end of 20th century Dr Amar Agarwal in canula which is conducted in all vitrectomies. Later on,
Chennai, India introduced one after another new he thought about using this system for cataracts for the
inventions in the field of ophthalmology (Fig. 1.60). anterior segment surgeon also. On 15th August 1998,
on India’s Independence day, he thought a needle could
be bent like a chopper which could be used for irrigation
and chopping of the nucleus.

In phacoemulsification the incision is 3 mm because of
the infusion sleeve which takes up a lot of space. The
titanium tip of the phaco hand piece has a diameter of
Section 1

0.9 mm which is surrounded by the infusion sleeve for

entry of fluid into the eye and also for cooling the
handpiece and prevention of corneal burn.
Fig. 1.60: Amar Agarwal
In phakonit, the infusion sleeve was taken out. The
1. No anesthesia cataract surgery titanium tip was passed inside the eye and as there was
In 1997, he thought of cataract operation without local no infusion sleeve present the size of the incision was
anesthesia. On 13th June 1998, a workshop was 1.2 mm. In the left hand an irrigating chopper was held
organized by Indian Intraocular Implant and Refractive which had fluid passing inside the eye through the side
Society at Ahmedabad, India, where Dr Amar Agarwal port incision. The assistant injects balanced salt solution
demonstrated cataract surgery without any anesthesia, (BSS) continuously at the site of the incision to cool the
Le. no topical anesthetic drops or intracameral anesthesia phakotip. On August 22nd 1998, Dr Amar Agarwal
was used. The workshop was attended by 250 eye performed Phakonit live surgery through 0.9 mm incision
specialists from all over India. Later on a similar study at Pune, India, at the Indian Intraocular Implant and
was conducted by Dr Amar Agarwal with Dr David Apple Refractive Society Conference where 350
and Dr Suresh Pandey which was subsequently published ophthalmologists watched his technique. In 1999,
in the Journal of Cataract and Refractive Surgery. Phakonit and no anesthesia cataract surgery were
2. In 1998-He introduced Phaconit (Microphaco) telecasted live via satellite from India to Seattle, USA in
Phaconit: ASCRS 99 Conference. The live surgery went very well
The name phaconit had been given by the inventor Dr. and on invitation Dr Amar Agarwal went to Seattle, USA,
Amar Agarwal with the idea that he did phaco using and gave lectures in the ASCRS. Subsequently live
a needle (N) through an incision (I) and with the tip surgeries were conducted on Phakonit and no anesthesia
(T) of the phaco needle for the surgery. He preferred cataract surgery in ASCRS, AAO and ESCRS
the nomenclature “PHAKONIT” not “PHACONIT” . Conferences.
Evolution of Cataract Surgery 21
Technique of Phakonit Surgery Phakonit irrigating chopper and phako probe without
A 26 gauge needle with viscoelastic making an entry in the sleeve inside the eye.
the sleeve inside the eye the area where the side port
is. This is for the irrigating chopper (Figs 1.61A to I).

The Phakonit needle in the right hand and an
irrigating chopper in the left hand, the crack created by
(A) karate chopping. The assistant continuously irrigates the
Clear corneal incision made with the keratome (1.2 phako probe area from outside to prevent corneal burns.
mm). The left hand has a straight rod to stabilize the

Section 11


The Phakonit is in process. The nuclear pieces are

(B) chopped into smaller pie-shaped fragments.
Rhexis started with a needle.

(C) (F)
22 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Phakonit completed. The nucleus has been removed Previous works:

and there are no corneal burns. 1. Steve Shearing in 1985 published a paper on
separating the infusion sleeve from the handpiece.
2. T Hara of Japan in 1987 did the same.
3. P Crozafon in 1999 reported the successful use of
a sleeveless 21 gauge teflon coated tip for minimally
invasive bimanual phaco. Crozafon felt that thermal
burn could be prevented by coating the phakotip
with teflon, which has a poor thermal conductivity.
In 1999, Hiroshi Tseunoka of Japan studied the use
of ultrasonic phacoemulsification and aspiration for lens
extraction through a microincision. Tseunoka used a large
incision as he felt that when the incision size is larger
(G) than phacotip, the tips get cooled by the leakage of
Bimanual irrigation aspiration started. infusion solution through the incision. The extraspace
according to him also prevents deformation at the incision
site due to the tip movement (Fig. 1.62).
Section 1

(H) Fig. 1.62: Hiroshi Tseunoka

Bimanual irrigation aspiration completed.

In 2001, Randall Olson from USA reported the feasibility
of sleeveless phaco through 1 mm incision using the
sovereign phacoemulsification with WhiteStar technology.
Olson found that tip heating could be minimized by
setting the machine for pulse mode so that ultrasound
was generated for extremely short intervals. He coined
the term “Microphaco”.
Randall defined Microphaco as completing cataract
surgery through two stab incisions of no more that 1
mm. Microphaco can have as its energy source
ultrasound, laser or sonic’energy. The emphasis is given
Figs 1.61A to I: Various steps of Phakonit surgery on laser or sonic energy to remove a cataract by
Evolution of Cataract Surgery 23
microphaco. The main reason of shifting to microphaco
is the problem of irrigation in traditional phacoemulsifi-
cation where irrigation and phaco aspiration needles are
wrapped together to avoid wound burn and to maintain
the chamber. The irrigation surrounding aspiration
requires at least 2.5 mm to 3 mm.

Steps of Microphaco
A 23 gauge capsulorhexis forceps makes work through
Figs 1.63A to D: Various step of microphaco
a 0.8 mm incision (Figs 1.63A to 0).

‘Oar-locking’ by a tight wound makes use of the irrigating

chopper on the left hemi-nucleus a difficult task.
Switching the irrigating and aspirating instruments from
the regular position (Upper) to an aspiration right position
(Lower) eliminates the sub-incisional cortex problem.
Jorge L Alio from Spain coined the term MICS or
Microincision cataract surgery - being done through a

Section 11
1.5 mm incision or less. This included laser cataract surgery
(Fig. 1.64).

Fig. 1.64: Dr Jorge L Alio

Advantages over Standard Co-axial
1. Expulsive choroidal hemorrhage though rare can be
prevented due to the smallness of the incision.
2. Ease of switching from one wound to the other in
regard to aspiration (phaco) needle.
In traditional phacoemulsification irrigation maintains
the chamber but otherwise is not a positive force.
Increased turbulence during irrigation results in spinning
(C) and bouncing the lens fragments which produces
24 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

endothelial damage. Furthermore, irrigation pushes

nuclear fragments away when we want to have the
particles come to the phacotip. Nuclear fragments
buffeted and pushed away by the irrigation and phacotip
is to be moved for aspiration. When irrigation is separated
from aspiration it can be a positive force by which free
nuclear fragments automatically flow to the phacotip
because this is the only exit if the wounds are tight. All
these irrigation advantages significantly decrease the
amount of fluid necessary and thereby damage to
endothelium is minimized which improves the efficiency
and safety of the surgery. Fig. 1.66: Dr Suresh K Pandey, Dr David J Apple, Dr
In 1999, He introduced ‘Air Pump’. One of the Liliana Werner
main problems in phacoemulsification is the fluidics. The
ThinOptX Rollable IOL
amount of fluid entering the eye is less compared to
the amount of fluid exiting the eye. Dr Sun ita Agarwal The problem of phakonit or microphaco is to find an
(sister of Dr Amar Agarwal) understood this problem IOL which would pass through such a small incision.
The ThinOptX company headed by Wayne Callahan
Section 1

and started pushing the air into the infusion bottle to

get more pressurized fluid out of the bottle. When it made an ultrathin lens using the Fresnel principle. The
worked she took an Aquarium air pump and connected first such lens was implanted by Jairo Hoyos from Spain.
it to the infusion bottle via an IV set. This gave a constant The second was implanted by Jorge Alio from Spain.
supply air into to the infusion bottle and the amount Dr Amar Agarwal, India, modified the lens to a 5 mm
of fluids coming out of the irrigation chopper was quite optic to make it pass through a smaller incision. The
enough (Fig. 1.65). special 5 mm lens was manufactured by ThinOptX and
as it is rollable it was called “ThinOptX Rollable IOL.”
On 2nd October 2001, Dr Amar Agarwal did the first
case of phaconit with rollable IOL at Chennai, India
(Fig. 1.67).

Fig. 1.65: Dr Sunita Agarwal

In 2000, Dye enhanced cataract surgery was

introduced by Dr Suresh K Pandey, Liliana Warner and
David J Apple (Fig. 1.66). Its purposes are:
1. Anterior capsular staining for capsulorhexis. 2.
Learning critical steps of phacoemulsification. 3. Posterior
capsular staining for posterior CCc.

Cataract Surgery in the 21st Century

In 2001, Dr Amar Agarwal introduced rollable IOL. Here
phacoemulsification can be done in 1.25 mm opening. Fig. 1.67: Dr Wayne Callahan
Evolution of Cataract Surgery 25
In 2001, Dr Anthony Maloof of Australia introduced 3. Patients will leave the OT immediately after to attend
“Sealed lens capsule irrigation”. Despite recent advances office or to attend a marriage ceremony.
in lens design, instrumentation and surgical technique 4. The picture absolutely simulates Susruta’s couching
-PCO remains the most common complication associated the only difference is high technology.
with cataract surgery particularly in the pediatric age Friends, please listen. You are not alone in the process
group (Fig. 1.68). of evolution. Almighty GOD is with you in trying to evolve
the human race in the direction of elimination of
shortcomings and enhancing benefits since the inception
of human creatures (Fig. 1.69).

Fig. 1.69: Process of evolution

Fig. 1.68: Dr Anthony Maloof
Throughout the centuries there were men all over the
This technique provided a new approach to targeting world who took the first step down new roads armed

Section 11
and modulating lens epithelial cells activity during cataract with nothing but their own vision or mission to restore
surgery which helps in keeping the posterior capsule free the eyesight of the blind (Fig. 1.70).
from the epithelial cells.

Future of cataract surgery - In the future generations:

1. Patients will come and sit-down in the OT chair.
2. The surgeon will make a small puncture by a 26 gauze
needle, and through the same opening
phacoemulsification (phakonit/microphaco) and
introduction of liquid lens in the capsular bag could
be carried out. Fig. 1.70: To restore eyesight of the world
26 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Human Crystalline
2 Lens Anatomy and Its
Relevance to Microphaco
Suresh K Pandey (Australia)
David J Apple (USA)

ANATOMY AND HISTOLOGY OF THE in these chambers, play a large role in the pathogenesis
HUMAN CRYSTALLINE LENS of lens abnormalities. The aqueous humor continuously
flows from the ciliary body to the anterior chamber,
The adult crystalline lens measures approximately 9.6 bathing the anterior surface of the lens. Disturbances in
Section 1

±0.4 mm in diameter with an approximate anterior- permeability of the lens capsule and epithelium can occur,
posterior diameter of 4.2 ±0.5 mm.1,3,11 Figures 2.1A leading to the formation of cataracts. Posteriorly, the
and B shows the empty capsular bag after removal of crystalline lens is supported by the vitreous (hyaloid) face
the crystalline lens. The diameter of ciliary sulcus 11.1 and lies in a small depression called the “patellar fossa.”
±0.5 mm, according to studies performed at the Center In younger eyes, the vitreous comes in contact with the
for Research on Ocular Therapeutics and Biodevices, posterior capsule in a circular area of thickened vitreous,
Storm Eye Institute, Charleston, SC, USA (now renamed the ligamentum hyaloideocapsulare. The potential space
as David J Apple, MD, Laboratory for Ophthalmic between the capsule and the circle of condensed vitreous
Devices Research, John A Moran Eye Center, Salt Lake is called Berger’s space. The lateral border of the lens is
City, Utah, USA).3 The anterior and posterior poles form the equator, formed from the joining of the anterior and
the optical and geometrical axis of the lens. Although posterior capsules, and is the site of insertion of the zonules.
the normal lens is transparent and clear in vivo, it is seldom The lens consists of three components: capsule,
completely colorless; even in childhood a slight yellowish epithelium, and lens substance. The lens substance is
tint is present that tends to intensify with age. a product of the continuous growth of the epithelium
The crystalline lens is a unique transparent, biconvex and consists of the cortex and nucleus. The transition
intraocular structure, which lies in the anterior segment between the cortex and nucleus is gradual. It does not
of the eye suspended radially at its equator by the zonular reveal a concise line of demarcation when observed in
fibers and the ciliary body, between the iris and the vitreous histological sections. The lines of demarcation are often
body. Enclosed in an elastic capsule, the lens has no better visualized by slit-lamp microscopy.
innervation or blood supply after fetal development. Its
nourishment must be obtained from the surrounding
aqueous and vitreous, and the same media must also
remove metabolic waste products. Therefore, disturbances The pediatric ocular structures, including the crystalline
in circulation of these fluids, or inflammatory processes lens, are significantly smaller than in the adult, especially
Human Crystalline Lens Anatomy and Its Relevance to Microphaco 27

Figs 2.1A and B: Gross photographs of the pediatric and adult human eyes obtained postmortem showing the capsular
bag, zonules shape, status after phacoaspiration/phacoemulsification of the lens substance. Both pictures were taken from
an anterior (surgeon’s) view; cornea and iris were excised to allow better visualization.
A. Empty capsular bag of a pediatric (aged 24 months) human eye obtained postmortem stained with 0.1% trypan blue.The
diameter of the crystalline lens and empty capsular bag were 9.2 mm and 9.6 mm, respectively. The anterior and posterior
capsulorhexis are also visible.
B. Empty capsular bag of a adult (aged 44 years) human eye obtained postmortem stained with 0.5% indocyanine green
dye. The diameter of human crystalline lens and empty capsular bag were 9.9 mm and 10.4 mm, respectively. Note
the zonules are stained green and clearly visible.

Section 11
in the first 1 to 3 years of life.9-13,17 the mean axial length posteriorly. By light microscopy the lens capsule appears
of a newborn’s eye is 17.0 mm compared to 23 to 24 as a structureless, elastic membrane, which completely
mm in an adult. The human crystalline lens grows surrounds the lens. It is a true Periodic acid-Schiff (PAS)
throughout life by the deposition of new fibers. Figures positive basement membrane, a secretory product of
2.2A to F shows the growth of the human crystalline the lens epithelium.1,15 Figures 2.3A and B demonstrates
lens. The most rapid lens-growth occurs from birth to histology of the anterior, equatorial, and posterior lens
2 years-of-age. The mean diameter of the capsular bag capsule using two different staining techniques. The
is about 7.0-7.5 mm at birth, which increases to about capsule functions as a metabolic barrier and may play
9.0 to 9.5 mm by the age of 2-years.9-13,17 Human a role in lens shaping during accommodation. The lens
crystalline lens growth is slower after the second decade. capsule is of variable thickness in various zones. At its
The lens does not increase much in size thereafter because thickest regions the lens capsule represents the thickest
of a relative loss of hydration and shrinkage of the lens
basement membrane in the body. The relative thickness
nucleus, which offsets some of the increase from new
of the anterior capsule compared with the much thinner
fiber deposition. Nuclear opacities (nuclear sclerosis) is
posterior capsule, may result from the fact that the former
the physiologic change that occur as the result of the
lies directly adjacent to and is actively secreted by the
above changes in hydration and nuclear size. The lens
epithelium, whereas the lens epithelium is not present
nucleus may become sufficiently opaque to cause visual
on the posterior surface. Local differences in capsular
difficulties. Also, the lens capsule thickens with age and
thickness are important surgically, particularly because
loses some of the inherent elasticity, which further
decreasing the capacity for accommodation and helping of the danger of tears or rupture of the thin posterior
to lead to presbyopia.5,6 capsule during cataract surgery. Remnants of the tunica
vasculosa lentis are common and appear as light-gray
Lens Capsule opacities (Mittendorf dots) at or near the posterior pole.
The lens capsule is a basement membrane elaborated These opacities are rarely responsible for significant visual
by the lens epithelium anteriorly and by superficial fibers loss.
28 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Figs 2.2A to F: Growth of the human crystalline lens.

A. Gross photographs of human crystalline lens taken from a child aged 4 months (left side). On the right side photographs
human crystalline lens from the adult aged 70 years.
B. Gross pictures of a pediatric human lens obtained postmortem, 20 months, showing human crystalline, zonules and
Section 1

ciliary body (anterior or surgeon’s view). The diameter of human crystalline lens was 8.5 mm.
C. Gross pictures of a pediatric human lens obtained postmortem, 20 months, showing human crystalline, zonules and
ciliary body (Miyake-Apple posterior view).
D. Gross photographs of pediatric human eyes obtained postmortem aged 3 years showing crystalline lens zonules and
ciliary body. Anterior (surgeon’s view): The diameter of human crystalline lens was 9.3 mm.
E. Gross photographs of pediatric human eyes obtained postmortem aged 3 years showing crystalline lens zonules and
ciliary body (Miyake-Apple posterior view).
F. Gross photographs of an adult human eye obtained postmortem (aged 60 years) showing crystalline lens, zonules
and ciliary body (Miyake-Apple posterior view). The diameter of human crystalline lens was 9.8 mm.

Lens Epithelial Cells capsule). They consist of relatively quiescent epithelial

It is pertinent to discuss some details about the lens cells with minimal mitotic activity. When disturbed, they
epithelial cells and their behavior after cataract surgery. tend to remain in place and not migrate. However, in
Postoperative proliferation of these cells may lead to a variety of disorders (e.g., inflammation, trauma), an
opacification of the posterior lens capsule, which in-turn anterior subcapsular epithelial plaque may form. The
may contribute to decrease vision after the cataract primary type of response of the anterior epithelial cells
surgery and implantation of the intraocular lenses.12-15 is to proliferate and form fibrous tissue by undergoing
The lens epithelium is confined to the anterior surface fibrous metaplasia.
and the equatorial lens bow (Figure 2.4). It consists of Recently, a new potential complication of A-cell
a single row of cuboidal-cylindrical cells, which can proliferation has emerged in the field of refractive surgery.
biologically be divided into two different zones with two The anterior subcapsular opacities that have been
different types of cells: described with various phakic posterior chamber (PC)
IOLs are based on A-cell proliferation. The fibrotic
A-cells response of the anterior lens epithelium is what
A-cells are located in the anterocentral zone, determines the degree of anterior capsular thickening
(corresponding to the central zone of the anterior lens following implantation of a phakic PC IOL in close
Human Crystalline Lens Anatomy and Its Relevance to Microphaco 29

Section 11

Figs 2.3A and B: Histological section of human crystalline lens showing

anterior, equatorial and posterior lens capsules.
A. Anterior lens surface stained by the PAS stain, which imparts a brilliant red hue to the basement membranes. The
anterior lens epithelium lays down a basement membrane, which is thick anteriorly; it is the thickest basement membrane
in the body. (Original magnification X 100).
B. Masson’s Trichome stain. (Original magnification X 100).
30 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

capsule opacification (PCO). E-cells are responsible for

the formation of a Soemmering’s ring, which is a donut-
shaped lesion, composed of retained/regenerated lens
cortex and cells that may form following any type of
disruption of the anterior lens capsule. This lesion was
initially described in connection with ocular trauma. It
is the basic precursor of classic PCO. The E-cells have
also been implicated in the pathogenesis of opacification
between piggyback IOLs, also termed interlenticular

Lens Substance (Cortex and Nucleus)

The lens substance consists of the lens fibers themselves,
Fig. 2.4: Schematic illustration of the microscopic anatomy
which are derived from the equatorial lens epithelium.
of the lens, showing the “A” cells of the anterior epithelium On cross-section these cells are hexagonal, and are
and the “E” cells, the important germinal epithelial cells of bound together by ground substance. After formation,
the equatorial lens bow. These lens epithelial cells plays
predominant role in the pathogenesis of various
the cellular nuclei of the lens fibers are present only
complication as postoperative opacification of anterior and temporarily. Subsequently they disappear, leaving the
Section 1

posteior capsule. lens center devoid of cell nuclei except in certain

proximity (or on) the anterior surface of the crystalline pathologic situations, (e.g. the maternal rubella
The original lens vesicle represents the primary
E-cells embryonic nucleus; in later stages of gestation the fetal
nucleus encircles the embryonic nucleus. The various
E-cells are located in the second zone, as a continuation
layers surrounding the fetal nucleus are designated
of the anterior lens epithelial cells around the equator,
according to stages of growth. The most peripherally
forming the equatorial lens bow, with the germinal cells.
located fibers, which underlie the lens capsule, form the
These cells normally show mitotic capability, and new
lens cortex. The designation of cortex is actually an
lens fibers are continuously produced at this site. Because
arbitrary term signifying a peripheral location within the
cell production in this region is relatively active, the cells
lens, rather than specific fibers.
are rich in enzymes and have extensive protein
metabolism. E-cells are responsible for the continuous The relationship between sclerosis and hardness is
formation of all cortical fibers, and they account for the uncertain. Traditionally the word “sclerosis” has been
continuous growth in size and weight of the lens associated with decreased water content of the crystalline
throughout life. During lens enlargement the location lens. Although there is no consensus in the past literature
of older fibers becomes more central as new fibers are about the extent to which the lens hardens, recent evi-
formed at the periphery. dence has demonstrated more consistently that increased
In pathologic states, the E-cells tend to migrate hardness of the crystalline lens occurs with age. Emery-
posteriorly along the posterior capsule; instead of Little proposed a classification of lens nuclei depending
undergoing a fibrotic transformation, they tend to form on varying degree of hardness. 4 Using postmortem
large, balloon-like bladder cells (i.e. Wedl cells). These human eyes, we have developed a model of inducing
are the cells that are clinically visible as “pearls.” These cataract of varying degree of hardness in a laboratory
equatorial cells are the primary source of classic setting using the Miyake-Apple posterior video tech-
secondary cataract, especially the pearl-form of posterior nique and this is shown in Figures 2.5A to E. 2,7,8
Human Crystalline Lens Anatomy and Its Relevance to Microphaco 31

Section 11
Figs 2.5A to E: Aging of the lens substance (nuclear
sclerosis). Emery-Little’s classification was proposed for the
hardness of nuclear cataract (varying from soft, semi-soft,
medium hard, hard and rock-hard), in clinical setting. We
have presented posterior view of the postmortem phakic
human eye showing an experimental example of induction
of different degrees of nuclear sclerotic cataract after injection
of Karnovsky’s solution in the lens substance.
A. Miyake-Apple posterior view of a human eye obtained
postmortem from a 79-year-old male, showing the
crystalline lens. There is a grade 1 of nuclear hardness
(soft cataract, according to the Emery-Little classification).
B, C, D and E. Same eye 5, 15, 20 and 30 minutes after
the injection of Karnovsky’s solution within the nucleus,
with the creation of grades 2, 3, 4 and 5 of nuclear
hardness, respectively.
32 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)
Section 1

Figs 2.6A to C: Parasagittal section of the phakic human eye obtained postmortem. Note the crystalline lens
suspended by the ciliary zonule.
A. Crystalline lens and zonules.
B. Higher magnification of crystalline lens, ciliary body and zonules from another case.
C. Higher magnification of ciliary body and zonules from another case. Miyake-Apple posterior view.

Figures 2.6A to C summarizes the anatomical relationship in the anterior segment of the eye suspended radially
of the human crystalline lens, ciliary body and zonules. at its equator by the zonular fibers and the ciliary body,
In summary, the crystalline lens is a unique between the iris and the vitreous body. The lens consists
transparent, biconvex intraocular structure, which lies of three components: capsule, epithelium, and lens
Human Crystalline Lens Anatomy and Its Relevance to Microphaco 33
substance. The lens substance is a product of the 9. Pandey SK, Wilson ME, Trivedi RH, Werner L, Apple DJ,
et al. Pediatric cataract surgery and intraocular lens
continuous growth of the epithelium and consists of the
implantation: Current techniques, complications and
cortex and nucleus. management. Int Ophthalmol Clin 2001; 41:175–96.
10. Pandey SK, Wilson ME, Apple DJ, Werner L, Ram J.
Childhood cataract surgical technique, complications and
ACKNOWLEDGEMENT management. In: Garg A, Pandey SK, (eds.). Textbook of
ocular therapeutics. Jaypee Brothers, New Delhi, India.
The authors gratefully acknowledge the partial support
11. Pandey SK, Thakur J, Werner L, Wilson ME, Werner LP,
of an unrestricted grant from Research to Prevent Izak AM. The human crystalline lens, ciliary body and
Blindness, Inc, New York, NY, USA. zonules: Their relevance to presbyopia. In: Agarwal A,
(ed.), Presbyopia: A Surgical Text. Slack Inc., Thorofare,
NJ, USA 2002, Chapter 2, PP 15–25.
REFERENCES 12. Pandey SK, Werner L, Apple DJ. Posterior capsule
opacification: Etiopathogenesis, clinical manifestations, and
1. Apple DJ, Auffarth GU, Peng Q, Visessook N. Foldable
management. In: Garg A, Pandey SK, (eds.). Textbook of
Intraocular Lenses. Evolution, Clinicopathologic
ocular therapeutics. Jaypee Brothers, New Delhi, India
Correlations, Complications. Thorofare, NJ:Slack, Inc.,
2000. 2002, PP: 408–25.
2. Apple DJ, Lim E, Morgan R, et al. Preparation and study 13. Vargas LG, Peng Q, Escobar-Gomez M, Apple DJ.
of human eyes obtained postmortem with the Miyake Overview of modern foldable intraocular lenses and
posterior photographic technique. Ophthalmology 1990; clinically relevant anatomy and histology of the crystalline
97:810–6. lens. Int Ophthalmol Clin 2001; 41(3):1–15.
3. Assia EI, Castaneda VE, Legler UFC, et al. Studies on 14. Werner L, Apple DJ, Pandey SK. Postoperative proliferation

Section 11
cataract surgery and intraocular lenses at the Center for of anterior and equatorial lens epithelial cells: A
Intraocular Lens Research. Ophthal Clin North Am 1991; comparison between various foldable IOL designs. In:
4:251–66. Buratto L, Osher R, Masket S, (eds.). Cataract surgery in
4. Emery JM, Little JH. Phacoemulsification and aspiration complicated cases. Thorofare, NJ:Slack, 2000; 399–417.
of cataracts; Surgical techniques, complications, and results. 15. Werner L, Pandey SK, Escobar-Gomez M, Apple DJ, et al.
St Louis:CV Mosby, 1979; pp 45–8. Anterior capsule opacification: A histopathological study
5. Glasser A, Croft MA, Kaufman P. Aging of the human comparing different IOL styles. Ophthalmology 2000;
crystalline lens and presbyopia. Int Ophthalmol Clin 2001; 107:463–71.
41:1–15. 16. Wilson ME, Apple DJ, Bluestein EC, Wang XH. Intraocular
6. Glasser A, Kaufman PL. The mechanism of
lenses for pediatric implantation: biomaterials, designs and
accommodation in primates. Ophthalmology. 1999;
sizing. J Cataract Refract Surg 1994; 20: 584–91.
17. Wilson ME, Pandey SK, Werner L, Ram J, Apple DJ.
7. Miyake K, Miyake C. Intraoperative posterior chamber lens
haptic fixation in the human cadaver eye. Ophthalmic Surg Pediatric cataract surgery: Current techniques,
1985; 16:230–6. complications and management. In: Agarwal S, Agarwal
8. Pandey SK, Werner L, Escobar-Gomez M, Apple DJ, et al. A, Sachdev MS, Mehta KR, Fine IH, Agarwal A, (eds.).
Creating cataracts of varying hardness to practice Phacoemulsification, laser cataract surgery and foldable
extracapsular cataract extraction and phacoemulsification. IOLs. Jaypee Brothers, Medical Publishers, New Delhi,
J Cataract Refract Surg 2000; 26:322–9. India, 2000, pp 369–88.
34 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Introduction and
3 Evolution of
Microincision Phaco
“Medicine is Ever Changing Subject”

Kirit Mody (India)

INTRODUCTION irrigation handpiece, thereby decrease the size of incision

Phacoemulsification technology advances at an to 1.3 mm. The problem was the wound burn by
sleeveless phako needle, Soscia et al evaluated on
Section 1

astounding rate, considering the evolution of cataract

surgery from Susutra time till today has matured to cadaver eye and reported that use of irrigating chopper
great extent and benefiting to millions of people. (Olson—Irrigating chopper ASICO) would solve the
The most recent breakthrough in cataract surgery is problem and in few cases it may not increase significant
still further reduction in size of incision, and implanting wound temperature, and wound burn occurred only
IOL in less than 2 mm of incision. The technique is at 100 percent phako power and with complete cut-
called as: Microincision or bimanual microincision or off of inflow fluid.
phakonit or microphako (Olson) surgery. Crozafon in 1999 from Kyoto suggested Teflon (poor
Microincision phacoemulsification at this time is similar conductor of heat) coated tip for phako needle. In 1998,
to coaxial phako in mid 1980. Critics said there is no on August 15th Amar Agarwal from Chennai performed
reason to do phako through a 3 mm incision when the the first sub 1 mm (9 mm) phako and he called the
incision has to be enlarged to 7 mm for IOL implantation, technique as Phakonit (PHAKO) being done with a
but ophthalmologist over the world considered that needle (N) via an incision (I) and with the phakotip
phako, was better technique, than extracapsular (T).
extraction even though we had to enlarge the incision. Donnenfeld evaluated wound temperature using a
Later on research lead to foldable IOL and micropulse technique and showed minimal increase in
phacoemulsification has replaced the ECCE technique temperature and loss of endothelial cells are comparable
with much better results and least trauma to eye. Once to conventional phako at 3 months. Tsuneoka and
again we are at threshold of major breakthrough , called collegues reported the study of 065 cases with no
bimanual microincision phacoemulsification, while thermal burn by using a Tsuneoka irrigating hook, later
conventional phacoemulsification is of 3.2 mm and on known as Tsuneoka tip on duet system. Howard
microincision phako is 1 to 1.2 mm. Fine, Olson, Mehta, Agarwal and Alio and many more
Dr. Steven shearing from Las Vegas in 1985, has have expanded, modified and refined the technique,
suggested the separation of ultrasound/aspiration and bringing to present level.
Introduction and Evolution of Microincision Phaco 35
The problems arising out of separating ultrasonic In NeoSoniX, a newer modality of phako, it has an
tip/aspiration and irrigation are solved by various oscillatory movement wih ultrasonic vibratory movement
ingenious innovations by many eye surgeons and at the tip, so it requires less energy and increased
research workers. followbility. While in aqualase the impact of the heated
The problem of wound burn and destabilization of fluid, delivered in pulses, disrupts and dissolves the
anterior chamber. lens. The Star sonic wave is totally cold phako with
A. Coating of needle oscillation at the tip is only 40 to 400 hertz compared
B. Pouring of cold saline over the needle to 20 to 66 kilohertz of conventional phako. In new
C. AC maintainer millennium by Bausch and Lomb new software called
D. Irrigating chopper Phakoburst has been introduced with lowest ultrasound
E. Anti-chamber collapser, device which injects air into of 28 khz of fixed pulses at varying intervals.
the infusion bottle (Fig. 3.1) The improvement in fluidics, either with the rigid
elastomer membrane in the peristaltic pump or coaxial
cylinders filtering out the cataract material thereby
avoiding blockage of aspiration line fro surge reduction
and cruise control. There is separation of aspiration and
ultrasound, offering the choice of together or

Section 1
independent functioning of these two controls.
The efficacy and predictability of microincision
phacoemulsification surgery has now been well-
established, but as far as IOLs are concerned, we are
again at the same stage of development from ECCE
to phako. Do we have 3 mm. IOL for phako incision?
Was the question every ophthalmologists’ was asking and
the research came with the new material called acrylic
or silicone foldable IOLs and the problem was solved
for conventional phako from ECCE.
On 2nd Oct, 2001 first phakonit rollable IOL
Fig. 3.1: Antichamber collapser device ThinOptX called Choice 1.0 IOL was implanted by
Dr Agarwal through less than 1.2 mm incision in his
F. For prevention of surge small bore aspiration line Phakonit technique by pouring the cold BSS saline over
tubing, microflow tips, dual linear for control, the needle.
incorporation of microprocessors in the system good Ultra thin lenses for microincision cataract surgery
wound construction and use of more phako are the future of IOL technology. They will need time
aspiration and chop and the nucleus into smaller to raise up to the standards of conventional IOLs. We
pieces. have currently 4 types of IOLs are available and there
The newer and safer methods of phacoemulsification are four issues like size of incision, insertion techniques,
has brought number of newer technologies like Laser instruments and stability of eye are to be considered for
(Erbium) phako, Dodick photolysis, photon laser 1 or sub1 mm incision. (Fig. 3.2).
photolysis, Sonic phacoemulsification, cold phako, ThinOptX UltraChoice 1.0 is perhaps “ the most
NeoSoniX and aqualase. innovative of the lot “with 5.5 mm optic diameter and
36 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

11.2 mm total diameter, 18% hydrophilic acrylic with incision, in future the redesigned lens may be available
particular design of very thin 50 μm to 400 μm optic for a smaller incision, it has firm hold in the bag due
and 50 μm plate haptics, the lens can be rolled into to four point fixation.
cartridge and injected through an incision less than Since the time of Charles Kelman’s inspiration in
2 mm. It is the real innovation of thin lens, while one dentist’s chair, advances in phacoemulsification
surface retains a continuous curvature of a traditional technology have produced ever increasing benefits to
lens while other surface is divided into a series of patients with cataract. The ten minute surgery was not
concentric rings 50 μm in height with slightly different possible before few years and only recently prolonged
curvature at each step, so when light enters the eye hospital stays were common after cataract surgery (Figs
the design of back surface of the lens directs them to 3.3 and 3.4). The competitive business environment and
focus on the same point in the retina and thereby well spring of human ingenuity continue to demonstrate
reducing spherical aberration. synergistic activity in the improvement of surgical
technique and technology Howard Fine.
Section 1

Fig. 3.2: ThinOptX IOL Fig. 3.3: Bimanual phacoemulsification

The second IOL is AcriFlex 46 CSE , 25% hydrophilic

acrylic with hydrophobic coating over the surface,
5.5 mm diameter and to be implanted with special self-
blocking capsular tension ring.
AcriSmart same as above with square edge design
to prevent capsular opacification.
Hydriol slim is 26% water content hydrophilic acrylic
material with 6 mm of optic and injected through 2.2 mm Fig. 3.4: Bimanual phacoemulsification
Clinical Significance of Bimanual Phaco in Modern Cataract Surgery 37

Clinical Significance of
4 Bimanual Phaco in
Modern Cataract Surgery
and its Learning Curve
Ranjit H Maniar (India)

INTRODUCTION Briefly these are:

It has been a decade and a half since the procedure a. Minimum energy expenditure and
b. Total control of the operating system or intraoperative

Section 1
of cataract extraction by phacoemulsification has
established itself as the premier technique, nay, the only milieu.
worthwhile technique, to deliver quality vision and rapid
Energy Expenditure
This “phaco era” has witnessed the change from Removal of the cataractous lens from the capsular bag
retrobulbar to peribulbar to topical anesthesia, from and replacing it with an IOL entails energy expenditure.
uniplanar to multiplanar tunnel incisions, from can- Historically, during ECCE, we expended mechanical
opener capsulotomy to capsulorhexis, from divide energy, which was applied wholly and purely manually.
conquer to stop and chop, from high energy to high The early-automated 1/A systems in ECCE, did herald
vacuum phaco, from rigid to foldable IOLs. the dawn of a new era in energy expenditure. For the
And then came bimanual phaco (or Microphaco)— first time we had access to a foot-operated, reproducible
bringing with it a deluge of advances, modifications and and controllable automated energy expenditure. This
evolving techniques. As we shall see in the following pages, partly replaced the manual 1/A systems. (Was it a case
no other advance, barring phacoemulsification itself, has of science overshadowing art in cataract extraction?)
ushered in such a revolution in thought, design and This, then, was the first shift—from manual application
technique. Before we examine these minutely, let us to automated application of mechanical energy.
first appreciate the basic guiding principles underlying Phacoemulsification marked the next logical shift—
the procedures of phacoemulsification. automated application of ultrasound energy for nucleus
delivery. The shift to phacoemulsification, however, did
not do away with mechanical energy expenditure in Toto.
EFFICIENCY IN MODERN CATARACT SURGERY Mechanical energy, applied manually, was still required
For any system, surgery or operative procedure to deliver for all the other steps of cataract extraction.
its stated goals and objectives efficiently, it has to satisfy Ultrasound energy, however, was too powerful and,
two basic parameters. if not controlled properly and judiciously, did more harm
38 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

than good. (Thousands of ruptured capsules and bullous h. Chopping: Better chopper designs and techniques
corneas bear a not-so-silent witness to this lack of control lend a greater margin of safety, especially to the
during sometimes-painful learning curve.) posterior capsule.
Phacoemulsification, more than any other procedure,
i. Better fluidics: These have permitted us to work at
highlighted the need to monitor and control, not just
higher vacuums and yet maintain a stable anterior
energy expenditure, but also the entire operating milieu.
Control of the Operating Milieu j. Foldable IOLs with improved designs: The square
We are finally coming to grips with the importance and posterior edge controls PCO, while the rounded
need, to totally control the complete intraoperative milieu anterior edge reduces glare. A smaller diameter IOL
during cataract surgery. A few examples of attempts at (10.5 mm—Stabibag) with triple arc fixation becomes
achieving greater control would not be out of place at more “Bag Friendly”, while the larger arc “Cushion
this stage. loop” (Centerflex) provoke less decentration.

a. Anesthesia: For the patient, topical and intracameral

Better Outcomes
anesthesia, not only do away with the dreaded and
fearful peribulbar injections, but also introduce a sense Thus, the optimum use of energy with a greater control
of comfort and relaxation. of the intraoperative milieu resulted in faster
Section 1

rehabilitation, better visual acuity scores, as also

b. Irrigating fluids: For the surgeon, the shift from normal improved contrast sensitivity values.
saline and Ringer’s lactate to specially manufactured But was this enough? Did we need to raise the bar
irrigating fluids, balanced in terms of pH, osmolality, still higher?
constituents and sterility, introduce an additional Certainly, the bar required to be raised, as the issue
margin of safety, by eliminating a variable source of of residual astigmatism needed to be addressed. With
ocular irritation. a view to improve outcomes still further, as also to
c. Incision: Well-designed blades and diamond knives decrease energy expenditure and facilitate a greater
have ensured accuracy and hassle free tunneling. degree of intraoperative control, there has been a gradual,
but perceptible shift to microphaco.
d. Viscoelastics: Sodium hyaluronidase and its poorer
cousin, methylcellulose, have served as adequate
space maintainers during vital steps of surgery. MICROPHACO—CLINICAL SIGNIFICANCE
Like all novel and path breathing operative procedures,
e. Capsulorhexis: One cannot over-emphasize the
microphaco too, has spawned a number of new ideas,
importance of this step that has added a virtual third
techniques and instruments. While refinements in
hand and contributed so significantly to the success
technique represent an evolutionary trend, modifications
of phacoemulsification.
in equipment, instruments and IOL designs are a logical
f. Hydro procedures: Not only help to minimize post- outcome of the dictum: Necessity is the father of
operative PCO but also to mobilize the nucleus for invention. Once the procedure of microphaco had
greater ease during chopping. demonstrably arrived, it was a forgone conclusion that,
g. Ultrasound tips : Flared and angled titanium tips lend in time, phaco systems, instruments and IOLs too, would
more flexibility in nucleus delivery and vacuum evolve to keep pace with the procedure. Be that as it
settings. may, the most exciting aspect about microphaco is the
Clinical Significance of Bimanual Phaco in Modern Cataract Surgery 39
fact that it unleashed a virtual revolution in concepts; This enables us to use higher vacuum, less energy
it has freed the minds of ophthalmologists all over, and become more efficient.
brought them out of the “Comfort zone complacency
c. Inflow placement: Standard phaco places the fluid
rut” of standard phacoemulsification.
inflow along with the phaco handpiece, so that it also
This shall be the greatest legacy of microphaco for
cools the tip as it flows into the eye. Initially, in
which we need to salute its inventor. Dr Amar Agarwal
microphaco we removed the inflow from the phaco
(Chennai, India) take a bow.
handpiece and located it on the chopper. Thus was
Microphaco represents a quantum leap on this
born the irrigating chopper with its myriad of designs
journey to perfecting cataract surgery outcomes. It takes
and modifications. The use of the irrigating chopper
you to the next level, both in terms of controlling the
however, involves re-learning chopping all over again.
intraoperative environment and in expending the least
We have to make allowance for the “away push”
ultrasound energy in cataract extraction.
from the chopper inflow. A longer learning curve
Let us examine what these modifications are and how
means temporary loss of control, which by itself is
they improve efficiency leading to better outcomes.
not a step forward, but a retrograde step. We have
a. Incision: Cataract extraction with sub 2 mm incision now come to realize that we need not locate the inflow
is now a reality. system on either handpiece. A study of anterior
Specially constructed disposable blades and diamond chamber hydrodynamics with a mobile inflow system,

Section 1
knives ensure an exact wound architecture. Be sure have shown how we create multiple and varying fluid
to make the tunnel a little longer (2.5 mm) to obviate eddies in such a small space. This fluid turbulence
the tendency for iris prolapse caused by a higher leads to a phenomenon I term as hydrofisting.
working pressure. Needless to say, a smaller puncture Hydrofisting may be defined as the damage caused
equals lesser astigmatism and instant rehabilitation. to the internal structures of the eye induced
by repeated fluid impact. This has been well-
b. Inflow control: In the pre-microphaco era, we were
documented beyond any doubt.
content to let the inflow pressure be gravity
The obvious answer, then, is to have a stationary
dependant, with progressively lesser partial pressures,
inflow that creates the least amount of turbulence.
as the bottle emptied. Not any more. Today, for the
A circumferentially directed inflow through an AC
first time in cataract surgery, we have begun to actually
maintainer is the only way to achieve this goal. As
control and dictate the pressure of fluid flowing
more and more surgeons realize this, we shall see
through the eye.
a shift from the irrigating chopper to the ACM used
This creates a constancy in the operating
in conjunction with a standard chopper. This also has
environment, eliminates a variable factor and
the advantage of shortening the learning curve and
therefore affords greater control of the operating
making the transition from phaco to microphaco,
milieu. This has been made possible by the use of
an air pump device which pumps in filtered air at virtually seamless.
a constant pressure and maintains a constant pressure d. Pressurized inflow: The need for a pressurized inflow
within the bottle. Pumps may be external devices or stems from the use of the irrigating chopper. As the
built into phaco system. They may be foot operated flow from the chopper tended to push away the
or microprocessor controlled. Be that as it may, the nuclear fragments, a higher vacuum was necessary
important aspect is that today we operate under a to pull the fragments to the phacotip. In order to
constant pressure and hence a constant AC depth. work at this higher vacuum and yet maintain a stable
40 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

anterior chamber, it was necessary to pump in fluid a lens tilt (“lens salute” as described by Dr Keiki Mehta)
faster and at a higher pressure. Thus, the air pump This facilitates subsequent chopping.
became an integral component of the microphaco
h. Chopping techniques: There are as many techniques
system. However, when you work with an AC
of chopping as there are chopper designs. Each one
maintainer, there is no repulsion of nuclear fragments. claims to be better than the other. Only two points
On the contrary, the circumferential flow obtained merit consideration: (i) during chopping limit collateral
with the ACM, creates predictable eddies that facilitate damage to the capsule and zonules and (ii) use the
fragment grab and emulsification. It is, therefore, not least force to chop by placing your side port
mandatory to work with higher vacuum when you judiciously. Work with a chopper design that
use the ACM. This fact begs a question. Do we still translates your force vector onto the nucleus most
need to use the air pump along with an ACM? Yes, efficiently.
we do; because a pressurized inflow ensures and Hence the logical approach is to chop outside the
maintains constancy of the anterior chamber depth bag in the iris plane, while continuing to phaco within
at all times. the bag (The lens salute technique).

e. Sieved outflow: In order to maintain a sustained high i. Modes of energy expenditure: The first generation
vacuum it became imperative to ensure that the of phaco machines offered the surgeon very little by
outflow channel did not get blocked with nuclear way of choice, in terms of how to expend ultrasound
Section 1

debris, as this would result in a sudden and calamitous energy. Today’s phaco systems, however, are more
drop in outflow suction. elaborate in terms of choice. One European system,
Dr Chang developed (for the first time again) a for example, has 84 different parameters and
programs for you to choose from.
device that would separate the debris from the main
This evolution has been fueled largely by
flow, thus allowing the vacuum to built up and remain
microphaco and the need to prevent thermal injury
constant at the desired levels. The device may
to the cornea by the bare phacotip.
undergo many design modifications with time. But
We have learnt to work at lower frequencies
the concept of a sieved outflow is a permanent legacy
(28000 MHz)and with greater efficiencies (4 and 6
of the special needs of microphaco. crystal handpieces).
f. Capulorhexis: There is essentially no change in the We have begun to truly modulate power with the
“burst mode” as also with pulse duration, width and
size, location and importance of rhexis. However,
amplitude modulation.
some surgeons who currently perform rhexis with
Better software has enabled us to alter footswitch
a forceps will have to switch to a needle. A 30 G
sensitively from the older fixed “0 to 100” settings
needle, which is easily and commercially available,
to individualized footswitch parameters too.
gives more “bounce” of the capsule because of its
Better hardware has resulted in a choice of dual
lesser weight. As a consequence, less force is
pump and dual linear systems.
transmitted to the tip and subcapsular cortex remains Many, if not all these design modifications and
virtually undisturbed. This makes for ease of operation improvements have been necessitated by the needs
and translates to greater control over the procedure. of a “cold tip” in microphaco.
g. Hydro procedures: Hydrodissection and delamination j. Cortical and capsular bag cleanup: A well performed
remain essentially unchanged, except that the hydrodissection and cortical hydration facilitate
quantum of fluid injected is just enough to induce complete bag cleanup, even with the older coaxial
Clinical Significance of Bimanual Phaco in Modern Cataract Surgery 41
tips. The bimanual I/A system, however, affords i. Firstly, if you are not already using one, switch
greater flexibility in terms of positioning—especially to an AC maintainer for all your routine phaco
for subincisional cortical matter. This advance, again, cases. Make a horizontal tunnel in the cornea at
was fuelled by the special needs of the thinner and 6 o’clock and place the ACM bevel down, such
longer incision in microphaco, which excluded the that its internal flow is circumferential. Use a
use of a conventional coaxial tip. (It needs to be stated separate fluid source (bottle) for the ACM, as you
here that, when an AC maintainer is used, we do continue to use one for your phaco handpiece.
not need the irrigating handpiece of the bimanual Once you are familiar with the flow dynamics,
I/A system). both in phaco and 1/A modes, only then should
k. IOLs : By far the greatest spin off of microphaco is you move to step 2.
the advance that has occurred, both in concept and ii. Practice rhexis under an ACM flow, without visco-
design of IOLs. It was the need of the incision, that elastics, with a 30 G needle.
a newer and more flexible generation of IOLs iii. Having mastered these two vital steps, now learn
emerged to replace the standard foldable IOL designs. to hydrodissect so as to induce a lens salute every
And this has come to pass. Today’s ultrathin lenses time. (learn to play with the nucleus and push
have taken but the first step on the long journey to it back into the bag).
an ideal lens design. Their importance, however, lies iv. Learn to reduce the nucleus down to its smallest

Section 1
in the fact that they are there and available. diameter with a good hydrodelamination. This
Special “kissing” injectors have been developed that reduces the total phaco energy required.
just abut the lips of the incision and deliver the lens v. Learn the process of folding the lens and inserting
into the anterior chamber. it into the injector. Use these microphaco IOLs
These, then, represent in a nutshell, the advances a few times even with standard phaco incisions.
that microphaco has triggered off. Become familiar with the folding and unfolding
of plate IOLs. Learn to nudge them gently within
vi. You are now ready to move on to microphaco.
a. You may well ask “But what’s in it for me? Why on
Cut the sleeve and continue irrigating the tip outside
earth should I abandon my time tested phaco
the eye. Introduce the naked tip, bevel down. Use your
existing chopper.
The answer to this is, “Learn now and be a master
tomorrow” or “Learn tomorrow and remain a student With a short burst, or with the burst mode, impale
forever”. The answer to the why is also linked to the the nucleus. Hold the nucleus in footswitch position 2,
when and how. and raise it partly out of the bag. Chop disengage the
b. When to convert? tip by coming to position one. Rotate the nucleus and
When you are comfortable with your technique and repeat the chop. Now eat as you chop further. It is safer
are delivering predictable outcomes, then is the time to chop in the iris plane outside the bag, but be sure
to shift to microphaco. to phaco within the planes and confines of the bag only.
c. How to move from one to the next? Use settings of power, flow and vacuum that you are
The learning curve can be short and flat and the familiar with. Do not experiment initially. You are well
transition seamless, provided you go about it in an on the way, now, to enjoying your surgery, each time,
orderly manner. everytime, always.
42 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

THE FUTURE The next goal is to study, understand, control,

modulate and use postoperative Bag behavior in order
We have said enough about the clinical significance and
to provide truly accomodative vision.
learning curve of microphaco. It is by no means the last
Let’s keep raising the bar!
word in cataract extraction.
Section 1
Pearls for Transitioning to Bimanual Microincision Phaco 43

Pearls for Transitioning

5 to Bimanual
Microincision Phaco

David F Chang (USA)

INTRODUCTION While the relative merits and drawbacks of bimanual

Section 1
microincisional phaco will be debated for many years,
Interest in the technique of bimanual microincisional
it is clear that this is a viable, safe, and effective alternative
phaco has been growing ever since the introduction of to standard coaxial phaco. I believe that its future
WhiteStar hyperpulse technology from Advanced popularity will be determined more by individual surgeon
Medical Optics in 2001.1 While pioneers such as Agarwal preference, rather than by any proven advantage of one
and Tsuneoka had previously published their innovative technique over the other. A similar situation exists with
research in this area,2,3 it was the ability to perform bimanual irrigation-aspiration (IA) for cortical removal,
sleeveless phaco without the risk of wound burn that with some surgeons preferring this method and others
transformed this concept into a popular movement. For preferring coaxial IA. Neither variation will displace the
the first time, surgeons could use a commercially available other purely on the basis of safety or efficacy. Nonetheless,
phaco machine with power modulations to prevent the emerging curiosity in bimanual microincisional phaco
clinically significant heat buildup during ultrasound. This is justified, and this chapter will outline strategies for
learning and mastering this technique.
is accomplished through software modifications that
Removing a cataract through a 1.2 mm incision
enable one to deliver extremely short and precise phaco
presents three distinct challenges. First, the capsulorhexis
pulses – 4 msec long—with a digitally driven phaco
and hydrodissection must now be performed through
handpiece. As a result, surgeons can vary the duty cycle
a much smaller incision. The risk of thermal injury from
during pulse mode, and can dramatically increase the a sleeveless phacotip must be reduced or eliminated.
pulse frequency. Randy Olson and others have Finally, fluidic chamber stability must be maintained in
documented the thermal safety of this strategy in cadaver the face of reduced irrigation inflow rates. When learning
eye experiments. 4-6 Most importantly, hyperpulse any new method, a helpful strategy is to master some
ultrasound is able to extract all densities of nuclei, including of the component skills in the setting of one’s regular
the brunescent end of the density spectrum. It is therefore phaco technique—in this case, standard coaxial phaco.
superior to other heat reducing technologies such as laser Fortunately, much of the bimanual microincisional phaco
phaco, sonics, and Aqualase (Alcon Laboratories). skill set can be learned in this way.
44 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)


Either an irrigating 25-gauge needle cystotome or a
microcapsulorhexis forceps can be used to create the
capsulorhexis through a 1.2 mm incision (Fig. 5.1). One
can practice and learn either small incision capsulorhexis
method immediately prior to initiating standard coaxial
phaco through a conventional incision. Performing
hydrodissection through a paracentesis is also more
difficult because viscoelastic will tend to block fluid from
exiting the incision. To prevent excessive deepening of
the anterior chamber, one should first burp out some
viscoelastic following completion of the capsulorhexis.
Even after the chamber is decompressed, the injection Fig. 5.2: Chang hydrodissection cannula (Katena) used
must still proceed carefully to avoid excessive deepening through paracentesis incision. Note corneal striae indicating
(Fig. 5.2). a hypotonous anterior chamber

benefits than learning bimanual microincisional phaco,

Section 1

and might represent the more important goal for a divide

and conquer surgeon. Certainly, one should learn and
refine basic chopping skills during standard coaxial phaco,
rather than when starting out with bimanual instrumen-
Bimanual IA is an excellent way to practice the
bimanual dexterity and coordination required for
bimanual phaco (Fig. 5.4). Fortunately, one can easily
experiment with bimanual IA following standard coaxial
phaco. In doing so, one will learn to recognize when
incisions are too tight (earlocking), and when they are
too large (decreased chamber depth and stability). One
Fig. 5.1: 25G needle used as irrigating cystotome
through paracentesis incision will also learn the ergonomic adjustments in hand position
that are basic to bimanual phaco as well.
While divide and conquer methods can be performed
with bimanual phaco instrumentation, most bimanual Since WhiteStar hyperpulse phaco was first introduced
practitioners prefer phaco chop (Figs 5.3A to C). in 2001 for the AMO Sovereign, other major machine
Naturally, surgeons proficient with phaco chop will have manufacturers have added similar technology to their
the easiest transition because they are already skilled at platforms. Hyperpulse is now available with the AMO
maneuvering and coordinating the two instruments Sovereign and Sovereign Compact, the Alcon Infiniti
simultaneously. With respect to overall safety and and Legacy, and the Bausch and Lomb Millennium.
efficiency, learning phaco chop will provide greater Surgeons should first contact their phaco equipment
Pearls for Transitioning to Bimanual Microincision Phaco 45

Fig. 5.4: Bimanual irrigation-aspiration

for cortical cleanup

representative to review recommended phaco and fluidic

settings for bimanual microincisional phaco. These
recommendations will usually be based upon the

Section 1
collective experience of other surgeons using the same
system to perform bimanual phaco.
Fortunately, one can also use routine coaxial phaco
cases to experiment with different programming options
for burst, pulse, and hyperpulse mode. Different settings
may work better for varying densities of nucleus. One
should switch from the standard 19-gauge tip to a micro
20-gauge phacotip to learn its effect on each phaco step.
Smaller gauge phacotips provide better control and safety
when aspirating epinucleus and crumbling soft nuclear
fragments. However, they slow down evacuation of large
nuclear pieces. Finally, they reduce followability and
increase chatter as mobile brunescent fragments are
emulsified. One therefore needs to chop these fragments
into smaller pieces in order to optimize followability with
a micro phacotip. All of these differences can be
evaluated with standard coaxial phaco, and many
surgeons will develop an overall preference for micro
phacotips regardless of technique.
When using a 20-gauge phacotip, the fluidic settings
Figs 5.3A to C: Bimanual horizontal phaco chop using 20G must also be adjusted in order to maintain the
phacotip and MST 20G Chang horizontal irrigating chopper comparable aspirating performance of a 19-gauge tip.
(MicroSurgical Technologies). Sovereign (AMO) overlay
indicates use of WhiteStaar hyperpulse and 400 mmHg Because of the smaller lumen, fragment evacuation will
vacuum setting proceed too slowly unless the aspiration flow rate is
46 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

increased. In addition, the smaller tip surface area reduces

the holding power for any given vacuum level, so the
latter must be increased to compensate for this. On the
other hand, one can experiment during routine coaxial
phaco cases to determine what minimum levels of
aspiration flow and vacuum are needed to efficiently
remove the nucleus. In the event of chamber instability
with bimanual instrumentation, one will have already
predetermined a less aggressive set of aspiration
parameters to use.

Although it was not originally designed for this application,
Fig. 5.6: Closeup of 0.3 mm internal lumen of
Staar Surgical’s Cruise Control device is a wonderful cruise control device
adjunct to bimanual microincisional phaco. 7,8 This
disposable, inexpensive flow restricting device can
dramatically reduce post-occlusion surge, which
Section 1

otherwise limits the ability to use higher vacuum levels

with bimanual microincisional phaco. This is because
irrigating choppers cannot provide infusion rates
comparable to those of coaxial phaco sleeves. The Cruise
Control device can be quickly attached to the aspiration
tubing of any phaco machine (Fig. 5.5). A 2-cm long
flow restrictor with a 0.3 mm internal lumen acts to
preferentially limit surge outflow, without affecting the
lower flow rates used to attract mobile particles to the
phacotip (<50 cc/min) (Fig. 5.6). This clever design
features a mesh filter that traps the nuclear emulsate
before it can enter and clog the flow-restricting segment
(Figs 5.7A and B).

Fig. 5.5: Schematic diagram of cruise control device Figs 5.7 A and B: Cruise control mesh filter before and
(Courtesy Staar Surgical) after use showing trapped nuclear emulsate
Pearls for Transitioning to Bimanual Microincision Phaco 47
Many curious surgeons will be interested in trying
bimanual microincisional phaco, without convincing
evidence that it offers any major advantages. Fortunately,
one does not need to invest in expensive alternative
technology (For example laser phaco machine) to
experiment with this method. If one already has a latest
generation phaco machine, the need for additional
instrumentation is minimal. While 1.2/1.4 mm trapezoidal
diamond blades produce microincisions that seal better,
a disposable 1.2 mm metal keratome or MVR blade will
Fig. 5.8: High vacuum (400 mmHg) setting provides work fine (Figs 5.9A and B). In addition to the disposable
maximal holding power for elevating chopped fragments

Because chamber stability is a prerequisite for safely

performing bimanual microincisional phaco, proper
incision sizes and fluidic settings are extremely important.

Section 1
From a fluidic standpoint, bimanual phaco is much less
forgiving than coaxial phaco. Cruise control significantly
increases the margin for error, and should be used during
the transition phase when the learning curve with respect
to fluidic settings and incision size is greatest. Needless
to say, surgeons can familiarize themselves with the use
and setup of this device while performing routine coaxial
phaco cases.
I still use cruise control on every bimanual micro-
incisional phaco case to optimize my ability to use high
vacuum. I have documented the fluidic stability it
provides in a series of 35 consecutive bimanual
microincisional phaco cases using vacuum levels of 400
mmHg 8 (Fig. 5.8). In addition, I find that this device
is helpful with standard coaxial phaco in complicated
circumstances, such as in the presence of zonular defects,
or when the posterior capsule is trampolining due to
insufficient zonular traction. In such cases, the risk of
capsular aspiration is high despite using vacuum levels
that are otherwise safe when employed with a normally Figs 5.9A and B: Disposable metal keratome
taut posterior capsule. (MicroSurgical Technologies) creates 1.2 mm incision
48 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

cruise control device, the only other instrument required familiarity with the phaco parameters while performing
is an irrigating chopper. coaxial phaco, one is finally ready to start performing
Instrument manufacturers now offer a wide variety bimanual phaco. Proper case selection is always
of horizontal and vertical irrigating chopper designs. MST important when learning any new technique. One should
(MicroSurgical Technologies, Redmond, WA) offers avoid overly brunescent nuclei, small pupils, narrow
bimanual irrigating/aspirating handpieces with anterior chambers, and deep-set globes.
interchangeable screw-in tips. A second important One remaining decision is whether to make a separate
decision is whether to choose a front or side-irrigating incision for the IOL, or to enlarge either of the two
chopper. This refers to the position of the irrigation ports, 1.2 mm incisions for this purpose. My advice would be
and indicates whether there is a central internal lumen, to use a separate clear corneal incision for the foldable
or an external peripheral sleeve for irrigation inflow. Most IOL, as this will generally seal better following
bimanual phaco surgeons prefer front irrigating chopper implantation. This is particularly important for the
designs because of the greater lumen diameter and transitioning surgeon, whose priority should be to
higher infusion flow rates.7 This also avoids the problem evaluate the merits and suitability of the bimanual phaco
of inadvertently retracting a side-irrigating chopper too method, rather than to perform as many surgical steps
far, such that the infusion ports exit the eye. However, as possible through a 1.2 mm incision.
a front-irrigating chopper also produces a strongly By first concentrating only on the bimanual phaco
directional stream of fluid (Fig. 5.10). If pointed toward
Section 1

chop technique, one can simplify the transition

the phacotip, this may dislodge particles being aspirated
significantly. I recommend first making the 2.7 mm
and emulsified. Therefore, one must develop the habit
temporal clear corneal incision for the IOL. Since it is
of aiming the chopper, with this invisible fluid current,
self-sealing, this will not leak during the phaco procedure.
away from the phacotip. Eventually, one learns to exploit
The two 1.2 mm bimanual incisions can be made on
this directional flow to steer peripherally located particles
each side of the central IOL incision. This allows the
toward the center of the chamber.
transitioning surgeon to complete both the capsulorhexis
THREE INCISIONS VS TWO and hydrodissection steps through the familiar standard
sized incision. In addition, having already created the
After having obtained the necessary instrumentation,
larger incision, the surgeon can easily change back to
practiced the component surgical skills, and gained
a coaxial phacotip if the chamber is unstable, or if difficulty
is encountered with the bimanual method. In this way,
the IOL incision serves as a contingency incision as well.


I suggest using a straight 20-gauge micro phacotip,
because flare tips, and curved Kelman tips are not
appropriate for 1.2 mm incisions. A 30 degrees bevel
will facilitate passing the tip through the snug incision.
Small amounts of fluid exiting the phaco incision will
splash against the exposed phaco needle hub causing
an annoying mist to spray onto the cornea. To prevent
Fig. 5.10: Front irrigating chopper with strongly
directional flow stream his, one should cut the shaft off of a standard silicone
Pearls for Transitioning to Bimanual Microincision Phaco 49
In conclusion, many curious surgeons are justifiably
interested in trying bimanual microincisional phaco. The
transition is fairly easy for surgeons already proficient
at phaco chop. If one’s phaco machine offers hyperpulse,
then the additional instrument requirements are minimal.
With respect to fluidic chamber stability, cruise control
provides a much greater margin of error for the novice
bimanual phaco surgeon. Finally, in preparation for the
transition, one can use the familiar setting of
routine coaxial phaco cases to learn the component skills
and to experiment with different phaco parameters and
Fig. 5.11: Cut blue sleeve to prevent splashing against phaco-
tip hub. Closeup view of Chang horizontal irrigating chopper REFERENCES
(MicroSurgical Technologies)
1. Chang DF. Can cold phaco work for brunescent nuclei?
Cataract and Refractive Surgery Today 2001;1:20–3.
irrigation sleeve, leaving only the hub (Fig. 5.11). 2. Agarwal A, Agarwal A, Agarwal S, et al. Phakonit:
Threading this over the needle will leave the phacotip Phacoemulsification through a 0.9 mm corneal incision.

Section 1
J Cataract Refract Surg 2001;27:1548–52.
exposed while shielding the needle hub from splashing
3. Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic
fluid.7 phacoemulsification using a 1.4 mm incision: Clinical
The irrigating chopper should be inserted prior to results. J Cataract Refract Surg. 2002; 28:81–6.
4. Soscia W, Howard JG, Olson RJ. Bimanual phacoemulsi-
introducing the phacotip to prevent chamber collapse. fication through 2 stab incisions. A wound-temperature
However, because the small incisions seal so tightly study. J Cataract Refract Surg. 2002; 28:1039–43.
5. Soscia W, Howard JG, Olson RJ. Microphacoemulsification
with internal hydrostatic pressure, one should
with WhiteStar. A wound-temperature study. J Cataract
momentarily go into foot pedal position zero as the Refract Surg 2002; 28:1044–46.
phacotip enters. If the attached irrigation tubing is 6. Donnenfeld ED, Olson RJ, Solomon R, et al. Efficacy and
wound-temperature gradient of WhiteStar phaco-
stiffly coiled, it can be difficult to maneuver and orient emulsification through a 1.2 mm incision. J Cataract Refract
the chopper once it is in the eye. Therefore, one should Surg 2003; 29:1097–1100.
7. Chang DF. Bimanual Phaco Chop—Fluidic Strategies. In:
take a moment to hold the chopper in the desired Phaco Chop: Mastering techniques, optimizing technology,
orientation outside the eye. If the tubing tends to torque and avoiding complications. Slack Inc, 2004.
8. Chang DF. 400 mmHg high-vacuum bimanual phaco
it out of position, it can be re-attached in a more attainable with the Staar cruise control device. J Cataract
favorable alignment. Refract Surg 2004; 30: 932–3.
50 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Transition to
6 Microincision Phaco

Kumar J Doctor
Mahendra D Dive
Narender Seshadri (India)
Section 1

INTRODUCTION First time in the world—cataract was removed and

Today’s phacoemulsification bears little resemblance to intraocular lens implanted through a 0.9 mm opening
the procedure that two decades ago usurped by a phaco technique called PHAKONIT. The name
extracapsular (ECCE) surgery’s place in the future of PHAKONIT has been given because it shows phaco
eye surgery. Clear corneal incisions, scleral tunnels, and (PHAKO) being done with a needle (N) opening via an
sutureless surgery are just a few of the incremental incision (I) and with the phakotip (T).
innovations that helped cataract extraction and IOL In this the cataract was removed through a 0.9 mm
implantation become what it is today. incision. The problem with this technique was to find
Cataract removal by means of phacoemulsification an IOL, which would pass through such a small incision.
has improved over the last 35 years in small, incremental On October 2nd 2001 Dr Amar Agarwal did the first
steps. The sequential introductions of capsulorhexis, case of a phakonit rollable IOL.
foldable IOLs, clear corneal incisions, and topical
anesthesia have made small improvements in the safety SYNONYMS
and efficacy of cataract surgery and as a whole have
Sleeveless phaco, bimanual phaco with microincision,
taken us one giant leap forward. There is a long history
microincision cataract surgery (MICS), ultrasmall incision
of bimanual cataract removal in pediatric cataract surgery,
cataract surgery and cool microincision phaco.
traumatic cataract, and in combination with vitreoretinal
procedures. Side-port irrigation, sleeve-free needles and
power modulation team up to take phaco to the next
level. Bimanual phaco is just another one of these small The microphaco rationale focuses on better intraopera-
steps that may ultimately enhance our ability to offer tive control. There is less turbulence, more chamber
the best surgical procedure to our patients. control, and the irrigation directs the material to the
Jorge Alió MD PhD, was the first to coin the term aspiration port for ultrasonic removal. All these have
MICS (Microincision cataract surgery). direct effect on patient satisfaction, postoperative comfort,
Transition to Microincision Phaco 51
wound integrity and safety, endothelial cell loss, likelihood for leakage and postoperative
postoperative corneal clarity, and reflux of ocular surface complications such as flat chambers or
debris into the eye that causes endophthalmitis. endophthalmitis.
3. Improvement in control of the surgery steps—
BIMANUAL MICROINCISION PHACO The major advantage we have seen from
bimanual microincisions has been an
With the development of new phacoemulsification
improvement in control of most of the steps
technology and power modulations, we are now able
involved in endocapsular surgery. Bimanual phaco
to emulsify and fragment lens material without the
may increase a surgeon’s access to nuclear
generation of significant thermal energy. Thus, the
material. The angle of attack can be steepened
removal of the cooling irrigation sleeve and separation
with a shorter tunnel, and also, a shorter tunnel
of infusion and emulsification/aspiration through two
undergoes less distortion, reducing the dimple-
separate incisions is now a viable alternative to traditional
down effect of the cornea and providing better
coaxial phacoemulsification. Machines such as the AMO
WhiteStar, STAAR sonic, Alcon NeoSoniX, and Dodick
Nd-YAG laser photolysis systems offer the potential of 4. Better capsulorhexis Control —Since viscoelastics
offering relatively “cold” lens removal capabilities and do not leave the eye easily through these small
the capacity for bimanual cataract surgery. incisions, the anterior chamber is more stable

Section 1
The transition to bimanual microincision surgery has during capsulorhexis construction and there is
permitted a glimpse regarding the advantages and much less likelihood for an errant capsulorhexis
disadvantages of this procedure and the pros may soon to develop.
outweigh the cons-especially in light of newer lens and 5. Hydrodelineation and hydrodissection can be
fluidic technology on the horizon. performed more efficiently by virtue of a higher
level of pressure building in the anterior chamber
The Advantages of Bimanual Phaco Using prior to eventual prolapse of viscoelastic through
Ultrasound the microincisions.
1. Astigmatic Neutral Incisions—Why do we need to 6. Ideal Fluidics—The separation of irrigation from
remove a lens through two 1 to 1.2 mm incisions aspiration allows for improved follow ability by
rather than a 2.5 to 3 mm incision? While it is avoiding competing currents at the tip of the phaco
true that coaxial phaco is an excellent procedure needle. In some instances, the irrigation flow from
with low amounts of induced astigmatism, the second handpiece can be used as adjunctive
bimanual phaco offers the potential for truly surgical device-flushing nuclear pieces from the
astigmatic-neutral incisions and the eye has normal angle or loosening epinuclear or cortical material
integrity immediately at the end of the surgery. from the capsular bag. Perhaps the greatest
Incision size has direct effect on patient satisfaction, advantage of the bimanual technique lies in its
postoperative comfort, wound integrity and safety, ability to remove subincisional cortex without
endothelial cell loss, postoperative corneal clarity, difficulty. By switching infusion and aspiration
and reflux of ocular surface debris into the eye handpieces between the two microincisions, 360°
that causes endophthalmitis. of the capsular fornices are easily reached and
2. Safety—In addition, these microincisions should cortical clean-up can be performed quickly and
behave like a paracentesis incision with less safely (Figs 6.1A and B).
52 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Table 6.1: Effective phaco time (EPT) and average power

Machine EPT (In Second) Average power
AMO Diplomax 16.36 60.0%
Legacy 11.51 15.0
NeoSoniX 1.5 6.5
System 7.5 8.41
Millennium 5.44 13.0
Phacoburst 3.1 8.8
STAAR wave 2.85 7.0
Sonic wave 3.95 7.6
Sovereign 2.65 2.0
WhiteStar 1.55 1.8

Table 6.2: No Edema or Straie 2 to 24 Hours Post-op.

Machine Percentage with no edema or straie

A AMO diplomax 86%

Legacy 90
NeoSoniX 98
System 77
Millennium 91
Phacoburst 100
Section 1

STAAR wave 96
Sonic wave 96
Sovereign 88
WhiteStar 100

Table 6.3: PostoperativeUncorrected VA 20/40 or

Better 2 to 24 Hours Post-op.
Machine Percentage UCVA 20/40 or better

AMO diplomax 81%

Legacy 70
NeoSoniX 96
System 54
Millennium 81
Phacoburst 100
STAAR wave 79
Fig. 6.1 Sonic wave 79
Sovereign 81
7. The small incisions increase the efficiency of phaco WhiteStar 94
by changing the movement of the currents within
the anterior chamber so that the separated 8. We have found the learning curve in making the
irrigation pushes material toward the sleeveless transition to this technique to be relatively short
phacotip. The lack of a sleeve also draws material and safe. The same coaxial technique (either
toward the phacotip. Increasing the effectiveness chopping or divide-and-conquer) can be
of phaco reduces the power delivered to the performed bimanually, differing only in the need
anterior segment, which translates to faster for an irrigating chopper for chopping methods
recoveries, less corneal edema, and less endo- (Figs 6.2 and 6.3). If difficulty arises during the
thelial cell loss (Tables 6.1 to 6.3). procedure, conversion to a coaxial technique is
Transition to Microincision Phaco 53
and postoperatively the patient may complain of
peripheral blurring. A sleeveless probe obviously
reduces corneal stromal hydration. Also, hydration
spreading from a wound 1.5 mm or smaller is
not as noticeable as from a wound 2.5 mm or
larger. Additionally, the newer lollipopping and
chopping techniques require the sleeve to be
pulled back farther on the probe, thus enhancing
hydration from the irrigating holes.
10. Rather than having to purchase nonultrasound
technology, this is an upgrade to a conventional
phaco machine (the sovereign system) that allows
Fig. 6.2 us to remove even brunescent lenses where laser
phaco is ineffective. Also, WhiteStar circumbents
the chatter and turbulence that is normally seen
with brunescent fragments and a micro-phacotip.
The “cold” energy source does not cause wound

Section 1

Advantages in Difficult Situations

Bimanual microincision surgery offers improved fluidics
along with enhanced chamber stability, and it greatly
minimizes incisional outflow so that it approaches the
ideal scenario of operating in a completely closed system.
Because of these reasons, surgeons can use it in a variety
of difficult situations like zonular weakness or dialysis.
The bimanual setup is ideal for this situation due to the
tight incisions and low inflow/outflow volumes. There
Fig. 6.3 is no loss of viscoelastics during capsulorhexis and
therefore no fluctuation of the lens with stress on the
simple and straightforward, accomplished by the already compromised zonular apparatus. Also, we can
placement of a standard clear corneal incision alternate the microincisions to emulsify the nuclear
between the two bimanual incisions. material towards the area of dialysis as pulling away can
9. Using a sleeveless phaco probe also offers the stress and unzip the remaining intact zonules.
advantage of decreased hydration of the corneal In the situation where the capsule is torn and you
stroma surrounding the tunnel incision. A sleeved need a gentler and more precise I/A system, bimanual
probe has two irrigating holes in its side that allow is fabulous to remove residual cortex from the capsular
BSS to flow tangentially from the probe and bag in the presence of an open posterior capsule.
directly hydrate the corneal tunnel incision stroma. Another situation might be Fuchs’ dystrophy, for
The secondary whitening of the stroma can which less total irrigation volume might be safer and might
obstruct the view of the surgeon intraoperatively, better preserve the viscoelastic shield.
54 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Moreover, even when implanting a conventional IOL needle or finding some forceps to do the
after microincision phacoemulsification, surgeons will capsulorhexis through a microincision.
have the option of creating a new incision for an IOL Solution: Capsulorhexis construction requires the use
insertion as an astigmatic tool to treat any pre-existing of a bent capsulotomy needle or specially fashioned
cylinder. coaxial rhexis forceps that have been designed to
In case of recurrent microhyphema due to iris perform through these small incisions (Figs 6.4 A to
neovascularization, cauterization is achieved under direct C). Surgeon has to use the fingers instead of the wrist.
visualization with a microcautery through one of the Although more time is initially required, with
microincisions and pinch the tubing of the irrigating experience, these maneuvers become routine.
handpiece through the other. A laser capsulorhexis is very easy and safe to do even
Finally, we find that our refractive lens exchanges through a 1.0 mm incision, but a mechanical
are dramatically facilitated by this technique. capsulorhexis is more resistant against capsular breaks
during phacoemulsification. Hence the laser
Disadvantages of Bimanual Phaco Using handpiece is preferred only in pediatric cases, patients
Ultrasound with a hypermature cataract, and in all those cases
The disadvantages of bimanual phacoemulsification are with increased risk of capsular rupture during
real but easy to overcome. capsulorhexis.
Section 1

A standardized technique has not been developed 3. Problem: Maneuvering through 1.2 mm incisions
yet for cataract surgeons to use with bimanual phaco, can be awkward early in the learning curve. Because
so the technology requires a certain sense of adventure the instruments move so tightly through the incisions,
and creativity. The main disadvantage is that, compared there are issues of “oarlock”, in which any lateral
to conventional phaco, the procedure is less forgiving movement of the instrument tends to move the entire
with respect to incision size (must be exact), fluidics (easier eye and distorts the cornea.
to experience surge), and chopper maneuverability Solution: Surgeon must learn how to move the
(more cumbersome and can lose inflow when retracted). instruments to and fro, similar to a piston, as they
1. Problem: The incision size is critical. An incision that perform the procedure. If lateral movements are
is too large compromises chamber stability, and one necessary, the incision must act as the fulcrum for
that is too tight restricts the movement of the the movement of the phacotip or irrigating chopper,
instruments. Wounds must be tight in order to just like an orelock for an ore. Surgeons can learn
prevent intraoperative leakage. Therefore, extraction these techniques by performing bimanual I/A first A
probes, irrigating choppers, bimanual I/A instruments, Kelman style curved phacoemulsification needle can
and even vitrectomy probes must all be standardized be used because it enhances the ability to maneuver
to the same gauge. the nucleus.
Solution: A disposable 20G MVR blade produces a 4. Problem: The nondominant hand holds the chopper
reproducibly exact incision for the 20G and carries out most of the work. The increased
instrumentation. diameter and weight of the irrigating chopper
2. Problem: The problem involved is performing a somewhat limits the mobility and the user must avoid
capsulorhexis through a 1.0 mm incision. As lot of retracting the chopper so far that the irrigation port
surgeons stopped doing a full-needle capsulorhexis slides out of the anterior chamber.
sometime back and been using forceps since so it Solution: Practice holding on to a heavier instrument
is either a question of re-learning how to use the with your nondominant hand by using bimanual
Transition to Microincision Phaco 55
I/A. Surgeons can actually practice the nucleus
manipulation with the irrigating nucleus rotator but
without infusion as you use coaxial phacoemulsification
in the transition phase. For the surgeon using the
divide-and-conquer technique, irrigation can be
accomplished with the bimanual irrigation handpiece
that can also function as the second “side-port”
instrument, negating the need for an irrigating chopper.
5. Problem: When finishing a case or encountering
trouble, the surgeon’s natural reflex is to remove the
second instrument (hook or chopper) first before
removing the sleeved extraction probe. This technique
prevents the eye from collapsing, but it must be
reversed when using an irrigating chopper.
Solution: The surgeon should remove the extraction
probe before the irrigating chopper in order to
prevent chamber collapse. The surgeon must learn

Section 1
this unnatural behavior.
6. Problem: Fluidics is a big problem by nature of the
size of these incisions, less fluid flows into the eye
than occurs with coaxial techniques. It is a low inflow/
outflow technique. Most current irrigating choppers
integrate a 20 gauge lumen that limits fluid inflow.
This can result in significant chamber instability when
high vacuum levels are utilized and occlusion from
B nuclear material at the phacotip is cleared. Using high
vacuum is more difficult and requires a machine that
allows changing vacuum memory settings on the fly
with the foot pedal.
Solution: One must maximize the bottle height and
lower the aspiration flow and vacuum. Thus, infusion
needs to be maximized by placing the infusion bottle
on a separate IV pole that is set as high as possible
above the eye. Also, vacuum levels usually need to
be lowered below 350 mmHg to avoid significant
surge flow. By bringing cataractous material to and
holding it at the phacotip, bimanual phaco allows
the surgeon control and efficiency despite its less
aggressive settings.
C Anterior chamber maintainer can be helpful for
Figs 6.4A to C beginners. It allows the surgeon to use skills and
56 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

techniques he has already developed. It works best incisions. The recent and ongoing development of
when situated 180o from the cataract incision. IOLs, which can be inserted through incisions less
7. Problem: In addition, there was a considerable than 1.5 mm, should really bring microincision
amount of spray from the phacoemulsification needle, phacoemulsification into its own as a routine
particularly the hub. Not as in conventional procedure.
phacoemulsification, where the sleeve covering the Bimanual phaco takes a little longer to perform it
needle prevents the spray. is somewhat more difficult to maneuver the instruments.
Solution: To prevent it when using a sleeveless Additional equipments are necessary. All of the major
technique, place the phacoemulsification sleeve hub instrument companies are currently working on irrigating
normally and then tear the sleeve off. choppers and other microincision adjunctive devices.
Also, one has to make some adjustments with the • Microincision keratomes (Figs 6.5A and B)
configuration of the system’s fluidics. To correct • Capsulorhexis forceps (Figs 6.6A to C)
inadequate irrigation, use an instrument with more • Hydrochoppers (Figs 6.7A to F)
than 40 cc/minute flow used for irrigating and the • Bimanual I/A handpieces (Fig. 6.8).
bottle height is raised. Also one can try using an
aquarium pump for forced infusion. In addition, to TECHNOLOGIES AVAILABLE ON
prevent siphoning from the irrigation outlet on the DIFFERENT MACHINES (Figs 6.9A to F)
Section 1

handpiece, place a plastic syringe cap on the top of The newer generation ultrasound systems allow any
the outlet. cataract phaco surgeon to provide the benefits of
8. Problem: Spindling—Additionally, there are times
when the material being emulsified will actually spindle
on the sleeveless phacotip. The tip will puncture right
through the fragments, which will then slide down
the tip, forcing the surgeon to pull the tip back and
immobilize the fragment in order to access it.
9. Problem: The current limitations in IOL technology
perhaps the greatest disappointment are the need
to place a relatively large 2.5 mm incision between
the two microincisions in order to implant a foldable
IOL. An analogy is clear to the days when phaco
was performed through 3 mm incisions that required
widening to 6 mm for PMMA IOL implantation. It
was not until the development of foldable IOLs that
we could truly take full advantage of small-incision
phaco. Similarly, we believe the advantages of
bimanual phaco will prompt many surgeons to try
this technique, with the hopes that the “holy grail”
of microincision lenses will ultimately catch-up with
technique. Although these lenses are currently not
available, many companies are developing lens B
technologies that will be able to employ these tiny Figs 6.5A and B
Transition to Microincision Phaco 57

Fig. 6.6C
Fig. 6.6A

Fig. 6.6B

Section 1


Figs 6.7A to F
58 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 6.8

Section 1



6.9B 6.9E
Transition to Microincision Phaco 59
• CMP-Oertli (Swiss)
• Infiniti, NeoSoniX, accurus-alcon (USA)
• Advantec-legacy
• STAAR sonic, and
• Dodick Nd-YAG laser photolysis systems

How does WhiteStar work?
In WhiteStar technology, a microprocessor allows the
ultrasound on/off cycle to occur in a variable ratio in
two-tenths of millisecond intervals. This is so rapid that
the natural propulsive force or jackhammer effect of the
ultrasound is counteracted by vacuum, thereby
improving efficiency and followability, giving an almost
magnetic appearance to the behavior of the fragment
on the phacotip. This becomes most significant at higher
6.9F powers of phaco energy for denser lenses where the

Section 1
Figs 6.9A to F required increase in the stroke length can cause chatter
of the more rigid fragments with standard technology.
bimanual microincision cataract surgery (MICS) to their In this system, the energy is delivered in extremely
patients. brief microsecond bursts interrupted by rest periods. The
Every surgeon with expertize in standard ultrasonic burst and rest periods lengths are independently variable
phacoemulsification can easily make the transition to and programmable, and full ultrasound cutting is
bimanual MICS. Some adaptation is required to work available. Thermal energy is markedly reduced at the
through and maintain a narrow, watertight incision, but incision because of this technology, which produces a
there is no need to overcome a significant learning curve. new and enhanced kind of cavitation, that of transient
However, it is important to realize successful MICS cavitation, which is a major enhancement in the ability
involves not just removing the phacotip sleeve, but to cut and disrupt nuclear material.
requires the availability of specific power modulation Thus, the energy that breaks the cataract is a
software and instruments. Otherwise, there will be combination of both the jack hammer force and the
efficiency without safety or safety without efficiency. MICS cavitation effect acting synergistically. We can use a linear
has advantages for minimizing trauma and improving setting for the power and adjust it based on the nuclear
patient outcomes, and MICS performed with low density. One can set the intervals of on/off differently
ultrasound phaco is universal in many respects. for the unoccluded state when we are trying to hold
Ultrasound is the only energy source powerful enough the lens and then become maximally efficient when the
to be used for all types of cataracts. The procedure can tip is occluded so that we use it to our greatest advantage
be performed with virtually any newer generation phaco (Fig. 6.10). With WhiteStar the author does not have
machine, and with adequate instruments, by any phaco to set the linear power any higher than 5 percent for
surgeon over a fast and smooth learning curve. fragment removal, even for the most brunescent nucleus.
• WhiteStar sovereign-allergan (USA) We get reduced effective phaco times (EPT) with
• Millennium-Bausch and Lomb (USA) effectively the same cutting level. For every microburst
60 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 6.10

Fig. 6.13

gets above 27 to 30°C. Hence much safe and no corneal

burn/whitening. A study showed a statistically significant
3-month postoperative difference between standard
sovereign and sovereign with WhiteStar, as endothelial
Section 1

cell loss were 450 and 320 cells per mm respectively.

This benefit directly translates into postoperative
preservation of endothelium and therefore quality of
Fig. 6.11
corneal health and vision of the patients (Fig. 6.14).

Parameters - raising the bottle height, decreasing vacuum

to 200 mmHg and reducing flow rate to 20 per minute.
Can use 66 percent power on and 33 percent power
off or vice versa.

Steps—The procedure is performed through two 1.4

mm incisions and 90° apart, which are the size of a 20

Fig. 6.12

there is the transient cavitation acting, the actual working

cavitation and hence the dosage of energy to the patient
is less (Figs 6.11 to 6.13).
WhiteStar technology allows use of the bare-needle,
20 gauge incision. The system uses pulsed bursts of
energy followed by a period that allows for heat
dispersion. It takes 60°C to damage collagen, whereas,
the temperature of the phacotip with WhiteStar never Fig. 6.14
Transition to Microincision Phaco 61
can learn how to use and maneuver the instruments
before attempting phaco. Additionally, the authors
believe that this technique is best used in a phaco chop
(Figs 6.16A and B) procedure, as manipulating these
instruments for sculpting is difficult.
• “Whitestar has given us safe microincision surgery.
The wound burn has disappeared and post-occlusion
surge has already been dealt with by the fluidics on
the sovereign system. This means that this surgery
is possible for those who use the sovereign just by
upgrading their system.”

Fig. 6.15

gauge needle. The primary incision (Fig. 6.15) accommo-

dates the sleeveless micro-phaco needle and the
secondary side-port incision is for the irrigating nucleus

Section 1
rotator or chopper. Beginners can re-check the size of
the incisions before proceeding further.
The small size of the incisions maintains the water
tightness of the incisions throughout the procedure and
the cool sleeveless phacotip eliminates the possibility of
burning the primary incision.
The capsulorhexis can be made with either a needle
or microforceps. After this step the primary incision can A
be enlarged.
Another step in the process of converting to a
bimanual procedure is learning to use the irrigation and
aspiration (I/A) instruments for bimanual I/A, the side-
port for aspiration, and alternating with the side-port
for aspiration or irrigation. While the surgeon is doing
that with the standard phaco incision, side-port aspiration
can be used to learn how to use the instrument with
the non-dominant hand. Micro-phaco is effective and
efficient and allows use of an ultra-small incision. There
is a significant learning curve with bimanual phaco. At
the beginning of the phaco procedure, the surgeon
should make two paracenteses and use one paracenteses
for irrigation and one for aspiration. This method teaches B
the same principles as bimanual phaco, and the surgeon Figs 6.16 A and B
62 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

• Whitestar has the major advantage of being able to Also, the millennium’s newer phacoburst power
emulsify grade 4+ brunescent nuclei, unlike the non- modulation technology reduces the total amount of
ultrasound modalities such as laser and sonic energy. energy delivered during the procedure and thus the risk
• Sovereign with WhiteStar offers the safety of laser of thermal injury.
while maintaining the efficiency of ultrasound for “The results of a study conducted comparing
cataracts of any hardness. phacoburst with pulse confirm the advantages of the
former technology for lowering energy delivery as
Millennium MicroSurgical System measured by reduced absolute power levels when
(Bausch and Lomb) operating on matched nuclei.”
Bimanual phacoemulsification can be performed safely One can operate through two 1.4 mm incisions using
and effectively with the Millennium MicroSurgical System the 1.1 mm microflow needle with a 30° bevel tip and
a 19 gauge irrigating chopper with two ports. The
(Bausch and Lomb), said Rosa M. Braga-Mele, MD,
machine settings consist of burst mode at 80 msec
presented two studies. She conducted investigating
intervals, 20 percent power, and a vacuum range of
bimanual sleeveless phaco with the millennium system.
165 to 325 mmHg; bottle height is set at 125 to 130
First, a feasibility study was undertaken in cadaver eyes
cm.The absolute phaco times (sec at 100% power)
where she measured temperature at the sleeveless
ranged from 0 to 4 seconds and the total procedure
phacotip using different operating conditions and found
time took 7 to 11 minutes with a median of 8.76
Section 1

no concerning temperature rises occurred when using

minutes. There is a learning curve for bimanual phaco,
usual clinical parameters. Reassured by those results, she
and the procedure time decreases with more experience.
moved into clinical use, and she reviewed her experience
At the 1-day postoperative visit, she found all the
in her first 30 patients that showed it was possible to
wounds were well-opposed and all eyes manifested 1+
remove 1+ to 4+ nuclei safely without causing wound
corneal edema around the wound, which was expected
burn while achieving good outcomes as measured by
because the incisions were enlarged to 3.2 mm for IOL
postoperative corneal clarity and visual acuities.
insertion. However, central edema of 1+ severity was
present in only a single eye, which represented the first
Advantages of System
case with a 4+ cataract. Median uncorrected visual acuity
It was postulated that it would be feasible to do a (UCVA) was 20/30 with a range of 20/25 to 20/50at
bimanual procedure with the millennium system based the 1-day visit, but at 1 week all eyes accept one with
on consideration of several of its features. Since it macular changes were seeing 20/20. Edema was
operates at a relatively lower ultrasound frequency than completely absent-both centrally and around the
other systems 28.5 kHz versus 40 to 50 kHz theoretically, wound-in all eyes at that follow-up.
the millennium would be expected to generate less heat Before beginning to perform bimanual phaco in her
compared with systems running at higher frequencies. patients, she investigated its safety in a series of cadaver
In addition, because the millennium features dual linear eyes. She used the 1.1 mm microflow needle modified
control of vacuum, the surgeon can rely more on to be fitted with a type J thermocoupler that would sit
vacuum to remove nuclear pieces while maintaining within the wound. Wound temperature was sampled
lower power levels. three times per second to monitor for elevations above
Furthermore, the on-flight control of vacuum with 45°C and the wounds were observed for whitening or
the millennium foot pedal minimizes anterior chamber contracture as signs of thermal injury.
instability during the procedure and so permits use of “These same endpoints were used previously in a
higher flow rates. study performed investigating temperature elevations
Transition to Microincision Phaco 63
occurring with the WhiteStar technology for the sovereign Ultrapulse Ultrasound vs Lasers
(AMO) system.” (Erbium: YAG, Dodick Laser)
Three test conditions were evaluated, each on two
The analysis of outcomes in cases of bimanual MICS
eyes: pulse mode at 5 pulses/sec; phacoburst at 80-msec
performed with WhiteStar, (Dr Franchini) reported the
burst width interval; and Phacoburst at 160-msec burst
effective phaco time was less than one second for 1+
width interval, while the wounds were irrigated with
cataract and averaged only 14 seconds for 4+ nuclei.
balanced salt solution (BSS) as would be done in the
In contrast, using the erbium laser, it took him 24 seconds
operating room.
on average to remove cataracts in eyes with 1+ nucleus
With phacoburst at 80-msec burst width interval and
and close to nine minutes for the hardest nuclei, he
power at 100%, the maximum temperature reached was
33.6°C when non-occluded and 41.8°C when occluded.
The ultrasound MICS procedure proved safe, with
Using the 160-msec burst interval, significant temperature
no statistically significant differences in postoperative
elevation occurred only when power reached 80 percent.
“This study showed that with the 80-msec burst uncorrected visual acuity outcomes, endothelial cell
interval, the temperature remained at a safe level whether density loss, or increased stromal thickness when
occluded or not. Using 160-msec burst interval, the comparing the WhiteStar series with eyes operated on
temperature rose to 53.2°C at 80 percent power. using the erbium laser. He compared his results
performing low ultrasound power MICS with

Section 1
However, in the clinical setting, one never needs to raise
the power above 20 percent to get the desired results, prechopping and reports from Warner et al. and
even in the hardest nuclei.” Kanellopoulos et al. who performed MICS with Dodick
Without occlusion and operating in pulse mode, laser photolysis.
power could be increased to 100 percent without causing
the temperature to rise above 43.8°C. However, in the IOL’s for MICS (Acri.Tec and ThinOptX)
occluded state, the temperature rose above the safety
Each seems to have its own unique set of advantages.
threshold at 30 percent power within 40 seconds.
The Acri. Smart IOL from Acri.Tec is a very comfortable
Power Modulation lens for the ordinary surgeon to use. Its hydraulic injector
New ultrasound power modulation technology allows is available on the market and is an excellent device,
MICS to be performed efficiently and safely without and in the eye, the Acri.Smart seems to behave as any
significant heat build-up at the ultrasound tip. For some foldable IOL with a superb optical performance and a
surgeons sovereign® with WhiteStar™ (AMO) is the very low or minimal rate of PCO.
ultrasound system of choice for performing MICS, while ThinOptX has also developed a very innovative
others prefer the Accurus (Alcon) with burst mode and injector for its IOL. This IOL also offers good optical
the 1.2 mm sleeveless tip of the Mackool system. Both performance, and while the PCO rate is under
reported advantages of using ultrasound compared with investigation, he noted YAG laser capsulotomy could be
laser. An erbium: YAG laser has a safety advantage performed successfully and without any further
compared with ultrasound because it dramatically reduces complications in eyes implanted with the ThinOptX IOL.
the amount of energy expended in the eye, its use is Other favorable features of the ThinOptX IOL include
limited to soft nuclei. Sovereign® with WhiteStar™ offers its capability for pseudo-accommodation, the implications
the safety of laser while maintaining the efficiency of of which are being further investigated, and its feasibility
ultrasound for cataracts of any hardness. for implantation in the sulcus.
64 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 6.18: ThinLensTM optics

ThinLensTM Optics
The drawing labeled ThinLens TM optics (Fig. 6.18)
illustrates the optical characteristics of the ThinOptX lens.
The front surface is a curve that approximates a radius.
The back curve is a series of steps with concentric rings.
The back surface can be concave, convex, or plano. The
Section 1

combination of steps with the front radius corrects for

spherical aberrations. The convex and plano back designs
can be used for positive power lenses. The concave or
meniscus back surface is used for negative powered
B lenses. In the drawing labeled refractive lens (Fig. 6.19)
Figs 6.17A and B lines intersecting the lens represent parallel light. The
light is bent at the intersection of the lens surface in
ThinOptX Rollable IOL accordance with Snell’s Law. When light strikes the lens
ThinOptX the company that manufactures these lenses surface, the light is bent toward the central axis. The
(Figs 6.17A and B) has patented technology that allows light travels to the back edge of the lens and again is
the manufacture of lenses with plus or minus 30 diopters bent toward the central axis. All the parallel light rays
of correction on the thickness of 100 microns. The entering the back of the lens come to focus at
Thickest part of the lens is 350 μm and the haptic part approximately the same point, therefore the lens is a
of the lens is as thin as 50 μm. The ThinOptX technology refractive lens.
is not limited to material choice, but is achieved instead
of an evolutionary optic and unprecedented nano-scale Glare
manufacturing process. The lens is made from off-the- The diagram in Figure 6.13 illustrates an eye and lens.
shelf hydrophilic material, which is similar to several IOL The light (Figs 6.19A and B) hits the edge of the lens
materials already on the market. The key to the and is reflected unfocused into the eye. With the
ThinOptX lens is the unique optic design and nano- condition, halo, streaks and a general loss of contrast
precision manufacturing. The basic advantage of this lens would seem logical.
is that they are ultrathin lenses. These lenses are called With the ThinLensTM technology each ring has an
the ultrachoice 1.0 lenses. exposed edge of 50 microns or less. On average there
Transition to Microincision Phaco 65
Other Aberrations
The ThinLensTM is so thin that the error goes away. With
a central axis thickness of 50 microns for a meniscus
lens and 300 microns for a bi-convex or plano optic,
there is little error in measuring the lens due to thickness.
In fact, with the ThinLensTM one can measure lens
designed to the same power without adjusting the lens
bench. The thinness is one of the reasons the ThinLensTM
can be manufactured in 1/8 diopter increments.

Fresnel Lens
By definition, the ThinOptX lens is not a Fresnel lens.
The drawing labeled Fresnel lens is shown in Figure 6.20.
As seen from the drawing (Fig. 6.20), the lens has
multiple focal points. This makes this style lens diffractive.

Section 1
Figs 6.19A and B: Glare and halos

are three rings per lens plus the outer edge of the lens. Fig. 6.20

The cumulative ring edges are 200 microns. This is much

The normal lines on the back surface of the Fresnel
less area than a standard or meniscus lens. This helps lens do not originate from the same point; therefore,
patients not complaining of glare or halos, even under the back surface of the lens functions as a series of prisms.
low light conditions. By selecting the angle the incoming light rays make with
the normal line of each prism, one can choose the focal
Spherical Aberration pattern of the resulting light. One such application is the
The ThinOptX lens is manufactured to eliminate most headlamps of an automobile. The second surface of the
of the spherical aberrations. Each curve on the back has ThinLensTM is designed to assist the front surface in
a slightly different radius. The slight change in curvature focusing the light at a single point, which by definition
on each back surface will assure one focal point. is a refractive lens.
66 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 6.21

The lens is taken out from the bottle (Fig. 6.21). The
lens is then held with a forceps. The lens is then placed
in a bowl of BSS solution that is approximately body
temperature. This makes the lens pliable. Once the lens
is pliable it is taken with the gloved hand holding it
Section 1

between the index finger and the thumb. The lens is

then rolled in a rubbing motion. It is preferable to do
this in the bowl of BSS so that the lens remains rolled
well. It is better to do this without gloves as the rolling
is much better.
The lens is then inserted through the incision carefully B
Figs 6.22A and B
(Figs 6.22A and B). The tip of the haptic should have
a pointed shape, which will allow the lens to penetrate
the corneal wound. One can then move the lens into
the capsular bag (Fig. 6.23). The teardrop on the haptic
should point in a clockwise direction. The smooth optic
lenticular surface will be facing posterior. The natural
warmth of the eye causes the lens to open gradually
(Fig. 6.24). Viscoelastic is then removed with the
bimanual irrigation aspiration probes (Fig. 6.25). The
tips of the footplates are extremely thin which allow the
lens to be positioned with the footplates rolled to fit the
eye (Figs 6.25 and 6.26).
Medennium is developing its SmartLens—a
thermodynamic accommodating IOL. It is a hydrophobic
acrylic rod that can be inserted through a 2 mm incision
and expands to the dimensions of the natural crystalline
lens (9.5 mm 3 3.5 mm). A 1 mm version of this lens Fig. 6.23
Transition to Microincision Phaco 67
is also being developed. ThinOptX lenses will also be
able to be implanted through 1 mm incisions. Injectable
polymer lenses are being researched by both pharmacia
and Calhoun Vision.13,14 If viable, the Calhoun Vision
injectable polymer offers the possibility of injecting a light-
adjustable lens through a 1 mm incision that can then
be fine-tuned postoperatively to eliminate both lower-
order and higher-order optical aberrations. Collamer
lenses (STAAR) is highly biocompatible poly HEMA based
copolymer lens into which collagen and UV absorbing
chromophore have been covalently bonded. Because
of collagen’s negative ionic charge it prevents protein
Fig. 6.24 deposits and hence inflammation is minimized. It is
exceptionally foldable and opens slowly into the eye and
hence allows better control for the surgeon. It has a
unique ability to repair itself after exposure to YAG laser

Section 1
1. Every surgeon with expertise in standard ultrasonic
phacoemulsification can easily make the transition to
bimanual MICS.
2. For their initial cases, surgeons should choose a
posterior subcapsular cataract with a 1+ or 2+
nuclear hardness to build confidence. They can easily
Fig. 6.25
convert to their usual technique to prevent any
3. Performing bimanual microincision phaco requires
to rethink your cataract process.
4. An important step in the process of converting to
a bimanual procedure is learning to use the irrigation
and aspiration (I/A) instruments for bimanual I/A. Use
two 1 mm paracenteses on either side and develop
bimanual dexterity.
5. Holding onto a heavier instrument with one’s non-
dominant hand is something that every surgeon
should practice before trying bimanual phaco.
6. The viscoelastics used during the procedure need to
be managed differently from during a standard
Fig. 6.26 procedure, in that there must be fluid egress during
68 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

hydrodissection to avoid rupturing the posterior 2. Dr.Braga-Mele. Assistant professor of Ophthalmology,

University of Toronto, Ontario.
capsule, which can easily be done when using high- 3. David F. Chang. MD, is Clinical Professor at the University
density cohesive viscoelastics. of California, Dr. Chang may be reached at (650) 948–
7. Parameters—With the new technology, the surgeon
4. Fine IH, Packer M, Hoffman RS. New phacoemulsification
will learn the fluidics, because the bottle height, technologies. J Cataract Refract Surg 2002; 28; 1054–
vacuum, and flow must be adjusted with the new 1060.
5. Joseph F. Gravlee, Jr, MD, MSEE, ABES. Dr. Gravlee may
bimanual technology. be reached at (251) 990–3937;
8. The procedure can be performed with virtually any 6. Laura J Ronge: Clinical Update; Five ways to avoid phaco
newer generation phaco machine, and with adequate burns; Feb 1999.
7. Soscia W, et al .J Cataract Refract Surg 2002; 28; 1044
instruments, by any phaco surgeon over a fast and 8. Sunita Agarwal, Athiya Agarwal, Mahipal S. Sachdev, Keiki
smooth learning curve. R. Mehta, I Howard Fine, Amar Agarwal: Phacoemulsifi-
cation, Laser Cataract Surgery and Foldable IOL’s, Second
edition Jaypee Brothers; 2000, Delhi, India
BIBLIOGRAPHY 9. William J. Fishkind, MD, FACS. Dr. Fishkind may be
reached at (520) 293–6740;
1. Benjamin F Boyd, Agarwal S, Agarwal A, Agarwal A: Lasik
and Beyond Lasik; Highlights of Ophthalmology; 2000,
Section 1
Ocular Biometry and Intraocular Lens Power Calculations in Microphaco 69

Ocular Biometry and

7 Intraocular Lens Power
Calculations in
Arif Adenwala
S Natrajan (India)

Section 11
INTRODUCTION Applanation A-scan Biometry

The various technological advances in phacoemulsifi- In cases of A-scan biometry using applanation method,
the ultrasound probe is placed directly on the corneal
cation, phaco machines and IOL design have resulted
surface. Initially topical anesthetic eyedrop is instilled in
in increase in expectation of both surgeon and patient.
the eye and then probe is placed on cornea. This can
One of the important step in postoperative visual
be done at slit lamp or by holding the probe with hand
outcome is A-scan biometry and IOL power calculations.
which is commonly used.
The major components of IOL power calculations are
axial length, keratometry measurements and use of
accurate IOL formula. Thus, it is important that each
ophthalmic surgeon should have good knowledge of
biometry and recent lens power calculations methods.
Recently a new technology using laser interferometry
(IOL Master) has been developed to improve the
accuracy of axial length measurement.
Fig. 7.1: Normal contact echogram (A- Anterior lens
capsule; P- Posterior lens capsule; R- Retina; S- Sclera)
The various spikes seen by these techniques are:
Different A-scan Techniques Available 1. Initial spike (cornea)
A. Applanation A-scan 2. Anterior lens capsule
B. Immersion A-scan 3. Posterior lens capsule
C. Immersion vector A/B-scan. 4. Retina
70 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

5. Sclera The technique is very useful on area of posterior

6. Orbit. staphyloma, mature cataract and high myopia.

Advantages: The main disadvantage of this technique Disadvantage: It is more expensive and requires greater
is compression of cornea due to applanation. This can level of skill to perform the technique.
lead to error in measurement of axial length. The error
is between 0.14 mm to 0.28 mm.
The main advantage is minimal learning curve and The main important reason for improper IOL power
very easier to perform in minimum time. calculation is an error is measurement of axial length.
Initially A-scan biometer using 10 MHz ultrasound
Immersion A-scan Biometry probe was used but had limited the resolution to
approximately to 0.10 mm.
In this technique, the ultrasound probe does not come
IOL Master is recent method of accurately measuring
in contact with the cornea directly.
the axial length.
A coupling fluid is placed between the eye and probe
It is non-contact method using partial coherent beam
in this technique. It requires the use of Prager scleral
of light. It uses infrared light source and has increased
shell or set of Ossoinig scleral shell. The shell is placed
accuracy from 0.10 mm to between 0.02 mm and 0.01
between eyelids over the cornea. It is then filled with
mm. It is about 5 times more accurate.
mixture of goniosol and dacrtose. The probe is then
Section 1

IOL Master uses a modified Michelson interferometer

placed on the solution avoiding contact with the cornea.
to measure axial length with good accuracy. This creates
The display screen will exhibit 6 spikes in the phakic
a pair of coaxial 780 nm infrared light beam with
patient than 5 because probe and cornea are no longer
coherence length of approximately 130 nm.
contact with each other, thus appearing separate.
When the ultrasound probe is properly placed, we Technique
can see few spikes on the screen and they are steeply Axial length measurements with IOL Master are very
rising. easy and quick. Patient is seated on chair with chin resting
The few spikes are of cornea, anterior and posterior on chinrest. The overview mode is used for course
lens capsule, retina and sclera. alignment. The patient looks at small yellow fixation
light. The patient then looks at the small red fixa-
Advantage: It is more accurate than applanation method
tion light so that accurate axial length measurements are
as it removes the error due to corneal indentation.
It also reduces technician dependency.
A high degree of flexibility is seen on measuring axial
Important: Change the settings on the machine to length. The examiner selects a best area and takes
immersion mode if it is not done automatically. measurement from that point. An ideal axial length
display is far more important than high signal noise ratio
Immersion Vector A-scan/B-scan Biometry
In this recent technique, there is two dimensional B-scan
display with the A-scan spikes. Ideal Axial Length Recording
The A-scan vector is adjusted such that it passes The characteristics are:
through center of cornea and thus the vector will intersect i. SNR ratio greater than 2.0.
the retina in region of the fovea. ii. Tall narrow primary maxima, with a thin well
The main advantage being direct axial length center termination and one set of secondary
measurement from and the region of the fovea. maxima.
Ocular Biometry and Intraocular Lens Power Calculations in Microphaco 71
IOL Master measures the central corneal power by
automated keratometry. The instrument takes five
keratometry readings within 0.5 seconds and takes the
average. The latest software version (3.01) has improved
keratometry software which will send alert signals in cases
of highly variable readings.
IOL Master also measures anterior chamber depth
using lateral slit illumination at approx. 30° to optical
axis. The various formulas put in IOL master are
Holladay, SRK/T, Haigis, SRK II and Hoffer Q. The
preferred formula which is used is SRK/T.
IOL Master software can accommodate as many as
20 doctors, each having 20 preferred IOLs and corres-
ponding lens constants.
This with the introduction of IOL Master, there is new
era of high resolution lens power calculation which is
highly accurate.

Section 11
Fig. 7.2: IOL Master
iii. At least 4 out of 20 measurements should be POWER
within 0.02 mm of each other.
Theoretical Formulas
Advantages All the theoretical formulas used for calculation of lens
It is useful in eyes with corneal opacities, high myopes power are based on a two lens systems, i.e. the cornea
or hypermetropics, aphakics and eyes filled with silicone and the pseudophakos lens focussing images on the
oil. retina.
It is more accurate and reproducible than contact 1. Basic theoretical formulas: These include
ultrasound in providing accurate AL measurements. Colenbrander’s, Fyodorov’s and Van der Heijde’s
Axial length, keratometric reading and anterior formula which yield approximately the same IOL
chamber depth can be measured. This concurs a save powers.
in time without need that the patient changes his position. Binkhorst’s formula yield 0.50 D stronger lens power.
As it is non-contact technique, the risk of corneal lesion 2. Modified theoretical formulas: These include Hoffer’s
and transmission of infection from patient to patient are formula, Shamman’s fudged formula and Binkhorst’s
also excluded. adjusted formula. The fudged formula is a
modification of Colenbrander’s formula.
Limitations The various theoretical formulas are described in Table
IOL Master being optical device, any media opacities 7.1:
in axial region will cause problem in measurement.
In case of mature or dark-brown/black cataract, Regression Formulas
corneal scars or vitreous hemorrhages, where there is These formulas are derived empirically from retrospective
interference in passage of partial coherent light, the test computer analysis of data of patients who have
is not highly accurate. undergone surgery before.
72 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Table 7.1: Theoretical formulas for emmetropic IOL power calculations

1. Basic theoretical formulas for emmetropia:

Colenbrander’s formula
_________________ 1336
P = – ___________________
L – C – 0.05 1336 – C – 0.05
Fyodorov’s formula 1336 – LK
(L – C) _________
1 – CK

Van der Heijde’s formula

__________ 1
P= – ______________________
L – C 1 – _______
____ C
K 1336

Binkhorst’s formula
1336 (4R – L)
P = ___________________
(L – C) (4R –C)
2. Modified theoretical formulas for emmetropia:
Section 1

Hoffer’s formula
1336 1336
P = _____________ – _____________
L– C– 0.05 1336
– C–0.05
K + E

Shamman’s fudged formula

1336 1
P =___________________________ – ___________________
L – 0.1(L – 23) – C – 0.05 _______
1.0125 –__________
C + 0.05
K 1336

Binkhorst’s adjusted formula 1336 (4R – L)

P =
(L – C) (4R – C)

The factors on which IOL power calculation depends 3. Postoperative anterior chamber depth (ACD): It is
are: least important factor in calculation of lens power.
1. Axial length measurement: This is the most important It is important in cases of Haigis formula.
step in calculation of lens power. The IOL Master An error of 1 mm affects the postoperative refraction
is recent method which gives high accuracy in by approx. 1.0 D in myopic eye, 1.5 D in emmetropic
measurement of axial length. An error of 1 mm affects eye and up to 2.5 D in hyperopic eye.
the postoperative refraction by 2.5 D approximately. The recent third generation 2 variable formulas use
It is measured in millimeters (mm). commonly are given below.
2. Corneal power: It is measured either in diopters or
in mm (radius of curvature). SRK Formula
Keratometer measures the radius of curvature of the 1. SRK I Formula
central part of anterior corneal surface. It is basic regression formula. It is given by:
K = 1000 (n–1) n = corneal index of refraction P = A – 0.9K – 2.5 L
R 1.3375 for Haag-Streit and Bausch and Lomb. where P = IOL power for emmetropia
Ocular Biometry and Intraocular Lens Power Calculations in Microphaco 73
K = Keratometric power reading the A – constant was chosen, pACD is derived from the
A = A constant A – constant [Hoffer, 1998] according to [Holladay et
L = Axial length in mm. al, 1988]
2. SRK II Formula: In this formula, a constant is adjusted pACD = ACD – const = 0.58357 * A – const –
to different axial length ranges. It is given by: 63.896
P = A1 – 0.9 K – 2.5 L
A1 = new constant Haigis Formula
A1 = A + 3 if Axial length (L) < 20 mm On of the final frontiers in ophthalmology is the consistent
A1 = A + 2 if L 20 – 21 mm accurate calculation of intraocular lens power in all the
A1 = A + 1 if L 21 – 22 mm eyes.
A1 = A if L = 22 – 24.5 mm The more recent formula which is developed, to
A1 = A – 0.5 if L > 24.5 mm increase the accuracy of lens power calculation is Haigis
3. SRK III Formula: This is new formula which is used formula. This formula was given by Dr. Wolfgang Haigis.
to produce a desired postoperative refraction R.
It uses three constants to set both the position and shape
I = P – cr R
of a power prediction curve. The IOL calculation
where P = power which is calculated by SRK II
according to HAIGIS is based on the elementary IOL
cr = another empirical constant defined as
formula for thin lenses.

Section 11
cr = 1 for P < 14
d = a0 + [a1 x ACD] + (a2 x AL)
cr = 1.25 for P > 14
where d = the effective lens position
Hoffer Q Formula ACD = measured anterior chamber depth of the
The Hoffer Q formula was published in 1993 [Hoffer,
AL = axial length of the eye.
1993], based on the earlier work of Kenneth J Hoffer,
a0 constant = same as lens constants for the different
MD (cf. references).
formulas given before.
The Hoffer Q IOL power is given by:
P = f (A, K, Rx, pACD) a1 Constant = tied to anterior chamber depth
It is a function of a2 Constant = measured axial length
A: axial length Thus, the value for d is determined by a function
K: average corneal refractive power (K-reading) rather than a single number.
Rx: refraction The a0, a1 and a2 constants area derived by multi-
pACD : personalized ACD (ACD – constant) variable regression analysis. The Haigis formula IOL
Likewise, the Hoffer Q refractive error Rx constants will appear different than normal as they
Rx = f (A, K, P, pACD) interact with the ACD and the AL.
depends on A, K, P and pACD. The main part of highly accurate IOL Power
For the calculations, the corneal radii, R1C and R2C Calculation is able to correctly predict ‘d’ for any given
in [mm] are converted into K in [D] according to: patient and IOL.
K = 0.5 (K1 + K2) with K1 = 337.5/R1C and K2 = ‘d’ for the five formulas commonly in use are:
337.5/R2C. SRK/T d = A constant
The personalized ACD (pACD) is set equal to the Hoffer Qd = pACD
manufacturer’s ACD – constant, if the calculation was Holladay 1d = surgeon factor
selected to be based on the ACD – constant. In case Holladay 2d = ACD
74 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Haigis d = a0 + (a1 x ACD) + (a2 x AL). errors have gained enormous popularity among patients
In actual practice, the two eyes with same axial length and the doctors. Most of these techniques permanently
and keratometric reading may have different lens power. and irreversibly alter the corneal shape and its effective
This may be due to: power. Thus, the routine formula used for IOL power
• Effective lens position, i.e. distance of the lens from calculation cannot be used these patients.
the cornea. Increased accuracy has increased both the surgeon
• Individual geometry of lens model. and the patient’s expectation for precise outcome and
Commonly used lens constants in different third more so in patients having undergone refractive surgery.
generation 2 variable formulas are: The different methods available for IOL power
SRK/T Formula —uses A constant calculations are:
Holladay 1 Formula—uses surgeon factor
Holladay 2 Formula—uses anterior chamber depth Hard Contact Lens Method
(ACD) This method uses a hard contact lens of known power
Hoffer Q formula—uses anterior chamber depth and base curve to determine true corneal powers. After
(ACD) refraction is over, a plano hard contact lens is placed
These constants are usually interchangeable. All the on the eye and over refraction is performed. If no
above formulas has limited axial length range of accuracy. differences exist between refraction, then the corneal
Section 1

Holladay 1—works well for normal – moderately long dietetic power is the same as the contact lens base curve.
axial length and If the over refraction is more myopic than refraction
Hoffer Q—works better for shorter axial length. without the contact lens, the lens is steeper than the
Hoffer Q formula is best for short eyes. Holladay for cornea. The change in refraction is subtracted from the
long eyes and SRK/T is best for very long eyes. Overall contact lens base curve to yield the corneal power.
SRK/T is probably most accurate in majority of cases. If over refraction is more hyperopic than the contact
lens refraction, the cornea is steeper than the lens. The
Holladay Formula change in refraction is then added to the contact lens
The components of the three part Holladay system are: base curve to calculate corneal power.
1. Data screening criteria to identify improbable axial In this situation, the clinical relationship:
length and keratometric measurement. Cbase + C power + R cl + R bare = K true
2. The modified theoretical formula, which predicts the Generally holds true, if the following are known:
effective position of the IOL based on the axial length Cbase = base curve of the contact lens in diopters,
and the average corneal curvature. and
3. Personalized surgeon factor (PSF) that adjusts for any C power= spherical power of the contact lens in
consistent bias on surgeon from any source. It is diopters, and
advance method, which requires patient refractions. R cl = spherical equivalent refractive error with
The initial formula uses the “Basic surgeon factor”. the contact lens and
It can be calculated from the A constant provided by R bare = spherical equivalent refractive error
lens manufacturer. without the contact lens, then
K true = the estimated corneal power after
Intraocular Lens Power Calculation after refractive surgery
Corneal Refractive Surgery To give accurate information, the refractive numbers
Keratorefractive surgeries done to decrease the refractive (R cl and R bare) must retain their corresponding plus
Ocular Biometry and Intraocular Lens Power Calculations in Microphaco 75
(hyperopic) and minus (myopic) signs, and be corrected (Cccp × 1.114) – 6.10 = post-LASIK adjusted
for vertex distance. corneal power.

Nomogram Based Correction

Clinical History Method
The following formula is used to predict IOL power to
It was first described by Holladay and later by Hoffer
maintain emmetropia after refractive surgery
for corneal power estimation as
After myopic LASIK;
Kp + Rp – Ra = Ka.
Post-LASIK IOL = PreLASIK IOL + (change in SE/
Kp = the average keratometry power before
After hyperoic LASIK;
refractive surgery,
Post-LASIK IOL = PreLASIK IOL – (change in SE/
Rp = the spherical equivalent before refractive
Ra = the stable spherical equivalent after refractive
IOL Power Calculations in Silicone Filled Eyes
Silicone oil in the vitreous causes an error in axial length
Ka = final central corneal power after refractive
measurement. This occurs due to change in the velocity
of sound through silicone oil. The error may be 3 to
This method requires knowledge of keratometry prior
4D. Axial length measurement should be done prior to
to refractive surgery, as well as induced refractive change,

Section 11
injection of silicone oil.
i.e. changes in spherical equivalent (S.E) before the
Regarding the spike pattern, it is difficult to get good
development of cataract.
retinal spikes.
A. For postmyopic procedure patients;
The axial length obtained can be corrected by the
Corneal diopteric powers = prerefractive surgery
following formula:
Ks – change in SE
Axial length = AL × Velocity (corrected)/Velocity
B. For posthyperopic procedure patients;
Corneal diopteric power = prerefactive surgery
+ change in SE
Accuracy of IOL Power Calculation
Calculated corneal diopteric power is then used
for IOL determination. In spite of recent advances in technology, there is no
single method to accurately determine the net central
Feiz and Mannes IOL Power Adjustment Method power of these post refractive surgery eyes. The current
method available is limited by lack of clinical experience
In this technique, initially the IOL power is calculated
on large scale and by the theoretic nature of all the
using the pre LASIK corneal power.
calculation methods.
The pre LASIK IOL power is then increased by the
The factors, which significantly affect the accuracy of
amount of refractive change at spectacle plane divided
SRK in IOL Power calculations, are:
by 0.7
1. The error in preoperative biometry with regard to
IOL power = (IOL) pre + DD/0.7
the difference between post and preoperative axial
DD = the refractive change after LASIK
length measurement.
2. The position of the implantation of intraocular lens.
Modified Maloney Method
3. The style of intraocular lens
In this method, the central corneal power is obtained 4. The preoperative corneal astigmatism
by using the axial map of Zeiss Humphery Atlas 5. Surgically induced corneal astigmatism
Topographer (Ccp) 6. The postoperative astigmatism.
76 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Conclusion 16. Kraff MC, Sanders DR, Lieberman HL. Determination of

intraocular lens power: A comparison with and without
According to various studies it has been seen that IOL ultrasound. Ophthalmic Surg 1978;9:81–84.
master is very good, accurate method of IOL power 17. Lal H. Biometry and IOL power calculation, manual of
phaco technique. 33–37 Haigis W, Lege B, Miller N,
calculation. It has increased the postoperative refractive Schneider B: Comparison of immersion ultrasound
outcome at par with recent techniques of cataract surgery biometry and partial coherence interferometry for
intraocular lens calculation according to Haigis.
like microphaco.
18. Liang YS, Chen TT, Chi TC, Chan YC. Analysis of
intraocular lens power calculation. J Am Intraocular Implant
Soc 1985;11(3):268–71.
BIBLIOGRAPHY 19. Olsen T, Thim K, Corydon L. Accuracy of the newer
1. Aramberri. Intraocular Lens power calculation after corneal generation intraocular lens power calculation formulas in
refractive surgery; double K method 3CRS 2003;29(11): long and short eyes. J Cataract Refract Surg 1991;
2003–8. 17(2):187–93.
2. Binkhorst RD. Pitfalls in the determination of intraocular 20. Olsen T. Sources of error in intraocular lens power
lens power without ultrasound. Ophthalmic Surg 1976;76: calculation. J Cataract Refract Surg 1992;18:125–9.
69–82. 21. Olsen T. Theoretical approach to intraocular lens
3. Buschmann W. Ultrasonic measurements of the axial calculation using Gaussian optics. J Cataract Refract Surg
length of the eye. Klin Monatsbl Augenheilkd 1964; 1987;13:141–5.
144:801–15. 22. Ouda B, Tawafik B, Derbala A, Youseif AB. Error correction
4. Connors R III, Boseman P III, Olson RJ. Accuracy and of intraocular lens (IOL) power calculation. Biomed Instrum
reproducibility of biometry using partial coherence Technol 1999;33(5):438–45.
interferometry. J Cataract Refract Surg 2002; 28:235–8. 23. Raj PS, Ilango B, Watson A. Measurement of axial length
Section 1

5. Determining corneal power following LASIK and PRK. in the calculation of intraocular lens power. Eye
6. Drews RC. Calculation of intraocular power, a program for 1998;12(Pt2):227–9.
Hewlett-Packard 97 calculator. Am Intraocular Implant Soc 24. Rajan MS, Keilhorn I, Bell JA. Partial coherence laser
J 1977;3:209–12. interferometry vs conventional ultrasound biometry in
7. Drexler W, Findl O, Menapace R, et al. Partial coherence intraocular lens power calculations. Eye 2002;16:552–6.
interferometry: A novel approach to biometry in cataract 25. Rose LT, Moshegov CN. Comparison of the Zeiss IOL
surgery. Am J Ophthalmol 1998; 126:524–34. master and applanation A-scan ultrasound: biometry for
8. Eleftheriadis H: IOL Master biometry: Refractive results of intraocular lens calculation. Clin Experiment Ophthalmol.
100 consecutive cases. Br J Ophthalmol 2003; 87(8):960– 2003;31(2):121–4.
3. 26. Sanders DR, Kraff MC. Improvement of intraocular lens
9. Findl O, Drexler W, Menapace R, et al. Improved prediction power calculation using empirical data. Am Intraocular
of intraocular lens power using partial coherence Implant Soc J 1980;6:263–67.
interferometry. J Cataract Refract Surg 2001;27:861–7. 27. Shammas HJ. A comparison of immersion and contact
10. Fritz KJ: Intraocular lens power formulas. Am J Ophthalmol techniques for axial length measurement. Am J Intra-Ocular
1981;91:414. Implant Soc 1984;10:444–7.
11. Gantenbein C, Lang HM, Ruprecht KW, Georg T: First steps 28. Suto C, Hori S, Fukuyama E, Akura J. Adjusting intraocular
with the Zeiss IOL Master: A comparison between acoustic lens power for sulcus fixation. J Cataract Refract Surg
contact biometry and non-contact optical biometry. Klin 2003;29(10):1913–7.
Monatsbl Augenheilkd 2003;220(5):309–14. 29. Tromans C, Haigh PM, Biswas S, Lloyd IC. Accuracy of
12. Kalogeropoulos C, Aspiotis M, Stefaniotou M, Psilas K. intraocular lens power calculation in paediatric cataract
Factors influencing the accuracy of the SRK formula in the surgery. Br J Ophthalmol 2001;85(8):939–41.
intraocular less power calculation. Doc Ophthalmol 30. Understanding the Haigis–
1994;85(3):223–42. 31. Vahid Feiz, Mark J Mannis. Intraocular lens power
13. Kielhorn I, Rajan MS, Tesha PM, Subryan VR, Bell JA. calculation after corneal refractive surgery – current opinion
Clinical assessment of the Zeiss IOL Master 1: J Cataract in ophthalmology. 2004;15:342–9.
Refract Surg 2003;29(3):518–22. 32. Verhulst E, Vrijghem JC. Accuracy of intraocular lens power
14. Kim JN, Lee DN, Joo CK. Measuring corneal power for calculations using the Zeiss IOL master. A prospective
intraocular lens power calculations after refractive surgery. study. Bull Soc Belge Ophthalmol 2001;(281):61–5.
JCRS 2002;28(II):1932–8. 33. Wainstock MA. Ultrasonography: Its role in the success of
15. Kiss B, Findl O, Menapace R, et al. Biometry of cataractous intraocular implant surgery. Int Ophthalmol Clin
eyes using partial coherence interferometry: Clinical 1979;19:43–50.
feasibility study of a commercial prototype I. J Cataract 34. Warren E Hill. The IOL Master—Techniques in
Refract Surg 2002;28:224–9. Ophthalmology 2003;1:62–7.
Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL 77

Corneal Topography in
8 Phakonit with a 5 mm
Optic Rollable IOL
Amar Agarwal, Soosan Jacob
Athiya Agarwal, Sunita Agarwal
Ashok Garg (India)

Section 11
Cataract surgery and intraocular lenses (IOL) have With the availability of the ThinOptX® rollable IOL
evolved greatly since the time of intra capsular cataract (Abingdon, VA, USA), that can be inserted through sub-
extraction and the first IOL implantation by Sir Harold 1.4 mm incision, the full potential of phakonit could be
Ridley.1 The size of the cataract incision has constantly realized. This lens was created and designed by Wayne
been decreasing from the extremely large ones used for Callahan from USA. Subsequently, one of the authors
ICCE to the slightly smaller ones used in ECCE to the (Am. A) modified the lens by making the optic size 5 mm
present day small incisions used in phacoemulsification. so that it could go through a smaller incision.
Phacoemulsification and foldable IOLs are a major
milestone in the history of cataract surgery. Large SURGICAL TECHNIQUE
postoperative against-the-rule astigmatism were an
invariable consequence of ICCE and ECCE. This was Five eyes of 5 patients underwent Phakonit with
minimized to a great extent with the 3.2 mm clear corneal implantation of an ultrathin 5 mm optic rollable IOL at
incision used for phacoemulsification but nevertheless Dr. Agarwal’s Eye Hospital and Eye Research Centre,
some amount of residual postoperative astigmatism was Chennai, India.
a common outcome. The size of the corneal incision The name PHAKONIT has been given because it
was further decreased by phakonit 2-4 a technique shows phacoemulsification (PHAKO) being done with
introduced for the first time by one of us (Am.A), which a needle (N) opening via an incision (I) and with the
separates the infusion from the aspiration ports by phacotip (T). A specially designed keratome, an irrigating
utilizing a sleeveless phaco probe and an irrigating chopper, a straight blunt rod and a 15º standard phacotip
chopper. The only limitation to thus realizing the goal without an infusion sleeve form the main pre-requisites
of astigmatism neutral cataract surgery was the size of of the surgery. Viscoelastic is injected with a 26G needle
the foldable IOL as the wound nevertheless had to be through the presumed site of side-port entry. This inflates
extended for implantation of the conventional foldable the chamber and prevents its collapse when the chamber
IOLs. is entered with the keratome. A straight rod is passed
78 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

through this site to achieve akinesia and a clear corneal should be pointing in a clockwise direction so that the
temporal valve is made with the keratome (Fig. 8.1A). smooth optic lenticular surface faces posteriorly. The
A continuous curvilinear capsulorhexis (CCC) is natural warmth of the eye causes the lens to open
performed followed by hydrodissection and rotation of gradually. Viscoelastic is then removed with the bimanual
the nucleus. After enlarging the side-port a 20 gauge irrigation aspiration probes (Fig. 8.1D). Figures 8.1A to
irrigating chopper connected to the infusion line of the D shows different steps of the surgery.
phaco machine is introduced with foot pedal on position.1
The phaco probe is connected to the aspiration line and
the phacotip without an infusion sleeve is introduced
through the main port (Fig. 8.1B). Using the phacotip
with moderate ultrasound power, the center of the
nucleus is directly embedded starting from the superior
edge of rhexis with the phaco probe directed obliquely
downwards towards the vitreous. The settings at this stage
are 50 percent phaco power, flow rate 24 ml/min and
110 mmHg vacuum. When nearly half of the center
of nucleus is embedded, the foot pedal is moved to
Section 1

position 2 as it helps to hold the nucleus due to vacuum

rise. To avoid undue pressure on the posterior capsule
the nucleus is lifted slightly and with the irrigating chopper Fig. 8.1A: Clear corneal incision made with a specialized
in the left hand the nucleus chopped. This is done with keratome. Note the left hand has a straight rod to stabilize
the eye
a straight downward motion from the inner edge of the
rhexis to the center of the nucleus and then to the left
in the form of an inverted L shape. Once the crack is
created, the nucleus is split till the center. The nucleus
is then rotated 180º and cracked again so that the
nucleus is completely split into two halves. With the
previously described technique, 3 pie-shaped quadrants
are created in each half of the nucleus. With a short
burst of energy at pulse mode, each pie shaped fragment
is lifted and brought at the level of iris where it is further
emulsified and aspirated sequentially in pulse mode.
Thus, the whole nucleus is removed. Cortical wash-up
is then done with the bimanual irrigation aspiration
technique. Fig. 8.1B: Agarwal’s phakonit irrigating chopper and
The lens is taken out from the bottle and placed in sleeveless phako probe inside the eye

a bowl of BSS solution of approximately body

temperature to make the lens pliable. It is then rolled
with the gloved hand holding it between the index finger
and the thumb. The lens is then inserted through the The preoperative best corrected visual acuity (BCVA)
incision carefully (Fig. 8.1C). The teardrop on the haptic ranged from 20/60 to 20/200. The mean preoperative
Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL 79
to 1.8 D) preoperatively. The mean astigmatism was
1.02 ± 0.64 D (range 0.3 to 1.7 D) by 3 months
postoperatively. Figures 8.3 and 8.4 shows mean
astigmatism over time. Figures 8.5A and B show a
comparison of the astigmatism over the pre and
postsurgical period.

Cataract surgery has witnessed great advancements in
surgical technique, foldable IOLs and phaco technology.
This has made possible easier and safer cataract extraction
utilizing smaller incision. With the advent of the latest
IOL technology which enables implantation through
Fig. 8.1C: The rollable IOL inserted through the incision
ultrasmall incisions, it is clear that this will soon replace
routine phacoemulsification through the standard 3.2
mm incisions. The ThinOptX® IOL design is based on
the Fresnel principle. This was designed by Wayne

Section 11
Callahan (USA). Flexibility and good memory are
important characteristics of the lens. It is manufactured
from hydrophilic acrylic materials and is available in a
range from –25 to +30 with the lens thickness ranging
from 30 μm up to 350 μm. One of the authors (Am.A)
has modified the lens further by reducing the optic size
to 5 mm to go through a smaller incision. The lens is
now undergoing clinical-trials in Europe and the USA.
In this study, no intraoperative complications were
Fig. 8.1D: Viscoelastic removed using bimanual irrigation encountered during CCC, phacoemulsification, cortical
aspiration probes
aspiration or IOL lens insertion in any of the cases. The
astigmatism as detected by topographic analysis was 0.98 mean phacoemulsification time was 0.66 minutes.
D ± 0.62 D (range 0.5 to 1.8 D). Previous series by the same authors showed more than
The postoperative course was uneventful in all cases. 300 eyes where cataract surgery was successfully
The IOL was well-centered in the capsular bag. There performed using the sub-1 mm incision.3 Our experience
were no corneal burns in any of the cases. and that of several other surgeons suggests that with
Four eyes had a best-corrected visual acuity of existing phacoemulsification technology, it is possible to
20/30 or better. One eye that had dry ARMD showed perform phacoemulsification through ultra-small
an improvement in BCVA from 20/200 to 20/60. Figure incisions without significant complications.2-6 In a recent
8.2 shows a comparison of the pre and postoperative study from Japan, Tsuneoka and associates6 used a
BCVA. The mean astigmatism on postoperative day 1 sleeveless phacotip to perform bimanual phacoemulsi-
on topographic analysis was 1.1 ± 0.61 D (range 0.6 fication in 637 cataractous eyes. All cataracts were safely
to 1.9 D) as compared to 0.98 D ± 0.62 D (range 0.5 removed by these authors through an incision of 1.4 mm
80 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 8.5A: Comparison of pre and postoperative day 1

Fig. 8.2: Comparison of pre and postoperative BCVA

Fig. 8.3: Mean astigmatism over time Fig. 8.5B: Comparison of 1 day postoperative and 3
months postoperative astigmatism

Time Eyes Mean Std. Dev. Mini. Max.

Section 1

Preop. 5 0.98 0.62 0.5 1.8

POD 1 5 1.1 0.61 0.6 1.9

POD 7 5 1.12 0.58 0.5 1.7

POD 30 5 1.08 0.62 0.5 1.8

POD 90 5 1.02 0.64 0.3 1.7

Fig. 8.4: Table showing pre and postoperative mean


or smaller that was widened for IOL insertion, without

a case of thermal burn and with few intraoperative
complications. Furthermore, ongoing research for the
development of laser probes 7,8 cold phaco, and
microphaco confirms the interest of leading ophthal-
mologists and manufacturers in the direction of ultra-
small incisional cataract surgery (Fine IN, Olson RJ, Osher
RH, Steinert RF. Cataract technology makes strides.
Ophthalmology Times, December 1, 2001, 12–15).
The postoperative course was uneventful in all the
cases. The IOL was well-centered in the capsular bag.
There were no significant corneal burns in any of the
Figs 8.6A and B: Topographical comparison during
cases. Final visual outcome was satisfactory with 4 of different surgical periods
Corneal Topography in Phakonit with a 5 mm Optic Rollable IOL 81
the eyes having a BCVA of 20/30 or better. One eye extraction, the greatest advantage of this technique being
that had dry ARMD showed an improvement in BCVA virtual astigmatic neutrality.
from 20/200 to 20/60. Thus, the lens was found to have
satisfactory optical performance within the eye. In our REFERENCES
study, the mean astigmatism on topographical analysis
1. Apple DJ, Auffarth GU, Peng Q, Visessook N. Foldable
was 0.98 ± 0.62 D (range 0.5 to 1.8 D) preoperatively, Intraocular Lenses. Evolution, clinicopathologic
1.1 ± 0.61 D (range 0.6 to 1.9 D) on postoperative correlations, complications. Thorofare, NJ, Slack Inc.,
day 1 and 1.02 ± 0.64 D (range 0.3 to 1.7 D) by 2000.
3 months postoperatively. Figures 8.5A and B showing 2. Agarwal A, Agarwal A, Agarwal S, et al. Phakonit:
a comparison of the pre and postoperative astigmatism Phacoemulsification through a 0.9 mm corneal incision.
indicate clearly that phakonit with an ultrathin 5 mm J Cataract Refract Surg 2001; 27:1548–52.
3. Agarwal A, Agarwal A, Agarwal A, et al. Phakonit: Lens
rollable IOL is virtually astigmatically neutral. Figures 8.6A
removal through a 0.9 mm incision. (Letter). J Cataract
and B depicting the topography comparison in different Refract Surg 2001; 27:1531–2.
surgical periods show clearly the virtual astigmatic 4. Agarwal A, Agarwal S, Agarwal A. Phakonit and laser
neutrality of the procedure and stability throughout the phaconit: Lens removal through a 0.9 mm incision. In:
postoperative course. Agarwal S, Agarwal A, Sachdev MS, Fine IH, Agarwal A,
There is an active ongoing attempt to develop newer (Editors): Phacoemulsification, Laser Cataract Surgery and
Foldable IOLs. New Delhi, India: Jaypee, 2000; 204–16.
IOLs that can go through smaller and smaller incisions.

Section 11
5. Tsuneoka H, Shiba T, Takahashi Y. Feasibility of ultrasound
Phakonit ThinOptX® modified ultrathin rollable IOL is
cataract surgery with a 1.4 mm incision. J Cataract Refract
the first prototype IOL which can go through sub-1.4 Surg 2001; 27:934–40.
mm incisions. Research is also in progress to manufacture 6. Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic phaco-
this IOL using hydrophobic acrylic biomaterials combined emulsification using a 1.4 mm incision: Clinical results.
with square-edged optics to minimize posterior capsule J Cataract Refract Surg 2002;28:81–6.
opacification. 7. Kanellpoupolos AJ. A prospective clinical evaluation of
100 consecutive laser cataract procedures using the Dodick
CONCLUSION photolysis neodymium: Yittrium–aluminum-garnet system.
Ophthalmology 2001;108:1–6.
Phakonit with an ultrathin 5 mm optic rollable IOL 8. Dodick JM. Laser phacolysis of the human cataractous lens.
implantation is a safe and effective technique of cataract Dev Ophthalmol 1991; 22:58–64.
82 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

9 Sterilization

Sunita Agarwal (India)

INTRODUCTION come from the operating room and then work oursel-
ves backwards in removing the source of the disease.
When viewed upon from the broader angle however
Section 1

We may be able to shift blame to a tooth infection

good a surgery may have been performed should it be
or septic foci in the sinus, however, should we be able
complicated with infection, the result is fraught with peril.
to first accept the operating room to be at fault, our
The patient suffers ultimately and the surgeon goes
energies would be directed in improving our facilities,
through hell. We have all had our share of infection and
thus averting further mishaps from occurring.
its disastrous effects.
The first rule in sterilization at least where developing
Should a surgeon say they have never had infection
spoiling their case, either they have never done surgery countries are concerned is not to believe any
or the truth lies hidden elsewhere. manufacturer when they claim to have sterilized their
Be that as it may we need to understand micro- wares. To be taken as guilty of infection unless proved
organisms in a much better manner. We need to give otherwise. This is true of not only suture material,
this topic full attention in our hospitals and continue to disposable needles and syringes but also of intravenous
give it the importance it requires by continuing quality and intraocular fluids. Many cases have been reported
checks at every interval regularly everyday and in every in India where bacteria have grown from the Ringer
case. lactate used. A startling study was carried out in the early
Some basic facts of postsurgical infection in human 90s where several eyes were lost due to balanced salt
eyes whether cataract surgery or any intraocular surgery solution (BSS) not being of pH 7.4, because the last
is concerned, are that we need to regard all infections rinse did not wash of the remnant soap from the glass
to arise from the operation theatre unless proved other- bottle.
wise. The operating room is certainly the most guilty in What we all need to remember is that when every-
providing the microorganism for postsurgical infection. thing is going fine nobody complains, but as soon as
It may be very easy to complain about patient com- there is a complication the surgeon is the first and often
pliance and dirtiness to be the cause of infection, and the last person to be held totally responsible for all
sometimes that may be true, however in our hearts it misdemeanors on anybody’s part. Thus, as captain of
is safer and better for us to accept that this infection has the ship the surgeon has to sink with his or her ship.
Sterilization 83
However, all this can be avoided by taking precautions won him the Nobel Prize for medicine and physiology
before entering the operating room. in 1905.
It took Louis Pasteur to bring out the emphasis of
HISTORY the “little beings” as those responsible for disease. His
paper on the importance of washing hands before
Dating back to the time that Sushruta from 500 BC
starting a obstetrical delivery shows the utmost signi-
explained the importance of washing hands and drap-
ficance of this one act towards a sterile atmosphere.
ing wounds with clean cloth, as well as having a clean
Throughout the 1800s pioneering technologies of
environment for surgical procedures, Indian medicine
Pasteur, Nizer, Klebs, Escherich, Cohn and Ehrlich played
has always kept this part of medical practice in good
major roles in the evolution of discovery of pathological
stead. Practicing principles of Dhanvantri medicine a
germs. Today the science of microbiology and medicine
Hindu physician-oculist wrote that surgeons should clean
are occupied by their names forming important
their nails prior to operating, wear fresh clothing, and
landmarks in the discovery of the importance of
spray sweet smelling vapors around the operating room.
sterilization techniques.
Little did he know the importance of these instructions.
Where hospital wards are concerned, making surgery
However, these were carried down through the ages by safe and banishing sepsis from hospital wards, an era
the Vaidyas (Hindu physicians), now with better know- of pre-Lister and post-Lister can be demarcated. This
ledge there is more understanding of the topic on

Section 1
was the importance of Joseph Lister on surgical outcome.
infection and sterilization control. He based a lot of his studies however on Ignaz
The middle ages saw European medicine catching Semmelweiss (1818–1865)—who was cruelly maligned
ground however, sterilization tactics were still very rudi- for his theory of the origins of child-bed fever that led
mentary. Most surgeons thought it to be fashionable not him to be institutionalized and die an unhappy man.
to wash hands, mayhap due to the cold climate of the The irony of the situation was his studies brought about
temperate zones. Thus, centuries of unknown prevailed a revolution in hospital wards and the prevention of
with thousands being lost to infection and disease even infection by antiseptics and cleanliness reiterated by
inside the operating room. It was considered hazardous Joseph Lister.
to lay a surgeons hand in the fear of losing the patient By the time Daimler brought out his first motorcycle
to “fever” as it was called then. in 1884, scientists round the globe had devised the
However, Hieronymus Fracastorus in 1546 published autoclave deriving from the fact that boiling did away
a landmark book that may have led to the discovery with microbes. This revolutionized hospital wards and
of bacteria. His theory of contagious diseases and their operation theatre sepsis to a great extent. So much so
treatment sparked off the original microbe hunter, to that till date some contraption of the autoclave is still
identify bacteria with his own saliva in 1675, using his used in every operation theatre in existence in the
microscope screwed together with some lenses, Antoni modem world.
van Leeuwenhoek had set about 2 centuries of hot debate By 1899 a century was going by and scientists
amongst the European scientists. believed this was the ultimate and that internal sepsis
In 1840, Jakob Henle postulated the theory of the was not going to be much more advanced beyond theory
contagion. This was further specified by Robert Koch and that the field was not likely to advance further. Today
in 1876 where he showed that by isolating the anthrax with much more information and knowledge we think
bacillus and was able to infect a normal animal with the contrary, that we still know only a drop in this ocean
same that the theory of contagion was true. This work of knowledge against disease and infection.
84 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Change is the spice of life and just as today changes World War had ended and humanity was once again
to another day, of more discovery and more scientific allowed to prosper. So much so that the scanning
achievements so to these pioneers were to discover much tunneling microscope could be developed by 1980 and
more. Sulfanilamide first discovered by Paul Gelmo in its fast developing clones that are in use today.
1908 was found to be effective on surgical wounds, by However, very soon the side effects of antibiotics were
Gerhard Domagk who first used the drug on humans noted with the classic example of chloramphenicol the
in 1935. This won Domagk the Nobel Prize for Medicine first broad-spectrum antibiotic, discovered in 1949,
and Physiology in 1939. effective against rickettsial infection, typhoid. A link was
Paul Ehrlich and Toju Hata discovered Salvarsan, the established between severe bone marrow depression and
arsenic derivative for the treatment of syphilis, it heralded aplastic anemia with its use. This curtailed the use of
yet another era, that of the antibiotic.
these eyedrops and oral regime in USA.
In 1929, Alexander Fleming published his classical
We owe a lot to these forefathers of modern medi-
work on Penicillin from London and history followed
cine and surgery, and today’s technological advance-
his every achievement. Through the World Wars his
ments have made us more wary of the microbe. It seems
medicine was of immense use in the control of infection
to be the more we advance the more microbes we find
and weeding out of disease. He showed first through
the cause of disease. Stress and other dietary factors were
in vitro studies that a contaminant of Staphylococcus
believed to be the cause for peptic ulcers, though now
Section 1

medium, Penicillium notatum had a destructive effect

we know bacteria to be the root. In a similar manner,
on the Staphylococcus bacteria that was growing on the
there are many more diseases that still retain their shroud
agar plate. In further experiments he showed that this
mold also had strong antibacterial activity against other of mystery.
pathogenic gram-positive bacteria as well as gram- Let us not rest on previous laurels and with the close
negative cocci and bacilli but was not effective against of this century believe that we have reached the ultimate.
organisms such as Escherichia coli. In reality, we have only skimmed the surface there is
While the world raged with War, yet another kind much more to be unraveled in this body beautiful of
of war was being fought for mankind inside the labo- the Homo sapiens.
ratories of HW Florey at Oxford University. By 1940 Tempting to say in the words of Louis Pasteur,
Ernst Chain showed the curative effects of penicillin in “Science knows no country, because knowledge belongs
vivo. In 1945, by the end of the World War II, these to humanity, and is a torch which illuminates the world.”
three men were awarded the Nobel Prize for Medicine
and Physiology. Selman-Waksman discovered spates of AREAS OF STERILIZATION
antibiotics in succession with streptomycin in 1944 for
Once we enter the operating room we expect that
tuberculosis and neomycin in 1949.
Much of today’s discoveries have been dependent everything must be in order, and somebody else is in
on the way we see these small “animalcules” of charge, not me. However, much to our utter astonish-
Leeuwenhoek, in 1933. Our eyes could see the destruc- ment seldom does anything go wrong, though when
tion of the world with Hitler as the Chancellor of it does, the blame is once again pushed on to somebody
Germany, and could see even greater destruction by else, not me. This is where the first principle of surgery
microbes since the invention of the first transmission has to be changed and restructured. The first and only
electron microscope by Ruska. Further developed to a person responsible for the whole team at work inside
phase contrast microscope by 1953, by which time the an operating room is the main surgeon. This is the person
Sterilization 85
who everybody in the operation theatre must report to. within. There are many ways of filtering clean air into
This is the person who before entering the theatre has the operating room. One of the easiest and best is to
to ensure that everything inside this pious area is under first make sure the rooms pertaining to the operation
strict control of the surgeon. This is the person who must theatre complex are sealed shut, with only one entry
take responsibility if an infection should arise in the into the complex. Now, we need to bring in clean air
patient’s eye within one week of surgery. into the operating rooms.
After carrying out so many tests and sterilization
techniques I would rather believe for the benefit of all Air-conditioning
future patients that infection in a postsurgical eye arises Ideally the whole operating area complex must be air-
from the operation theatre facilities. It is very difficult conditioned with the units stationed well outside the
to put infection inside a closed eyeball, though it is easy complex and only ducts bringing in fresh temperature-
enough while the eye coats are still open. More often controlled air into the complex. The air conditioning units
than not infection is carried into the eye by instruments could be in the form of towers or split units stationed
themselves. on the terrace or window firmaments outside.
There is however a small possibility that this may not
Filtration of air The ducts bringing in the clean oxy-
be the case and there may be a septic foci residing in
genated air need to have the air passing through filters
some corner of the human body like a tooth abscess
that can ward off bacteria which means they should be

Section 1
or such. Still these occurrences are very rare and far
0.2 micron filters. More often these filters need to be
between. Moreover, it is far more beneficial to all
changed and or cleansed on a daily pattern.
concerned to garner our resources and give a thorough
job of the operating room than to be witch hunting on Ultraviolet radiation Ultraviolet light bulbs could be
the patients habits and dirtiness. It is my belief that even placed in the path of the filtered air to make sure the
a dirty patient cannot infect the inside of his or her eye, air is disinfected as it enters the operating rooms.
if he or she has a postsurgical infection for sure it has Alternately these bulbs could be left in the operating
been carried in through the workings of the operation area and kept on throughout the night, this would also
theatre. ensure clean areas the next morning after 12 hours of
Going in a methodical manner from without to within exposure to the ultraviolet light.
anything entering the theatre has to be sterile. First the Ozone treatment Another technology gaining ground
operating room itself has to be sterile. for clean air is the ozone treatment plants that generate
ozone into the air. This breaks up the microorganisms
The Operating Room Air and clean, disinfected air is ensured. One unit for 5000
The air we breathe can be filled with pollutants, viruses, cubic feet of air space is recommended.
bacteria and irritants such as pollen, chemical gases, Ozone is a reactive molecule comprising three atoms
odors and smog. In critical situations—military command of oxygen. Because ozone is a reactive molecule it acts
centers and public arenas—there is also a threat of as a powerful oxidizing agent against all microbial
chemical and biological agents being released into the contaminants, organic toxins and most volatile organic
air. All these air-borne pollutants can be treated by using compounds (VOC’s) and because of its short half-life
various technologies. it rapidly reverts to water and oxygen.
We forget about the air coming into the operating When a combination of UV, moisture and ozone are
room, though however we should understand that if used a synergistic effect is seen. The absorption of UV
this itself is clean it is much easier to retain the cleanliness by the ozone-producing highly reactive substances that
86 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

effectively kill microorganisms including hard to kill spore Filtration

forming bacteria. This still finds the safest use in bringing in clean water
into the operating area. It could be done by many
Positive pressure A positive pressure pump is main-
methods, ceramic is one of them. However, today
tained to make sure the air entering the operating rooms
membrane filters seem to have replaced all else as here
are kept at a pressure above the rest of the area. These
they bring out the fluid bereft of bacteria. Sometimes
pumps can be installed in the ducting and positive
a suction pump is attached to the water jet so that the
pressure inside the operating areas would ensure that
filtration can take place at a faster pace.
the air comes only from this area and not through leaks
from windows or doors. The main door of the operating Reverse Osmosis
room must function for only air escaping the operating A high pressure is set about in the clean water and a
area and not for entering it. system of reverse osmosis sends back the mineral content
of the water while a filtration process blocks out the
Air curtain Entry points in the operating area would
microbial content. In this way water is able to reach the
do well to have automatic door closers so that the door
operating room with less minerals and is absolutely sterile
does not remain open unnecessarily. Also the door can
with no bacteria. This is also one of the techniques used
be fitted with an air curtain so that the outside air is
in the manufacture of bottled mineral water and can
curtailed off from entering.
be used very effectively in operating area complexes.
Section 1

Quality Check This water is now used for cleaning the operating rooms,
machines, and for surgeons while scrubbing. The water
Quality check is ensured by everyday/regularly carrying
coming from such a plant is placed in a storage drum,
out the PLATE TEST. This means leaving a bowl of clean
preferrably made of stainless steel.
sterile water in the room to be tested for 20 minutes.
Microorganisms present in the air would settle down on
Electronic Control
the surface of the water, a small sample is taken from
Water can be made to contain low mineral counts and
this and grown on a culture plate. If the sterilization
no bacteria through another technique of manufactu-
techniques have been effective the culture should be
ring mineral water. This is by producing cathode and
sterile in 24 to 48 hours. If the culture grows positive
anode electrodes on two ends of the water channel. The
growth remedial means have to be taken to ensure sterile
anions and cations would respectively move to their
cultures. corresponding electrodes and this would clear the fluid
of mineral content. A filter present below would clear
The Operating Room Water
the water of microorganisms. This is another method
The water coming into the operating room needs to be of producing sterile bottled mineral water.
free of microorganisms. After all the water with which
we are cleaning the most important area of the hospital The Operating Room Walls, Floor,
needs to be totally clean. If microorganisms are present Ceiling and Fixtures
in water then they would remain on the items cleansed All elements of the operating room need to be first
and the cleaning would be bad. The water coming into cleansed, then disinfected and last but not the least totally
the operating room must also contain adequate amounts sterile. The three steps in this process can be done by
of minerals. three different fluids and chemicals.
Sterilization 87
This is best done with a soap and water wash. Every
surface, every table, every chair and every fixture needs
to be cleansed with a direct application of soap and water
on the surface. After cleaning with this it needs to be
cleaned with plain water.

Benzalkonium chloride solution 4.5 percent could be
used as a disinfectant and as a general cleaning agent
for floors.
One of the best solutions used worldwide towards
the disinfection of operation theatres and consultation Fig. 9.2: Cleaning of the operation theatre walls with
suites is the Bacillocid made by Bode from Germany.
This contains 1,6 dihydroxy 2,5 dioxyhexane (chemi-
cally bound formaldehyde) with glutaraldehyde,
benzalkonium chloride and alkyl urea derivative. A

Section 1
2 percent solution is used for the operation theatre and
a 0.5 percent solution for the consultation areas. With
this solution all areas mopped and cleansed of vege-
tative organisms, fungus and viruses (Figs 9.1 to 9.3).
Formaldehyde in the form of liquid, tablets or gas
has been used extensively in the past, however, today
its use is put to question since culture tests have proved
positive with growth even after formaldehyde sterilization.

Fig. 9.3: Cleaning of the operation theatre floor with


The Operating Room Macroinstruments

All fixtures including fans, lights, air conditioning have
to be first cleansed carefully with a dry cloth and then
mopped with Bacillocid so that they can be disinfected.
Chairs, stools, operating tables, trays have to be first
cleansed with soap water and then mopped with Bacillocid
(Fig. 9.1) and left alone for over four hours to ensure
Care needs to be taken on operating theatre instru-
ments like Boyles apparatus, microscopes, phaco
Fig. 9.1: Cleaning of the operation table and chair, external
surfaces of the microscope, instrument table, IV poles with machines, diathermy machines, suction machines, laser
bacillocid machines. Though delicate these instruments need to
88 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

be thoroughly cleansed everyday. Many a time infection A vent exists that can release the pressure in the tubing
is found to be harboring in these areas and they are to atmospheric levels as soon as our footswitch transfers
difficult to clean. More sophisticated the machine more from position 3 to 2 to 1. In so doing the air from the
care need to be taken in its cleanliness. This task cannot operating room directly enters the tubings thus if there
be given to an untrained personnel and even then ideally should be bacteria in the air they would now have an
there should be a doctor supervising their cleaning. easy access to the most sterile line that we have been
trying to maintain.
Microscope These facts were not known to us for a long-time,
The rest of the microscope can be cleansed with soap and we had a spate of infections as Pseudomonas had
water as well as Bacillocid however the optics need special managed entry into the tubings present inside the phaco
care and need to cleaned only with a clean cloth machine. None of the companies’ representatives ever
preferrably silicon paper. Antifog chemical coating could let us know of this tubing and its existence and we never
be given to the optics. After cleaning and before closing racked our brains hard enough to trace the tubings, until
for the day the optics should be ideally wrapped in its this major catastrophy occurred. Over a spate of 12
original cloth or plastic casing and drying agents placed months we had taken out 4 intraocular lenses (IOL’s)
inside like silicon oxide. This allows the moisture inside from eyes with infection. We were able to save the eyes
to be absorbed by the chemical and with less moisture, from blindness however rendering them aphakic.
formation of fungus and other microorganisms on the We first accepted that the infection came from the
Section 1

optics is rare. operating room and now with a technology of omission

went about in a scientific manner trying to decipher where
Phaco Machines the infection came from.
As eye surgeons we need to be well aware of the pressure First the microsurgical instruments and tubings were
maintained inside the eye during phacoemulsification taken through the 10-step procedure as you will read
procedures for cataract surgery, but little do we realize later on. Now, they were tested for sterility by flowing
the importance of the machinery involved in giving us fluids through them and taking this fluid on a culture
this information. When the phaco probe is inside the plate. They were sterile, after fixing the tubings and probe
eye of the patient there is a continuous flow of fluid. onto the phaco machine the fluids were collected from
The fluid arises from the bottle suspended 65 cm above the drainage bag and sent for culture. The second one
the head of the patient and this produces a certain was positive. This told us that our sterilization techniques
pressure inside the eye. The fluid then goes through the were good however something was amiss.
irrigation line to the phacotip which enters the eye and We opened the phaco machine and found this tubing
leaves the eye through the suction tubing entering the running through it and found the vent as well. This vent
phaco machine. From the phaco machine another set ideally should have an air filter attached to it. We sent
of tubings takes the excess fluid away into a drainage the tubing for culture and replaced it with a fresh sterile
bag. What we have overlooked is between the tubing piece. The culture proved to us where the culprit lay,
entering the phaco machine and exiting into the drainage the Pseudomonas was grown from this tubing.
bag, it goes through a channel inside the phaco machine. The internal tubing cannot be changed with every
This part of the tubing is never sterilized in the proper case, though this would be ideal. So, we have devised
manner that is required before a cataract surgery. In a better structure for its disinfection. That is to keep the
fact, it cannot be sterilized as well. This part of the tubing air totally sterile and make sure no infection goes into
is attached to two manometers that gauge the pressure the tubing through the vent. This is ensured with the
in the tubing and give us a reading on the panel in front. ozone generator for the total operating room areas.
Sterilization 89
What we did realize through this study was that not
all cases turned up with infection even though the bacteria
must have been residing in the tubing for many a day.
The cases turned up with infection had something to
do with being the last few of the day. The cases which
turned up with infection had low immune status, either
diabetes or hypertension or such. The cases which turned
up with infection had a complication most often a
posterior capsular rupture on table thus resorting to
vitrectomy. This shows us some characters of infection
that we may already have known but not given them
their due acknowledgement.
However, what we have realized is that the phaco
machine has to be cleansed very well and air filters placed Fig. 9.5: Collection of Ringer lactate solution from the
on the vent. The tubing changed every week. And aspiration tube after the operation
culture tests done for every case before and after surgery
(Figs 9.4 and 9.5). What this means is when the tubings
and probe are attached to the machine before starting
the case first few drops of fluid entering the drainage

Section 1
bag is taken for culture (Fig. 9.6). Once again at the
end of the case this is repeated. If and when at anytime
a culture should turn positive we would know the
problem immediately. After these stringent measures
have been installed at our hospitals we have neither had
even one infection coming from the operating room
nor had to remove any more IOls lenses from infected

Fig. 9.6: Collection of Ringer lactate solution from the

front end of the internal tubing

Boyles Apparatus
Regular cleaning of all parts of the machine is necessary
with spirit as this evaporates and does not leave a residue
on it. However, the parts of the tubings that enter the
human system or are connected to them need to be
thoroughly cleansed, disinfected and then sterilized. The
method of choice for sterilization here is the ethylene
oxide gas chambers (Fig. 9.7). As most of the tubings
are plastic temperature of below 60°C are comfortably
taken by them. Needless to say that oxygen, nitrogen
Fig. 9.4: Collection of Ringer lactate solution from the dioxide, halogen levels should be monitored on a daily
aspiration tube before the operation basis with every case in particular.
90 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 9.8: Four trays arranged in sequence containing carbonic

soap with mineral water, 2 percent glutaraldehyde, 70 percent
Fig. 9.7: Ethylene oxide sterilizer isopropyl alcohol and mineral water

The Operating Room Microinstruments every lumen of every instrument is injected with 50 ml
Every case must be treated separately and all instru- of the liquid that it is dipped in. Thus, the cleansing action
ments must be cleansed thoroughly before the next case. is from the outside as well as from the inside of every
Section 1

Once a day a 10-step cleansing routine must be instrument. This is specially true of probes and tubings.
established. This 10-step routine includes:
Tray I with Liquid Soap and Sterile Water
1. Soap water wash with toothbrush
2. Ultrasonic cleansing with Lysol The first step in sterilization of instruments is its proper
3. Cidex cleansing and soaking for half an hour cleansing as whenever the microbial load will be less on
4. Isopropyl alcohol cleansing the sterilization technique used the better would be the
5. Plain sterile water cleansing results that can be achieved.
6. Plain sterile water cleansing This is best done with the old soap and water wash
7. Plain sterile water cleansing (Fig. 9.9). Liquid soap is used in a tray with clean sterile
8. Boiling in sterile water mineral water. First a plain cleansing with gloved hands
9. Ethylene oxide sterilization overnight is completed and then using a toothbrush into the small
10. Flash autoclave sterilization three times. crevices of instruments. This is of special importance to
instruments filled with blood and tissue. In ophthalmic
Four trays are kept aside on a long side table (Fig. matters special reference has to be given to machines
9.8). Water used in this sterilization must be mineral sterile like the automated flapper in LASIK (laser-assisted in
water, as this water is totally sterile, prove it by growing situ keratomileusis) cases, as it is known that corneal tissue
the water on a culture plate and making sure it is sterile. gets clogged into the tracks and other areas of the flapper.
The trays are filled with the respective fluids. Each tray is This can be removed much better using palmolive liquid
numbered and labeled so that mixing does not occur. soap as it contains some of the safest and yet cleanest
In each tray a toothbrush and 50 ml syringe with ways to get grid out of the system.
a yellow tubing taken off from an IV set is kept. All
microsurgical instruments are dipped in each tray Ultrasonic Cleansing
periodically. Every instrument is cleansed delicately with The mainstay of cleansing into cervices where the tooth-
gloved hands and toothbrush. When and where required brush cannot reach and this gets into the fulcrum of
Sterilization 91

Fig. 9.9: Wash all instruments in a tray of carbonic soap Fig. 9.10: Wash all instruments in a tray of 2 percent
and water with toothbrush glutaraldehyde

forceps and scissors to clean the instruments. A chemical Isopropyl Alcohol 70 Percent
solution like Lysol (Cresol and soap solution) could be This is still one of the best ways of killing the micro-

Section 1
used as an adjuvant to remove the debris from clogged organisms (Fig. 9.11). Instruments are soaked in the
surfaces. This breaks up the protein and organic matter solution for over 15 minutes and then cleansed using
so that it can come clean from instrument surfaces. Most a toothbrush and syringe to wash the internal elements
of the fluids used in the ultrasonic cleanser need to be of probes and tubings.
antiseptics as well so they can be used as disinfectants
on the instruments cleaned.

Cidex or Glutaraldehyde 2 Percent

Once activated Cidex solution manufactured by
Johnsons and Johnsons must be used within 14 days.
Some facts like these go unnoticed in hospital
environments and the use of substandard procedures
and drugs come into play. Reiterating the fact that the
doctor has to be on top of all these activities.
Instruments are left immersed in this solution (Fig.
9.10) for 30 minutes, which is sufficient time for dis-
infection however for sterilization 10 hours would be Fig. 9.11: Wash all instruments in a tray of 70 percent
isopropyl alcohol
needed. Within 10 minutes at room temperature most
vegetative organisms would be destroyed, including
Pseudomonas, fungi, and viruses. The solution is very Sterile Water
toxic to the eye and great care has to be taken to get Care must be taken to wash of the deleterious effects
the solution out of the instruments before using on of the above mentioned solutions. This is done effectively
humans. by first soaking and then washing all the instruments
92 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

through three trays of sterile water (Fig. 9.12). The lumen sterilization techniques like ethylene oxide and autoclave.
of the tubings must be clean with sterile water each time However, when subjected to boiling for 20 minutes the
50 ml of the fluid passing through the probes and tubings. tubings would be sterile. This once again reiterated our
belief in this age-old custom of boiling (Figs 9.13 to 9.15).

Fig. 9.12: Wash all instruments in a tray of mineral water

Section 1

Fig. 9.13: Diamond blades are cleaned using steam

Sterile Water
Once again cleansed with sterile water.

After going through a number of tests and methods of
sterilization we still find one of the best methods remains
the age-old custom of boiling. This brings about total
death of the microorganisms. Most rudimentary of
operation theatres would still contain means and methods
of performing this essential act of sterilization. However,
what needs to be detailed is whether the particular article
can withstand temperatures of over 100°C.
After having a spate of infections and removing IOLs Fig. 9.14: The external tubings, internal tubings, I/A probe
from infected eyes to save the eyes, my hospital and and metal knobs are boiled for 30 minutes
staff got spurned to find the cause of the infection.
Towards this a whole new regimen was set-up on clean- Ethylene Oxide Sterilization
sing, disinfection and sterilization of microsurgical This is not a preferred technology of sterilization for
instruments. After each methodology culture tests would microsurgical instruments because of the time duration
be taken to prove its efficacy. We did understand that taken is over 16 hours. However, we have started using
the silicon tubings had gram-positive cocci growing in this as one more step towards the end of the day. By
them. In a process of eliminating them we found that the time we finish all the cases of the day we take our
the cocci inside the silicon tubing withstood many instruments through this 10-step procedure ending it
Sterilization 93

Fig. 9.16: Statim autoclave cassette containing the tubings

Fig. 9.15: The instruments are separately boiled for and instruments is kept in the ethylene oxide sterilizer for a
30 minutes period of six hours

with a bout of ethylene oxide where the instruments need not be found in the operating room. This is not
rest for the night. However, the only aspect of this the place to keep stocks and inventory of medicines.

Section 1
technology is that the instruments must be cleansed of They could be kept in the prefunction area of the
the ethylene glycol residues that may be found over operating room but not in the operating room itself.
them. This is effectively done by steam autoclave and
washing intraocular instruments with Ringer’s lactate Linen
meant for intravenous use. Sterile operation theatre gowns, towels, gloves could be
of disposable variety, this is internationally accepted to
Autoclave be the best. However, it is not practical in all kinds of
As the last step in the sterilization cycle of instruments, atmospheres. In India we still recycle our operating
they are passed through the flash autoclave for 134°C clothes which are usually made of cloth. The
for 5 minutes and this cycle is repeated three times in methodology approached towards their care is explai-
the Statim autoclave from Canada (Fig. 9.16). It has ned in the same 3-step procedure.
a built-in computer that tells us of the efficiency of the
cycle. However, color indicators would also tell us of the Cleaning This is done by taking all the sullied clothes
physical measurements reaching the desired levels. and first taking away all clothes coming from an infected
After doing this, the instruments are laid on the patient being operated or from the septic operation
operating table and each instrument that enters the eye theatre are treated separately than that coming from a
is dipped in Ringer’s lactate before entering the eye. clean operating room. These clothes are preferably
disposed off in an incinerator. If they cannot then they
The Operating Room Linen and Accessories are soaked in Dettol solution, before the cleaning process
All operation theatre linen and accessories must be begins.
cleansed before entering the complex. Particular slots The clothes are cleansed preferably in a washing
should be kept ready and clean for them everyday. machine with adequate soap being used. Then the
Otherwise the operation theatre should be totally bereft clothes are passed into a drying machine. Try not to
of any other article. Anything that is not used everyday leave these clothes on the drying rope for nature to dry,
94 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

because with this outside bacteria and fungus can settle to be reautoclaved to improve efficiency in sterilization
on these clothes. Inadvertently they may fly off the techniques.
clothes line and this would also create much increase
Ethylene oxide sterilization: With todays emphasis on
of the microbial load for sterilization.
better sterilization techniques and total dependence on
However, if machinery is not available these clothes
them, a move has come into using the gas industrial
are first soaked for half an hour in hot water with soap
sterilization for hospital purposes. As there is more surety
solution inside a large tub. A rod is taken and rotated
on its efficacy this is even a preferred technology over
round and round for five minutes. This will shake off
the autoclave. However, it does have its drawbacks which
the dirt and grind from the clothes.
are that the hospital needs to keep a bigger inventory.
After this each cloth is taken separately and washed
This is due to the fact that these clothing need to be
with hand and the clothes thrown into another tub of
aired out for over 48 hours before they can come into
hot water with a few drops of Dettol solution in it. The
contact with human skin. Easily achieved by having four
clothes are left for another half an hour in this solution
times the number of gowns and towels one would
and then rinsed off with plain water.
A separate enclosure should be made for the drying ordinarily keep.
of these clothes. When the clothes are placed on the The advantage of ethylene oxide sterilization for linen
clothesline they should be pinned there as they may fly over autoclave is that we never get damp clothing which
should be regarded as not sterile. Moreover, the
Section 1

and hit the floor picking up germs. This could be avoided.

Once dry they are picked up, folded and sealed for personnel are always sure of ready stocks for operating
sterilization. at anytime. We do not have to start the autoclave and
wait for sterilization, we always have sterile clothing ready.
Sterilization Clothes could be sterilized by two methods,
whichever method is used what is important is that they Sealing and packing In ethylene oxide sterilization the
be folded away keeping each procedure in mind. That methodology employed towards its packaging is very
is to say if for one cataract procedure we need three important. High-grade thick plastic bags could be used,
operating gowns, ten towels and six shoulder bags, then alternately custom-designed bags are available for
they should be folded in such a way that these are all ethylene oxide sterilization. However, these custom-
kept together. One does not have to search for the small designed bags are more expensive than plain plastic bags
items by opening up every item sterilized. used commercially.
Sealing of these bags has to be immaculate as any
Autoclave: This still finds the pride of place in being the
porthole left gaping will now allow the atmospheric air
most accepted form of sterilization. However, one needs
containing microbes into the bag and once the seal is
to be aware that the clothes must not come out of damp.
broken the contents are not any more registered as
The steam in the autoclave must be saturated but dry.
sterile. Sealing machines are available in the market and
This means all the water vapor present in the air should
their use is much better than burning the bags with a
be gas and no droplets of water in the steam. If an
candle and sealing them.
autoclave is giving out of damp clothes that means it
is not working efficiently. The drums kept in the autoclave Ethylene oxide chamber The ethylene oxide (ETO)
must be closed immediately on removal from the gas comes compressed in gas cylinders that are attached
autoclave, ensuring that outside air does not enter the to the machine. These machines which use the gas
drum. Once autoclaved the items can be considered cylinder have a vacuum pump attached which first
sterile for only 24 hours which means to say they need empties the air in the ETO chamber, then we let in the
Sterilization 95
compressed ethylene oxide gas and leave it at about but the whole batch of Ringer lactate would and will
50°C for over 6 to 12 hours. Now, when the chamber be used on several eyes at a time and many losses have
has to be opened, once again the vacuum pump emp- been reported. From the Ringer lactate one surgeon lost
ties the gas out. The outlet from the machine needs to over 12 eyes to infection from the fluid. This cannot
be placed 6 feet above and outside into the atmosphere. be really taken as a mistake as we understand that fluids
This gas is toxic and its inadvertent entry inside the meant for IV therapy must be totally sterile, however
hospital premises is a health hazard for personnel. Care this is not always the case.
must be taken that the outlet tubing is placed well outside So to protect our patients from such a malady
the hospital premises, onto the terrace if possible. occurring we resterilize these bottles in the autoclave.
Once the ETO has escaped out the atmospheric air It is preferrable to use glass bottles. Studies have shown
is let in and the chamber pressure maintained at atmo-
the plastic polymers react with the fluids and can have
spheric pressure before it is opened. The materials can
drastic effects on the cornea of patients. Thus, world
now be kept on a shelf for airing. The shelf should be
over glass is a preferred carrier for use of fluids inside
just racks with ample room on either side for the gas
the eye. Moreover, plastic bottles cannot be autoclaved
to escape from its whereabouts. The linen can be now
as they would melt with the over 100°C needed for
used as sterile after 48 hours of airing.
autoclave sterilization.
Alternately gas ampules are present which can be
Even when we are sterilizing these glass bottles care

Section 1
placed inside the chamber, these ETO gas ampules need
has to be taken in their placement in the autoclave bins.
neither the vacuum pump nor the temperature
Autoclave indicator stickers are used on every bottle.
maintenance and can be easily placed inside a big plas-
The bottles are placed head up, and kept in the bin with
tic bag also prescribed by the company that manufac-
tures the ETO gas ampules. All the clothing is stacked space all around. Preferrably wrapped in some cloth
after sealing inside the big plastic bag that occupies the towel so that should they inadvertently break and blow
whole of the gas chamber. The ampule is broken and up, they would do so inside the wrapping. Care has to
this allows the ETO gas to permeate through the whole be taken to let the fluids reach a level of below 80°C
closed plastic bag inside the chamber. This is left so for temperature before opening the autoclave chamber as
12 hours and for another 14 hours when the gas escapes they may blow up on exposure to room temperature.
the chamber. After which the contents can be taken out All fluids used inside the eye are kept at 4°C for better
and placed on airing shelves. trauma control on the eye. As we know cold itself is an
anesthetic and controls blood vessels by constricting them
Medication we prefer to use cold fluids inside the eye. This would
Parenteral also ensure better control on the delicate tissues of the
IV fluids and intraocular fluids: Fluids used inside the eye and less trauma as well.
eye should be regarded as not sterile unless proved
otherwise. Towards this exercise we sterilize all our fluids, Methylcellulose 2 percent (VISCON): Much the same
like Ringer lactate, saline and even 2 percent technology is used in autoclaving methylcellulose. Glass
methylcellulose. Many a surgeon in developing coun- containers are once again preferred as plastic would react
tries has suffered immense loss by placing Ringer lactate with the fluids inside. The vials are kept wrapped in cloth
into the eye without prior sterilization. E. coli has been and placed inside the autoclave bins. Once sterile these
known to be grown from these fluids. At the moment are shifted into a refrigerator to keep them at 4°C, the
of an infection occurring not just one eye will be lost, preferred temperature for methylcellulose as we know
96 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

at this temperature the viscosity is the greatest and best

for intraocular use.

All other medication: These too need our undivided

attention as to their expiry. Most drugs are not re-ste-
rilized since the methodologies used might just dena-
ture the medication. However, place has to be kept in
the operating area complex for essential medication
necessary during the course of a surgery. These
medicines should not be stocked inside the main
operating room but in prefunction area.
Fig. 9.17: Flushing of I/A probe with 70 percent isopropyl
Care needs to be taken regularly to keep dusting
alcohol passing 200 ml of alcohol into every lumen
and keeping the area where medicines are kept to be
clean and free from germs. Thus, to do so everyday
this area must be cleaned, drawers, shelves all cleaned
with plain cloth and at least once a week with soap water
and/or Bacillocid.
Section 1

Probes and Tubings

All probes and tubings are usually of disposable variety,

and they could be kept in clean shelves or drawers with
names written on the outside.
Alternately today we could recycle probes and tubings
by first cleaning them well and then passing them
through ethylene oxide sterilization. However, these Fig. 9.18: Flushing of the lumen of the internal tubing and the
metal knobs with carbonic soap and mineral water passing
tubings and probes are usually made of plastic and for 200 ml of the same into the lumen
the gas sterilization to be totally safe and non-toxic they
need to be kept on the shelf for airing for over 15 days.
So, the date and time of ETO sterilization needs to be
marked on the color indicators when sterilizing these
A preferred methodology for sharp instruments to
be sterilized is also the ETO chamber, some of these
sharp instruments like disposable knives are also made
of plastic handles, which can withstand ETO temperatures
but not the autoclave. These too need to be kept on
a shelf for 15 days before use on human tissues.
The I/A probes, the internal tubing, external tubing,
Fig. 9.19: Flushing of the lumen of the internal tubing and
rectal knibs are all cleaned with various disinfectants (Figs the metal knobs with 2 percent glutaraldehyde passing 200
9.17 to 9.26). ml of the same into the lumen
Sterilization 97

Fig. 9.20: Flushing of the lumen of the internal tubing and Fig. 9.23: Flushing of the lumen of the external tubing with
the metal knobs with 70 percent isopropyl alcohol passing 2 percent glutaraldehyde passing 200 ml of the same into
200 ml of alcohol into the lumen the lumen

Section 1
Fig. 9.21: Flushing of the lumen of the internal tubing and
the metal knobs with mineral water passing 200 ml of the Fig. 9.24: Flushing of the lumen of the external tubings with
same into the lumen 70 percent isopropyl alcohol passing 200 ml of alcohol into
the lumen

Fig. 9.22: Flushing of the lumen of the external tubing with

carbonic soap and mineral water passing 200 ml of the Fig. 9.25: Flushing of the lumen of the external tubings with
same into the lumen mineral water passing 200 ml of same into the lumen
98 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

The personnel take off their shoes and are given

alternate operating area clogs, slippers or sandals. The
operating area footwear should also undergo vigorous
cleaning procedures everyday. At the end of the day,
all the footwear is taken in and washed with soap water
and cleansed with plain water and left for drying.

After changing the footwear all clothing needs to be
changed. A changing room has to be kept clean and with
lockers so that operating room personnel can keep their
clothes and valuables safely. The most often used personnel
clothing are pant with elasticated waist and shirts with loose
necks so that they could be slided into. It is preferrable
not to keep buttons and other such accessories on these
clothing as they would get damaged in the vigorous routine
that these clothing should go through.
After the operation theatre has finished for the day
Section 1

clothes from the personnel lockers are taken ideally into

Fig. 9.26: 100 ml of Ringer’s lactate solution is passed a washing machine and then through the dryer and sent
through the lumen of the internal tubings, external tubings, for sealing and packing through ethylene oxide sterilization
I/A probe and metal knobs ready for use four days from the day of sterilization.
Towards this rigmarole the hospital would need to keep
The Operating Room Personnel six times the number of clothes actually required.
Most often surgeons like to operate in the morning, However, if this is not possible the clothes could be
sometimes they need to operate through the whole day, washed by hand dried and then sent into the autoclave
however, it is a good exercise to see that all operating for sterilization. In these clothes one is not really looking
area personnel have a regular bath first thing in the for sterility but for disinfection and thus it is better to
morning before entering the operating area. All street go a step further and make them sterile before use.
clothing and footwear should be removed before
entering the operating area. Thus, most hospitals would Cap and Mask
keep the changing rooms as the first area of the operating The cap and mask need not be sterile, however they
area complex. should be clean and disinfected. Ideally the cap and mask
used can be of disposable variety since their cleaning
Footwear will then not become necessary. However, if they are
Separate areas should be demarcated to keep footwear. not and the hospital needs to use cloth cap and mask,
This should be kept outside the operating area complex. they can go through the same cycle of events like the
However, sometimes they could be kept just inside the other clothing.
door as we have seen many a surgeon goes in taking
out his or her shoes and when he or she comes back The Patient
his or her shoes are gone. This is specially true if he or The patient should also be made to go through a process
she wears lovely expensive new shoes. to make him or her clean and disinfected. Ideally all patients
Sterilization 99
should be told to have a bath before they go in for elective If anesthesia is necessary it can be given now after
planned surgery. This simple process does give large preliminary cleaning of the site. After injections are given
benefits. Shaving where men are concerned is essential the site to be operated is once again cleansed by a
and removal of make-up is necessary where women are scrubbed personnel with antiseptic solution.
Sterile Disposable Surgical Drape
Change of Clothes
The patient should change into operating room clothes Where the eye is concerned, in todays world the lashes
and take out all street clothes. Footwear has to be do not have to be cut for intraocular surgery. However,
removed before entering the operating room. Ideally whenever this is not done, then a plastic surgical
patients are requested to remove all their clothing disposable sterile drape is used over the eyes. This has
including undergarments and a patient gown given to a gummy on the undersurface, keeping the eyes open
them. This is done in the benefit of the patient so that the surgeon places the gummy directly on the cornea
at any particular time should an emergency procedure and keeps the lashes turned out so that they could stick
be called for it can be applied without interference from to the gummy surface and keep out of the surgical field.
essential clothing. Moreover, all patients need to be The drape used in the ophthalmic field manufactured
monitored for their heart and blood oxygen these by Dr. Agarwal’s Pharma is also equipped with a drainage
electrodes are usually placed close to the heart. bag. So, once the drape is stuck to the patient’s eye,

Section 1
However, in ophthalmic practice it is customary in the central plastic over the palpebral fissure is cut open
a day care surgical center that the clothes need not come with sterile scissors after the surgeon has scrubbed and
off the patient. Simple removal of shoes and shirt or changed.
dress is sufficient. Patients are then given sterile disposable A whole 20 cc of sterile refrigerated 4°C Ringer’s
gowns that can be worn over their undergarments. This lactate fluid is squirted over the eye, to carryout a
process is found to be satisfactory for ophthalmic patients. thorough cleaning procedure as well as to produce
All patients are also given a disposable cap so that cryoanalgesia. The surgery can now be started. This
all hair can be placed inside the cap and not interfere
cleaning process is found to be very necessary for a clean
in surgical procedures.
fornix and conjunctival sac.
Skin and Incision Site Disinfection
Many solutions are available for wound disinfection some STERILIZERS
of the best used worldwide are povidone-iodine and
Methods of Sterilization
chlorhexidine gluconate 1.5 percent with cetrimide 7.5
percent. All these antiseptics will be put to better use For a very long-time we had no idea that sterilization
if they are used in conjunction with simple cleaning is the basis of surgical correction, after all performing
procedures first. the best of surgery though introducing harmful microbes
The patient’s face could be washed with soap and could mar the effects of surgery irreparably. With the
water and all jewellery and accessories should be advent of the autoclave in 1884 we got to know a lot
removed. Once the patient lies down on the operating of details. However, most surgical ward history can be
table and is ready for surgery, a scrubbed nurse paints detailed as that before Lister and the era after Lister as
povidone-iodine or any other antiseptic on the skin. This this one person was responsible in explaining antiseptic
is removed with plain gauze. surgery as we understand it today.
100 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Terminology pressure to 2.4 bar would produce steam at 125°C and

increasing to 3 bar at 134°C. However, at subatmos-
To better understand this vast and varied aspect of pheric pressures this temperature would fall, thus at higher
surgery, first let us understand the terms and conditions altitudes water will boil at lower temperatures.
often used.
1. Quality of steam for sterilization: Steam is non-toxic
Sterilization: It is a process used to achieve sterility— and non-corrosive, though for sterilization it should
an absolute term meaning the absence of all viable micro- also be saturated, which means it should hold all the
organisms. water it can hold. It must also be dry, so it should
Disinfection: It is a process which reduces the number not contain water droplets. This has a greater lethal
of contaminating microorganisms, particularly those action and is quicker in heating up the article to be
liable to cause infection, to a level which is deemed no sterilized.
longer harmful to health. When dry saturated steam meets a cooler surface
it condenses into a small amount of water and
Antisepsis: It is used to describe disinfection applied to
liberates latent heat of vaporization. The energy
living tissue such as a wound.
available from this latent heat is considerable. For
Cleaning: It is a soil-removing process which removes example, 6 liters of steam at a temperature of 134°C
many microorganisms. The reduction in contamination will condense into 10 ml of water and liberate 2162
Section 1

by cleaning processes is difficult to quantify other than J of heat energy. By comparison less than 100 J of
visually. heat energy is released by the sensible heat from air
at 134°C to an article in contact with dry heat.
Decontamination: It is a general term for the treatment
Steam at a higher temperature than the
used to make equipment safe to handle and includes
corresponding pressure would allow is referred to as
microbiological, chemical, radioactive and other conta-
superheated steam and behaves like hot air. Steam
with water droplets is called wet steam and is less
Sterilization efficient.

An article may be regarded as sterile if it can be 2. Types of steam sterilizers

demonstrated that there is a probability of less than I A. Sterilizers for porous loads: For linen, and
in a million of there being viable microorganisms on it. wrapped instruments, so air could get trapped in
the textiles used. Thus, this type of sterilizer should
Methods Five main methods are used for sterilization.
have a vacuum-assisted air removal stage to
Head: A widely used method needs to reach tempe- ensure that adequate air is removed from the load
ratures above 100°C to ensure bacterial spores are killed. before admission of steam. The vacuum pulsing
Moist heat is more effective than dry as it coagulates of air also ensures that the load is dry on
and denatures the protein, where water participates in completion of cycle.
the reaction. This requires 121°C for 15 minutes with B. Sterilizers for fluids in sealed containers: Must have
moist heat. a safety feature to ensure that the door cannot
Temperatures above that of boiling water can be be opened till the temperature in the glass
attained more easily by raising the pressure in a vessel, containers has fallen below 80°C. Otherwise the
this is the principle of the autoclave. At sea level water thermal stress of cold air on opening the door
would boil and produce steam at 100°C, increasing the may cause the bottles to explode under pressure.
Sterilization 101
C. Sterilizers for unwrapped instruments and utensils: B. Red heat: Diathermy in ophthalmic hospitals would
These should not be used for wrapped articles, be done by burning a loop over a flame, this
recommended for dental clinics and LASIK would sterilize as well as cauterize the bleeding
stations. vessel. However, this is still used to sterile loops,
D. Laboratory sterilizers: Culture media in containers, wires, points of forceps. It is a still very much used
laboratory glassware and equipment may be in emergency situations.
contaminated, thus proper cleansing is necessary C. Flaming: Inoculating loops and needles are some-
before sterilization. times treated by immersing them in methylated
spirit and burning off the alcohol, though this does
3. Monitoring of steam sterilizers: Every load everyday
not produce a sufficiently high temperature for
everytime needs monitoring of some important phy-
sterilization. This is also done for sterilizing drums
sical measurements.
and trays over which sterile linen is placed. Once
• Temperature
again this is not totally sterile as spores may persist
• Pressure
over the short-term flame that is produced with
• Time with thermometers.
Detailed tests are undertaken with temperature-
D. Hot and sterilizer: Oil, powders, carbon steel
sensitive probes (thermocouples) inserted into standard
instruments, and empty glassware and laboratory
test packs. Though most indicators show color change

Section 1
dishes are sterilized with hot air sterilizers, though
on reaching particular temperatures.
the overall heating up and cooling may take
Biological indicators comprising dried spore suspen-
several hours.
sions of a reference heat-resistant bacterium Bacillus
E. Microwave sterilizer: This is the latest in roads into
stearothermopiles, are not used for routine testing.
sterilizers and can offer better results than hot air
Although spore indicators are essential for low tempe-
sterilizers with shorter time spans. Within 10
rature gaseous processes in which the physical mea-
minutes the material can be sterilized. However,
surements are very little to kill spores or not reliable.
because of the high temperatures reached it is
Most often used for ethylene oxide sterilization.
not very good for organic material or plastics. Very
Bowie-Dick test monitors penetration of steam into
good for microwave transparent material like glass.
wrapped pack and detects uneven steam penetration
by a bubble of residual air in the pack. 5. Factors influencing sterilization by heat would include:
Dry heat causes a destructive oxidation of the essential A. Temperature and time: They are inversely related,
cell constituents. Thus, killing spores here requires 160°C i.e. shorter time higher temperatures, holding time
for 2 hours. This may also cause charring of paper, is important loading and cooling time would make
cotton, organic material. the total time much longer (Table 9.1).

4. Types of sterilization by dry heat Table 9.1: Relationship between temperature and time
A. Incineration: Most cities around the world have
Process Temp (in°C) Holding time (min)
made it mandatory for most hospitals to have
Dry heat 160 120
incinerators in their campus for efficient waste
170 60
disposal where contaminated materials like dres- 180 30
sings, sharp needles and other clinical wastes. The Moist heat 121 15
high temperature reached kills all organisms and 126 10
134 3
disposes by charring and burning the material.
102 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

B. Microbial load: The number of organisms and oxide sterilization is usually carried out at tempera-
spores affects the rapidity of sterilization. Thus, tures below 60°C in conditions of high relative humi-
it is better to go through vigorous cleaning dity. To ensure sterility, material should be exposed
procedures before sterilization of products. to a gas concentration of 700 to 1000 mg/l at 45
to 60°C and a relative humidity above 70 percent
Ionizing radiation: Both beta (electrons) and gamma
for about 2 hours. Care must be taken because of
(photons) irradiation are employed industrially for the
toxicity to personnel, flammability and explosion risk.
sterilization of single use disposables.
The sterilized product must be aerated to remove
All accelerated electrons are lethal to living cells, that
residual ethylene oxide before it can be safely used
includes, γ-rays, β-rays, X-rays. Bacterial spores are the
on the patient, and turn round time is consequently
most resistant. Sterilization is achieved by the use of high-
speed electrons from a machine such as a linear
Some recommendations for boosting infection control
accelerator or by an isotope source such as cobalt-60,
as well as cut costs on EO sterilization:
a dose of 255 kGy is generally adequate, making this
• Cleaning is a necessary and important activity before
an industrial process. It is used for single use prepackaged
sterilization. I feel that you need to adopt standardized
items like plastic syringes and catheters.
and effective cleaning method.
Filtration: Filters are used to remove bacteria and other • Further the items cleaned have to be dried as any
Section 1

larger organisms from liquids that are liable to be spoiled wet item will react with ethylene oxide and the efficacy
by heating. Though virus can crossover they are felt to may be reduced.
be unimportant. • The items have to be packed in one of the three
Filters using pore size of less than 0.45 microns can materials: linen, paper or plastic. Each has its
render fluids free of bacteria. It is used in the preparation advantage but the limitation is the period that you
of toxins and thermolabile parenteral fluids such as can store these sterilized items. You can use plastic
antibiotic solutions, radiopharmaceuticals, and blood bags which are of a proper grade and store the
products. Viruses and some bacteria like mycoplasmas product up to one year after sterilization.
can pass through pore size of less than 0.22 microns. • The sealer used for sealing packs is inappropriate if
Filter materials could be unglazed ceramic Chamber- the heating is too weak for the packaging material
land filters, asbestos Seitz filters and sintered glass filters. used. This results in small holes in pack after sealing.
Though now membrane filters are usually used made An impulse heat sealer capable of sealing at higher
of cellulose esters or other polymers. temperatures.
• A safe EO machine which can complete the process
Sterilant gases: Ethylene oxide is used for sterilization
of aeration within all items can be used directly
of plastics and other thermolabile material. Formalde-
without any further handling.
hyde in combination with subatmospheric steam is more
• Aeration is a natural process which can be hastened
commonly used in hospitals for reprocessing thermolabile
by installing an aerator.
equipment. Both processes are toxic and carry hazards
to user and patient. 2. Low temperature steam and formaldehyde: A combi-
1. Ethylene oxide: Highly penetrative, non-corrosive nation process of steam generated at subatmospheric
and microcidal gas which is used to in industry for pressure 70 to 80°C and formaldehyde gives an effec-
single use, heat-sensitive medical devices such as tive sporicidal process. It is appropriate for heat-
prosthetic heart valves and plastic catheters. Ethylene sensitive articles that can resist temperatures of 80°C.
Sterilization 103
3. Propylene oxide: One of the latest and new techni- with ozone treatment plants is very effective in
ques is the use of propylene oxide which is a micro- disinfection.
cidal gas. It has a similar use and toxic effect like This is a low energy, non-iodizing radiation with poor
propylene oxide. penetrating power that is lethal to microorganisms under
Sterilant liquids: Glutaraldehyde is generally the least optimum conditions. The shorter UV rays that reach the
effective and most unreliable method. earth’s surface in quantity have a wavelength of about
290 nm, but even more effective radiation of 240 to
Disinfection 280 nm is produced by mercury lamps. It is used in
Disinfection is applied in circumstances where sterility is the treatment of water, air, thin films and surfaces such
unnecessary or impractical, like bed-pans, eating utensils, as laboratory safety cabinets.
bed linen and other such items. Similarly, the skin around
Gases: Formaldehyde is used as a fumigant though it
the site for an invasive procedure should be cleansed
does not have an all pervasive effect. Traditionally for-
to reduce chances of wound infection.
maldehyde gas was used to disinfect rooms previously
Cleaning occupied by patients with contagious diseases such as
smallpox. It is still used for disinfection of heat-sensitive
Thorough cleaning is a prerequisite for successful
equipment, however its efficacy is questionable with
disinfection and is a process of disinfection by itself. This
better products like Bacillocid available.

Section 1
can be enhanced by ultrasonic baths given to the
instruments to remove dried debris. Filtration: Air and water supplied to operation theatres
and other critical environments are filtered to remove
Methods hazardous microorganisms, though viruses cannot
Heat: Steam or water could be used. remain out altogether. However, they are considered
harmless in these environments.
1. Moist heat is the first method of choice, can be pre-
A properly installed high efficiency particulate air
cisely controlled, leaves no toxic residues and does
(HEPA) filter achieves 99.9 percent or better resistance
not promote the development of resistant strains.
to particles of 0.5 microns and can produce sterile air
Washing or rinsing laundry or eating utensils in water
at the filter face.
at 70 to 80°C for a few minutes will kill most non-
sporing microorganisms present. Similarly, steam Chemical: Several chemicals with antimicrobial proper-
maintained at subatmospheric pressure at 73°C is ties are used as disinfectants.
used in low temperature steam disinfectors in hospitals Antiseptic can be regarded as a special kind of
to disinfect thermolabile reusable equipment. disinfectant which is sufficiently free from injurious effects
to be applied on the surface of the body, though not
2. Boiling: Exposure to boiling water for 20 minutes
suitable for systemic or oral administration.
achieves highly effective disinfection, although this
Some would restrict the use of antiseptic prepara-
is not a sterilization process it can be useful in
tions applied to open wounds or abraded tissue and
emergencies if no sterilizer is available.
would use the word skin disinfection for removal of
Ultraviolet radiation: It has limited application for dis- organisms from hands and intact skin surfaces.
infection of surfaces, some piped water supplies but lacks 1. Factors influencing the performance of chemical
penetrative power, however newer modifications in use disinfectants:
104 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

A. The concentration of the disinfectant: The they are volatile, alchohols are recommended as
optimum concentration required to produce a rapidly drying disinfectants for skin and surfaces.
standardized microbial effect in practice is However, they may not achieve adequate
described as the in-use concentration. Care must penetration and kill, particularly if organic matter
be taken in preparing accurate in-use concen- such as blood or other protein-based contami-
trations while diluting product. Accidental or nation is present. Alcohols are suitable for
arbitrary over dilution may result in failure of physically clean surfaces such as washed
disinfection. thermometers or trolley tops but not for dirty
B. The number, type and location of microorganism: surfaces. Care must be taken when used on the
The velocity of the reaction depends upon the skin in conjunction with diathermy and other
number and type of organisms present. In general instances of flammable risk. Alcohols with chlor-
gram-positive bacteria are more sensitive to disin- hexidine or povidone-iodine are good choices for
fection than gram-negative bacteria. Mycobacteria hand disinfection, they are applied to the dry skin
and fungus are resistant while spores are highly often with added emollient to counteract the
resistant, while viruses are susceptible. drying effect.
Glutaraldehyde is highly active against B. Aldehydes: Most aldehyde disinfectants are based
bacteria, viruses and spores. Other disinfectants on glutaraldehyde or formaldehyde formulations,
Section 1

such as hexachlorophene have a relatively narrow alone or in combination. Glutaraldehyde has a

range of activity, predominantly against gram- broad spectrum action against vegetative bacteria,
positive cocci. fungi, viruses, but acts more slowly against spores.
C. The temperature and pH: Some disinfectants are It is often for equipment such as endoscopes that
more active or stable at a particular pH. Though cannot be sterilized or disinfected by heat. It is
glutaraldehyde is more stable under acidic an irritant to the eyes, skin and respiratory mucosa,
conditions its microbial effect is seen better when and must be used with adequate protection of
the pH is 8.0. staff and ventilation of the working environment.
It must be thoroughly rinsed after treated
D. The presence of organic or other interfering
equipment with sterile water to avoid carryover
substances: Disinfectants can be inactivated by
of toxic residues and recontamination. The
hard tapwater, cork, plastics, blood, urine, soaps
alkaline buffered solution is claimed to remain
and detergents, or other disinfectants. Information
active for several days, but this will vary depending
should be sought from the manufacturer or from
on the in-use situation, including the amount of
reference authorities to confirm that the disinfec-
organic material.
tant will remain active in these circumstances.
2. Common chemicals in use: C. Biguanides (chlorhexidine): This is commonly
A. Alcohols: Isopropanol, ethanol, and industrial used for disinfection of skin and mucous
methylated spirit have optimal bactericidal activity membranes. It is less active against gram-negative
in aqueous solution at concentrations of 70 to bacteria such as Pseudomonas and Proteus sp and
90 percent and have little bactericidal effect in aqueous solution has limited virucidal,
outside this range. They have limited activity tuberculocidal and negligible sporicidal activity. It
against mycobacteria and are not sporicidal. is often combined with a compatible detergent
Action against viruses is generally good. Because for handwashing or with alcohol as a handrub.
Sterilization 105
Chlorhexidine has low irritancy and toxicity and E. Phenolics: These have been widely used as
is effective even on exposed healing surfaces. It general purpose environmental disinfectants in
is inactivated by organic matter, soap, anionic hospital and laboratory practice. They exhibit
detergents, hard water and some natural materials broad-spectrum activity and are relatively cheap.
such as cork liners or bottle closures. Clear soluble phenolics have been used to disinfect
environmental surfaces and spillages if organic soil
D. Halogens (hypochlorites): These broad-spectrum
and transmissible pathogens may have been
inexpensive chlorine-releasing disinfectants are
present. As hospital disinfection policies are ratio-
that of choice against viruses. For heavy spillage
nalized, phenolics are being replaced by detergents
such as blood, a concentration of 10,000 ppm
for cleaning and by hypochlorites for disinfection.
of available chlorine is recommended.
Most phenolics are stable and not readily inacti-
These are inactivated by organic matter and
vated by organic matter, with the exception of
corrode metals, so that contact with metallic instru-
the chloroxylenos (Dettol) which are also
ments and equipment should be avoided. The
inactivated by hard water and not recommended
bleaching action of hypochlorites may have a
for hospital use. Phenolics are incompatible with
detrimental effect on fabrics and should not be
cationic detergents. Contact should be avoided
used on carpets.
with rubber and plastics, such as mattress covers,
Chlorine-releasing disinfectants are relatively

Section 1
since they are absorbed and may increase the
stable in concentrated form as liquid bleach of
permeability of the material to body fluids. The
as tablets (sodium dichloroisocyanurates) but
slow release of phenol fumes in closed
should be stored in well-sealed containers in a
environments and the need to avoid skin contact
cool dark place. On dilution to the required con-
are other reasons for care in use of phenolics.
centration for use, activity is rapidly lost.
The bis-phenol hexachlorophane has particular
Hypochlorites have widespread application as
activity against gram-positive cocci, and has been
laboratory disinfectants on bench surfaces and in
used in powder or emulsion formulations as a
discard pots. Care should be taken to remove all
skin disinfectant, notably for prophylaxis against
chlorine-releasing agents from laboratory areas
staphylococcal infection in nurseries. There has
before the use of formaldehyde fumigation to
been some concern about the possible toxic effect
avoid the production of carcinogenic reaction
of absorption across the neonatal skin barrier on
repeated exposure. An alternative, which has been
Iodine: Like chlorine, iodine is inactivated by used in the control of methicillin-resistant
organic matter and has the additional dis- Staphylococcus aureus outbreaks is triclosan.
advantage of staining and hypersensitivity. The
F. Oxidizing agents and hydrogen peroxide: Various
iodophors which contain iodine complexed with
agents, including chlorine dioxide, peracetic acid
an anionic detergent of povidone-iodine a water-
and hydrogen peroxide, have good antimicrobial
soluble complex of iodine, polyvinyl and
properties but are corrosive to skin and metals.
pyrrolidone are less irritant and cause less staining.
Hydrogen peroxide is highly reactive and has
Aqueous and alcohol-based povidone-iodine
limited application for the treatment of wounds.
preparations are used widely for skin and ocular
disinfection as well as other mucous membrane G. Surface active agents: Anionic, cationic, non-ionic
disinfection. and amphoteric detergents are generally used as
106 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

cleaning agents. The cationic (quaternary ammo- able to withstand high amounts of torture only to make
nium compounds) and amphoteric agents have sure their breed lives on. Bacteria are not that much
limited antimicrobial activity against vegetative different from us in this intrinsic need to propagate, grow
bacteria and some viruses but not mycobacteria and leave their legacy behind. Still we need to be on
or bacterial spores. Quaternary ammonium com- top of them to allow them to grow where we need them
pounds disrupt the membrane of microorganisms, and the operating room is definitely not a place we need
leading to cell lysis. Care must be taken to avoid any of them at all. Here are some of the reasons why
overgrowth by gram-negative contaminants and these bacteria do withstand our torture.
inactivation by mixing cationic and anionic agents.
Species or strain of microorganism As usual the spores
Disinfection may be enhanced by appropriate
are more resistant than vegetative bacteria or viruses.
combination of a surface active agent with
Though some strains of species have wide variations.
disinfectant to improve contact spread and
Enterobacteriaceae D values at 60°C range from a few
cleansing properties.
minutes (E. coli) to 1 hour (Salmonella senftenberg).
Quality Control The typical D value for Staphylococcus aureus at 70°C
Every method used must be validated to demonstrate is less than I min compared with 3 min for Staph.
microbial kill. With heat and irradiation a biological test epidermidis. However, an unusual strain of Staph. aureus
may not be required if the physical conditions can be has been isolated with a D value of 14 min at 70°C.
Section 1

proved to have reached their ultimate design. Such variable could be attributed to the morphological
and physiological changes such as alterations in cell pro-
D value The D value or the decimal reduction value
teins or specific targets in the cell envelope affecting
is the dose that is required to inactivate 90 percent of
the initial population. When the time required or the
Thus, we should not understand the inactivation data
dose required to reduce the population from 1,000,000
for one disease forming organism would withstand by
to 1,00,000 is the same as the time or dose required
another. Creutzfeldt-Jakob disease is a highly resistant
to reduce the population from 1,00,000 to 10,000 the
agent requiring six times the normal heat sterilization
D value remains constant over the full range of the
cycle (134°C for 18 minutes).
survivor curve. Extending treatment beyond the point
where there is one surviving cell does not give rise to Physiological stage Organisms grown under nutrient-
fractions of a surviving cell but rather to a statement of limiting conditions are typically more resistant than those
the probability of finding one survivor. Thus, by grown under nutrient-rich conditions. Resistance usually
extrapolation from the experimental date it is possible increases through the late logarithmic phase of growth
to determine the lethal dose required to give a probabi- of vegetative cells and declines erratically during the
lity of less than 1 in 1,000,000 which is required to meet stationery phase.
the pharmacopoeial definition of sterile.
Ability to form spores Bacterial endospores are more
Factors Influencing Resistance resistant than fungal spores, some of them are used as
bacterial indicators especially for ethylene oxide sterilizers
Many factors affect the ability of the microorganism to
to monitor their efficacy. Disinfection has no efficacy
withstand lethal procedures of sterilization. This in fact
where spores are concerned.
is the reason why we need to keep updating ourselves
as to the methods of sterilization and their efficacies. This Suspending menstrum Microorganisms occluded in salt
also happens to be the reason why living creatures are have greatly enhanced resistance to ethylene oxide, the
Sterilization 107
presence of blood or other organic material will reduce • The processes and products available for sterilization
the effectiveness of hypochlorite solution. Thus, and disinfection must be made available for all to
suspended particles will alter efficacy of various see and inspect. An effective policy may include a
techniques. limited number of process options, restrictions on the
range of chemical disinfectants eliminate unnecessary
Number of microorganisms Quite obviously the initial
costs, confusion and chemical hazards.
“bio-burden” the more extensive must the process of
• The category of process required for each item,
sterilization be to achieve the same assurance of sterility.
sterilization for surgical instruments and needles, heat
disinfection for laundry, crockery, bedpans, cleaning
Sterilization and Disinfection Policy
of floors, walls, furniture and fixtures.
All hospitals should go through a rigmarole of infection • The specific products and method to be used for each
control and agree on a particular policy to be followed item of equipment, the site of use and the staff
uniformly by all concerned in this infection control team. responsible for the procedure. These should all be
This should be headed by the chief surgeon and each earmarked in a record so that one can get back to
one must report to the leader of the team everyday. the lapse when it happens.
It has been noticed over centuries of medical prac- Effective implementation of the policy requires liaison
tice when a surgical team gets to do routine surgeries and training of staff and updating the policy. Safety
everyday for many days and years, a kind of apathy

Section 1
considerations for staff and patients require a careful
sets into the system and somewhere someone lapses. assessment of specific procedures to minimize risks.
These instances have been the most common cause for The staff for implementation of these processes must
infection. To avoid such lapses the infection control team wear protective gear where necessary. Gloves, aprons,
should meet each week to update themselves on the caps and masks must be included in the policy. Where
latest happenings in their hospital and to bring to the dangerous gases are used eye goggles similar to swim
notice such lapses so that a tightening of procedures can goggles can be used to protect the eyes from the noxious
be applied. At each lapse the chief surgeon must be held gases.
responsible for the actions of his or her team. For proper sterilization control, it is important to go
All members of the team must familiarize themselves back into every case that gets infected to try and pry
with the items to be sterilized and the chemicals necessary and find out what was the reason for the infection. This
to do so. A microbiologist should be included in this team can effectively be done by the weekly meeting of the
as they alone can monitor the efficacy of the said infection control team where everyone tries to pitch in
processes. Along with should also be a pharmaceutical their inputs.
person who has full knowledge of the various chemicals Staff should not be penalized for accepting their
used, their action and the efficiency in said matters. It wrong-doings, because if they are penalized they will
is very instrumental to include these persons on the not accept the cause of the infection next time it occurs.
infection control team of a hospital. The staff should be goaded into performing better by
The hospital policy should be common and should putting the patients best interests in view and not for
include: witch hunting and blaming.
• The sources to be sterilized (equipment, skin, envi-
ronment, air, water, personnel) for which a choice CULTURE RATE
of process is required to be commonly accepted by The most important mechanism for the proper function-
the team for infection control. ing of an operation theatre is the fact that no organism
108 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

should grow from this area. To find out whether an

organism is growing or not we need to make sure it is
present or not, that can effectively be done by growing
it on a culture media. Some of the most common culture
media used in hospitals is discussed here.

MacConkey’s Agar
To make this culture plate (Fig. 9.27) is simple enough.
According to directions 51.5 gm of the powder made
available through Himedia Laboratories is dissolved in
1000 ml of distilled water. This is allowed to boil till the
powder is completely dissolved and the fluid has boiled
for over 15 minutes, thus sterilizing the fluid further. It Fig. 9.27: MacConkey’s blood agar culture plates
could be still sterilized by autoclaving though most
hospitals find 15 minutes of boiling to suffice in its Dissolve 0.1 gm of crystal violet in distilled water and
sterilization. make-up the volume to 100 ml. Heat the solution in
steam at 100°C for 30 minutes.
This culture medium contains:
Section 1

Peptic digest of animal tissue 17 gm/lit To 200 ml of the base solution, melted and cooled to
Peptone 3 about 60°C add aseptically 0.6 ml of the neutral red
Lactose 10 solution and 0.2 ml of solution with crystal violet. Mix
Bile salts 1.5 well and distribute into sterile Petri dishes.
Sodium chloride 5 Incubate the plates at 37°C for 24 hours (Figs 9.28
Neutral red 0.03 to 9.30) and examine for contamination. Inoculate four
Agar 15 plates from the following stock culture Salmonella typhi,
At a final pH at 25°C of 7.1
Escherichia coli, a mixture of Salmonella typhi and E.
coli and Shigella flexneri. This will prove the efficacy of
Alternately if the readymade powder is not available
then the following procedure can be applied to the above-
mentioned ingredients.

Base solution Dissolve agar in 500 ml of distilled water

by autoclaving at 121°C for 20 minutes. Dissolve the
peptone, bile salts and sodium chloride in the remaining
500 ml of distilled water, and bring the solution to boil.
Combine the two solutions mixing thoroughly. Dissolve
the lactose and adjust the pH to 7.2. Distribute in screw-
capped bottles and sterilize with autoclaving at 121°C
for 15 minutes.

Dissolve 1 gm of neutral red in distilled water and make-

up the volume to 100 ml. Heat the solution in steam Fig. 9.28: Culture specimen taken using sterile swab
at 100°C for 30 minutes. stick from the instrument table
Sterilization 109
for 15 minutes. This would also sterilize the medium and
it is ready for use after cooling. The powder contains:

Peptic digest of animal tissue 5 gm/lit

Sodium chloride 5
Beef extract 1.5
Yeast extract 1.5
Agar 15
At 25°C the pH is 7.4.

Alternately if the powder is not available the separate

entities can be taken, mixed and steamed for 2 hours.
The pH should be adjusted first to 6.8 then clear the
Fig. 9.29: Culture specimen taken using sterile swab
fluid with egg albumin. Filter and bottle. Autoclave at
stick from the operation table head rest 15 lbs pressure for 20 minutes or steaming for 30
minutes each day on three successive days.

Blood Agar

Section 1
An enriched medium for general use in routine culti-
vation of the more delicate microorganisms like Neisseria
meningitidis, N. gonorrhoeae and Diplococcus
pneumoniae. The medium also serves as an indicator
of hemolysin production by bacteria.
It is very simple to make. Add 6 to 10 percent defi-
brinated blood to melted nutrient agar and cool to 45
to 60°C. Pour plate or slant, incubate 24 hours to prove

Fig. 9.30: Culture specimen taken using sterile swab stick STERILIZATION CONTROL
being streaked on the MacConkey’s blood agar culture plate
The infection control team which consists of a
microbiologist must take regular samples from the
the culture media prepared and now it can be poured
different areas sterilized or disinfected. Some of the
into petri dishes and refrigerated to be used on need
quality checks necessary to be carried out are:
for culture plates. It is advisable to keep them for 24
to 48 hours and to keep making fresh batches very often. Plate Test
One of the easiest to perform and tells us quite a bit
Nutrient Agar
about the cleaning tactics used for the particular room.
A general purpose medium for the cultivation of
This test would not be so effective in open areas but
microorganisms and a base for enriched or special
is quite reliable for closed areas like operating rooms.
purpose media. It can be made very simply by the
powder available from Himedia laboratories by dissolving For closed rooms Where operating rooms are concer-
28 gm of powder in 1000 ml of distilled water and boiling ned once we have assured ourselves there is no con-
110 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

taminated air coming in, with door closers, air curtains prescribed by the microbiologist on the infection control
and filtered air-conditioned ducting, cleaning the room team.
with detergents and disinfectants should clear the air of
all bacteria. However, this does not remain so throughout Culture Test from Walls, Floor,
Fixtures and Furnitures
the day, and it is noticed that after a few surgeries due
to human beings inside the operating rooms bacteria Everyday the different areas should be taken for culture,
do escape to contaminate the air. This can be effectively it is advised to take eight different areas for culture from
controlled by keeping a watch on the cleaning procedures every room everyday. Methodology for taking culture
and making sure a disinfectant mop is used after every is to take a moist swab, by dipping a cotton tip applicator
procedure and on every item of the operating room. in sterile water and rubbing it in a streak fashion on the
However, testing for the efficacy of the cleaning culture plate.
procedures is devised by the PLATE TEST. Here a sterile The culture plates are made in Petri dishes about
bowl is used with sterile water and kept in the concerned 3 inches in diameter. The back surface of the Petri dish
room for 20 minutes. Should there be bacteria in the can be stroked with a marker pen and each culture plate
room they would settle down on the surface of the bowl divided into eight parts.
of water. Thus, skimming the surface a few drops are One culture plate can be ear marked for each room,
taken and placed on a Petri dish with culture media on and 8 objects from the room can be cultured. It is
preferrable to always include the floor, of the room
Section 1

it. This is incubated at 38°C for 48 hours and if this grows

bacteria then we know our disinfectant procedures were however different parts of the floor can be taken each
not enough and we need to plough ourselves further. day to ensure proper cleaning and disinfectant use. Other
If it is negative then we can proceed with the same policy. objects that can and should be cultured for are the fans,
This test should be ideally carried out everyday, before air-conditioners, lights, walls, tables, chairs, stools and
every procedure in every room of the operating area. all the equipment present in that particular room. Like
Boyles apparatus, phaco machines, etc.
For open areas Lounges where patients wait or the
outside arenas are to be cleansed as well, if we would All Fluids to be Cultured
like to have a tight infection control in the operating All fluids used in the operating room must be sent for
area. After all these areas lead to the operating area— culture tests, sometimes this becomes less possible as the
the most pious sanctum sanctorum of the hospital edifice. fluid is too little and necessary for parenteral application.
The plate test is carried out everyday every few hours, However, every batch of fluids used can be sent for
and an optimum time interval given to the hospital culture tests. This may not grow positive however its not
authorities where it can be stated that every four hours growing positive itself is an indication of the efficacy of
the hospital lounges should be cleaned with disinfectant the program. This sets aside any debate that the fluid
to maintain a clean bacteria-free atmosphere. This can may have contained bacteria.
now be controlled by taking plate test samples every Of special importance is fluids used for intraocular
four hours before cleaning procedures are done and use, or for intravenous use. As soon as each IV bottle
making sure the tests remain negative for growth in all is opened the first few drops from the IV set can be
the tests taken. If not the program needs to be revised placed on a culture plate for incubation.
and the hours shortened. Many eye surgeons from our subcontinent have
This test should also be carried out in the consul- grown E. coli from the Ringer’s lactate used intraocu-
tation areas and optimum time intervals for cleaning larly. However, most often this has happened after a
Sterilization 111
tragedy of multiple eyes have succumbed to postcataract Biological chemical indicator One or more biological
surgery infection. Thus, by performing this simple step chemical indicator can be placed in the steam or ethy-
we may be able to thwart further mishaps. lene oxide test packs and the process passed through
Should any one batch of fluids be found to be positive the sterilization cycles. If used to monitor a 270°F steam
it is a good idea to report the matter so that others can “flash” cycle, place a wire mesh bottom instrument tray
be forewarned and to take every bottle from that batch. and then proceed.
After sterilization processing has been completed,
All Fluids used Parenterally to be allow the biological chemical indicator to cool until safe
Checked for pH Value to handle and open. Remove the indicators and allow
Great importance should be given to the pH of fluids to cool an additional 10 to 15 minutes. Observe chemical
inside the body especially where the eye is concerned. process exposure indicator on vial label to verify color
We presume that all fluids marked for parenteral or change corresponding to sterilization cycle, i.e. ethylene
intraocular use come at the pH close to 7.4, however, oxide turns gas process indicator to gold and steam turns
it is alarming to note the amount of times I have the steam process indicator to brown.
personally seen surgery go wary only due to the fact If chemical process indicator is unchanged, exposure
that the pH was either 5.6 or above 8. This can produce to the sterilization process may not have occurred. Check
havock on the patient’s cornea. the sterilization process.

Section 1
In 1992, over 300 cases were reported lost due to If the chemical process exposure indicator on the vial
hazy opaque corneas following extracapsular cataract label did change to the proper color and the indicator
surgery in some states of India. This was followed by has cooled to touch, firmly seal the biological indicator
a widespread search for the culprit. What was found by pushing the cap to close till the cap reaches second
was alarming to all concerned, a balanced salt solution blue bar on the vial label.
(BSS) was sold in small bottles. It was learned that this Crush the inner ampule from the outside wall of the
solution carried an alkaline pH, because while cleaning plastic vial to ensure that the growth medium is released
the glass bottles the last rinse of soap solution (BSS) was from the crushed ampule and is in contact with the spore
not totally washed out and the remaining soap solution disk.
left behind an alkaline pH which recked havoc on the Place the activated indicators in an incubator and
cornea producing total blindness. incubate it at 37°C for EO sterilization and 55°C for steam
It took the investigating authorities over six months sterilization.
to procure this data and cause by which time multiple If there is a color change in the medium from deep
surgeries had been carried out with much devastation. blue to bright yellow and turbidity is evident, it means
A simple technology to avoid such future catastro- there is a positive growth. Indicators positive for growth
phies is to check out the pH on table before the surgery. will often be evident prior to maximum recommended
A few drops of the fluid can be dropped on a simple incubation time, but indicators not evidencing growth
litmus strip and one minute later the color change noted mtiust be allowed to incubate for at least 24 hours (steam)
with a rough estimate of the pH value noted. and 48 hours (ethylene oxide) to assure confidence in
This should be ideally carried out for all cases. the negative reading.

Specialized Equipment Cultures

When, where and why to use biologicals
Special tests are performed for special machines, like • Once a day in every sterilizer
the one available for the ethylene oxide sterilizer. • Once a week in steam sterilizer cycle used
112 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

• Every steam load with implants There are many surgeons who believe in different
• Every EO load. technologies of scrubbing. While some would swear with
Three consecutive times before using new sterilizer the pounding away of epithelial tissue by a brush others
and after repairs. would want to keep the epithelium intact at all times.
Where? While some would swear with a last dip into alcohol,
All sterilization processes. others would keep alcohol well out of the way of
Why? surgeon’s hands.
• To challenge your sterilizer’s effectiveness However, it has been seen that three times to lather
• To assure load sterilization parameters were up with soap and wash hands is a uniform tendency of most
to standard. surgeons.

Surgeons Hands Cultured

Linen and Textiles Cultured
Right after scrubbing and ready for operation a surgeon’s
hands should be regularly swabbed and taken for culture Efficacy of sterilization on the different linens and textiles
so that a close check can be carried out to the efficacy used in surgery should be tested by taking culture tests
of the cleaning and scrubbing solutions. from these items just after surgery.
Section 1
Anesthesia in Microphaco 113

10 Anesthesia in
Ashok Garg (India)
Francisco J Gutiérrez-Carmona (Spain)

INTRODUCTION Also in 1884 Herman Knapp described retrobulbar

injection as local anesthetic technique for ocular surgery.
Anesthesia for Cataract Surgery has undergone
He used 4 percent cocaine solution injected into the

Section 11
tremendous changes and advancements in last century
orbital tissue close to posterior part of the globe to achieve
(Table 10.1). In 1846 general Anesthesia techniques
adequate Anesthesia but in the subsequent injections
were developed which were not found suitable and
patients experienced pain. In 1914 Van Lint introduced
satisfactory for ophthalmic surgery. In 1884 Karl Köller
discovered surface Anesthesia techniques using topical orbicularis akinesia by local injection to supplement
cocaine for cataract surgeries which found favour with subconjunctival and topical Anesthesia. However, this
the ophthalmologists. However, due to significant technique found favour only after 1930 when procaine
complications and side effects of cocaine this technique (Novocaine) a safer injectable agent made it feasible.
was abandoned. With the development of hyaluronidase as an additive
Table 10.1: Evolution of anesthetic techniques for to the local anesthetic solution Atkinson in 1948 reported
cataract surgery that large volumes could be injected with less orbital
Technique Year Author pressure and improved safety injections into the cone
General anesthesia 1846 Morton (retrobulbar) were recommended and gained rapid
Topical cocaine 1884 Köller
Injectable cocaine 1884 Knapp favour becoming anesthetic route of choice among
Retrobulbar (4% cocaine) 1884 Knapp ophthalmologists.
Orbicularis akinesia 1914 Van Lint, O’Brien, Atkinson
Hyaluronidase 1948 Atkinson In Mid 1970s, Kelman introduced an alternative
Posterior peribulbar 1985 Davisy Mandel
Limbal 1990 Furata and coworkers
technique of local Anesthesia for ocular surgery known
Sub-tenon anesthesia 1990 Hansen as peribulbar injection. However, till 1985 this new
Anterior peribulbar 1991 Bloomberg
Subconjunctival 1991 Petersen technique was not published in ophthalmic literature.
Topical anesthesia 1992 Fichman In 1985 Davis and Mandel reported local anesthetic
Pinpoint anesthesia 1994 Fukasaku
Topical plus intracameral 1995 Gills injection outside the cone into the posterior peribulbar
No anesthesia 1998 Agarwal space (periocular).
Cryoanalgesia 1999 Gutiérrez-Carmona
Xylocaine jelly 1999 Koch, Assia Further modifications of both retrobulbar and
Hypothesis, no anesthesia 2001 Pandey and Agarwal
periocular injection techniques were made by
Viscoanesthesia 2002 Werner, Pandey, Apple
Bloomberg, Weiss and Deichaman, Hamilton and
114 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

colleagues, Whitsett, Murdoch Shriver and coworkers. patient or when cataract surgery requires a long time
These modifications consisted of more anterior for completion. Patients who are extremely apprehensive,
deposition of anesthetic solution with shorter needles deaf, mentally retarded, unstable or cannot communicate
and smaller dosages. well with the surgeon are more suitable for general
With the introduction of small incision cataract surgery, Anesthesia. General anesthetic facilities with expert
Phacoemulsification and other micro-surgical procedures anesthetist are mandatory.
in ophthalmology, use of shorter needles with smaller Local Anesthesia in Microphaco have superseded
dosages became more common. Fukasaku and Furata general Anesthesia due to their indisputable advantages,
et al. reintroduced subconjunctival anesthetic techniques. such as the potential for ambulatory surgery, rapid
Fichman in 1992 first reported the use of topical recovery and lack of complications. However, local
tetracaine Anesthesia for phacoemulsification and anesthetic surgery using the retrobulbar or peribulbar
intraocular lens implantation starting an era of topical technique is not without possible complications, such as
Anesthesia in ocular surgery. perforation of the eyeball accompanied by retinal
With the advent of many ocular anesthetic techniques detachment and severe intraocular hemorrhage,
in past two decades indicates the need for the retrobulbar hematoma, diplopia, direct optic nerve
development of an ideal anesthetic and technique for trauma caused by the retrobulbar needle, increased
ocular surgery. Every existing technique has its own intraocular pressure, postoperative ptosis, or systemic
complications such as accidental administration of
Section 1

advantages and disadvantages. General Anesthesia for

anesthetic to the bloodstream or nervous system.
cataract surgery is virtually out of favour with
Moreover, in the last decade, topical Anesthesia in
ophthalmologists. Retrobulbar Anesthesia, periocular
Microphaco has gained more interest on the part of
(peribulbar, sub-conjunctival, sub-Tenon or parabulbar,
surgeons as it eliminates the risks involved in using general
orbital and epidural) and topical Anesthesia or a
and local Anesthesias. However, this method should be
combination of peribulbar and topical are being used
performed by an expert surgeon who has mastered the
in present day ocular surgery.
technique and who can perform it rapidly. No anesthesia
Now with the advent of under 1.0 mm incision
Microphaco surgery is also becoming popular among
technique, foldable and rollable intraocular lenses, no
ophthalmologists worldwide.
Anesthesia cataract surgery is becoming increasingly
popular, this technique was designed by Agarwal (India)
in 1998.
In 1999, Gutiérrez-Carmona (Spain) designed the Local ocular anesthesia is the mainstay of Microphaco.
cryoanalgesia technique for cataract surgery modifying Local Anesthesia minimizes the risk of wound rupture
Agarwal’s method.. a complication frequently associated with coughing
during extubation and postoperative nausea and
vomiting (in general Anesthesia) (Fig. 10.1). Generally
the use of 1:1 mixture of 2 percent xylocaine and
Microincision Cataract extraction may be performed 0.50 percent bupivacaine alongwith adrenaline and
under general Anesthesia, local Anesthesia or topical hyaluronidase in facial, retrobulbar and peribulbar blocks
Anesthesia, depending upon condition of patient cataract achieve rapid Anesthesia, akinesia and postoperative
status and surgeon choice. analgesia for several hours.
Usually for Microphaco general Anesthesia is not On the other hand, we have sub-Tenon or parabulbar
given. It is advisable only in highly anxious/nervous Anesthesia performed with a blunt cannula which avoids
Anesthesia in Microphaco 115

Fig. 10.2: Peribulbar anesthesia

The required local anesthetics are lidocaine 1 percent
Fig. 10.1: Diagrammatic surface distribution of sensory nerves. and bupivacaine 0.75 percent with hyaluronidase.
Note branches derived from ophthalmic nerve (V 1) and
maxillary nerve (V2) a division of the trigeminal nerve Bupivacaine is preferred as it is a longer acting anesthetic
agent which can provide prolonged anesthesia and
the complications arising from the use of needles. analgesia.
Intraoperative analgesia and akinesia are similar to the In the first stage, injection of 0.5 cc of 1 percent

lidocaine with a 26 gauge needle is done under the skin

Section 11
peribulbar technique.
Care should be taken to avoid intravascular injections at about I cm away from the lateral canthus in the lower
of anesthetic agents because refractory cardiopulmonary lid, along the orbital rim. The same needle is passed
arrest may result from an inadvertent intravenous or deeper to inject 0.5 cc of lidocaine into the orbicularis
intra-arterial injections. muscle and 1.0 cc into the muscle sheath. A second
Many patients express pain of facial and retrobulbar injection is done in the similar fashion in the upper eye
injections and other complications so these techniques lid just below the supraorbital notch. Pressure is applied
are now out of favour. at both for a minute using gauze pieces.
Out of various local anesthesia techniques available In the second stage, combination of 6.0 ml of
today, only following techniques are commonly used 0.75 percent bupivacaine, 3 ml of 1 percent lidocaine
for Microphaco surgery. and 0.25 cc of hyaluronidase is filled into a 10 ml
disposable syringe fitted with a, 1-1/4 inch 23 gauge,
Peribulbar (Periocular) technique hypodermic needle. The needle is first introduced deep
Since the exit of retrobulbar akinesia, peribulbar akinesia into the orbit through the anesthetized site in the lower
is considered a safe and effective technique of local eye lid. One ml is injected just beneath the orbicularis
anesthesia for Microphaco. It is method of choice with muscle and then the needle is advanced up to the equator
eye surgeons for giving local Anesthesia to cataract. As of the globe to inject 2 to 3 ml of the solution. The same
the name indicates, peribulbar Anesthesia is a technique procedure is followed in the upper nasal quadrant
in which a local anesthetic is injected into peribulbar space through the preanesthetized site to inject 1ml and
and is not aimed at blocking a particular nerve. another 1 ml may be injected around superior orbital
fissure, by deeper penetration.
Technique At the end of the procedure, fullness of the lids is
Periocular Anesthesia is administered at two sites: lower noted due to the volume of the injected. Firm pressure
temporal quadrant and nasal to caruncle (Fig. 10.2). with the flat of the hand is applied over the globe and
116 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

is maintained for a minute. Then, before surgery, any 6. It does not reduce vision on table.
pressure device as per the surgeon’s choice like Honan’s 7. No facial block is required.
balloon, super pinky ball, balance weight or simple pad-
bandage is applied for 20 to 30 minutes, to achieve the Drawbacks
desire response of hypotony. The possible drawbacks of this procedure are:
The efficacy of the Anesthesia is evaluated after about 1. Chemosis of conjunctiva.
10 minutes of injection and if inadequate, 2 to 4 ml 2. Delayed onset of anesthetic effect and
more can be injected. In case of persistent inferior or 3. Potential risk of orbital hemorrhage. Though, it
lateral movement injection lower temporal quadrant and occurs rarely, the magnitude of the problem is
in case of persistent movements upwards of nasally, the comparable to retrobulbar hemorrhage and
necessitates postponement of surgery.
upper quadrant could be infiltrated in the same fashion.
Hyaluronidase is essential as it helps in the spread
of the drug. Otherwise, there are chances of the eye
The exact mechanism is not known but this procedure
being proptosed due to high orbital pressure induced
may best be described as ‘Infiltration Anesthesia’ where
by the large quantity of the fluid injected.
nerve endings in all tissues in the area of injection get
Single injection of 5 to 6 ml of anesthetic mixture
injected from any site posterior to equator of the globe
Peribulbar Anesthesia is a safe and reliable technique
Section 1

also achieves same results. For convenience, however, for achieving akinesia and Anesthesia of the globe.6 In
it may be done through lower lid the junction of lateral case of inadequate Anesthesia, repeat injections in the
and middle one third, along the floor of the orbit. similar manner can be safely used to achieve the purpose.
Adequacy of akinesia is determined by the absence
Superior rectus injection: The induction of temporary
of ocular movements in all directions.
paralysis of the superior rectus muscle is essential for
This technique is certainly better than retro-ocular
any intraocular operation where the surgical field is upper
technique and has least complications.
half of the eye. This injection also affects the action of
levator palpebrae superioris.
In this injection patient is asked to look down. The
The advantages reported are : upper lid is retracted and 2.5 cm long needle is passed
1. The injection is done outside the muscle cone and into tenon’s capsule at the temporal edge of the superior
so, the inherent complications of passing the needle rectus muscle. The needle is directed posteromedially
into the muscle cone is completely eliminated. and about 1 ml of anesthetic mixture of 2 percent
2. It does not enter the retrobulbar space and thereby xylocaine is injected around the muscle belly behind the
avoids retrobulbar hemorrhage, injury to optic nerve equator. This injection can also be made through the
and entry of anesthetic agents into subarachnoid space skin of the upper orbital sulcus.
and other complications like respiratory arrest.
Tenon’s capsule injection: The Injection of anesthetic
3. Since the needle is constantly kept parallel to the bony
mixture can be given into Tenon’s capsule around the
orbit, it avoids injury to globe and entry of anesthetic
upper half of the eyeball and into the belly of superior
agents into the eye ball. rectus muscle. It is considered safer than the retro-ocular
4. It causes less pain on injection. injection across the post ganglionic fibers of the cillary
5. The procedure is easier and can be performed without body and may be effective in inducing extraocular muscle
causing damage to vital structures. akinesia.
Anesthesia in Microphaco 117
Parabulbar (Flush) or Sub-tenon Akinesia Technique
This is a very valuable alternative technique to the retro We use a blunt or Greenbaum cannula with the
and peribulbar methods. In this technique, we attempt to anesthetic or mixture chosen. The patient needs to look
place the anesthetic in the intraconical space, near the ciliary up and in the direction of the eye to be operated on
ganglion. This method consists of a limbal sub-Tenon so that we can see the inferior nasal quadrant. We place
administration of retrobulbar Anesthesia using a blunt topical Anesthesia and next we perform an conjunctival
irrigating cannula (Figs 10.3 and 10.4). This technique can and Tenon incision with Wescott scissors creating a deep
be used for anterior and posterior segment surgery. tunnel. We introduce the blunt cannula through the
tunnel, injecting the anesthetic. After, we place a Honan’s
balloon or Super Pinky decompressor for 10 minutes
at 30 mmHg.

Retrobulbar hemorrhage: This can be produced when
we perform the mucous-Tenon dissection, or when we
introduce the cannula through the tunnel or when we
vary this technique by using a continuous infusion with

Section 11

Conjunctival edema: This is produced when we inject

the anesthetic in the sub-conjunctival space and not in
the sub-Tenon space, diminishing the possibility of
achieving complete denervation of the eyeball.

Hyposphagma: This is frequently produced

Fig. 10.3: Parabulbar (flush) local anesthesia (cross
section view) postoperatively, leading to un-desired aesthetic results.

Since the advent of retrobulbar and peribulbar
techniques in the early part of this century, both
procedures are mainstay of local Anesthesia for
intraocular surgery till today. They do carry the risk of
perforation of globe, optic nerve and the inadvertent
injection of anesthetic at wrong places.
These accidents are mainly due to:
• Carelessness on the part of ophthalmologist who
considers the procedures lightly and occurs more often
with senior eye surgeons.
• Using long needles for these techniques endangers
the perforation of globe, piercing the optic nerve
Fig. 10.4: Parabulbar (flush) local anesthesia (surgeon view) and entering crowded retrobular space and even
118 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

touching the intracranial space on forceful injection grade nuclear sclerosis are relative contraindications
of copious amounts. for topical Anesthesia.
• Anesthetics given through local injection with little • Eye surgeon operating with topical Anesthesia should
knowledge of anatomy of this area. be proficient and experienced at phacoemusification.
• Retrobulbar hemorrhage with its adverse effects on • This procedure requires the use of foldable IOL either
nerve and globe is very common complication of as a silicone lens or an acrylic lens. This is essential
this technique. because corneal tunnel suture lens incision cannot
• Injury caused by perforation of globe can lead to be larger than 3.5 mm. Otherwise corneal
hole formation, retinal detachment, vitreous complications may arise and the incision would not
hemorrhage and central and branch vein occlusions. be self-sealing.
To overcome all these practical difficulties use of
How to achieve surface Anesthesia for intraocular surgery:
topical Anesthesia in intraocular surgery has been widely
Generally 3 applications of 4 percent xylocaine or 0.4
suggested and used at an international ophthalmic level.3
percent benoxinate HCL or 0.5 to 0.75 percent
Topical Anesthesia meaning topical application of
proparacaine 10 minutes apart starting 30 minutes before
4 percent xylocaine or 0.5-0.75 percent proparacaine
surgery are recommended (Fig. 10.5). A drop is
one drop 3-4 times at regular intervals in the eye has
thereafter instilled prior to the incision. 1 cc of 4 percent
become increasingly popular and accepted.7 In present
xylocaine or 0.4 percent benoxinate HCI or 0.5-0.75
Section 1

day high tech intraocular surgery specially phaco surgery

proparacaine (from fresh vail) is drawn into sterile
topical Anesthesia is the Anesthesia of choice with the
disposable syringe and OT staff person is asked to instil
eye surgeons world wide.
a few drops of the same prior to cauterization of bleeders
Indications to use Topical Anesthesia and if required during surgery conjunctival Anesthesia
is used (pinpoint and mini pinpoint surface Anesthesia).9
• Its indications in intraocular surgery are mainly when
performing phacoemulsification and IOL implantation
through a clear corneal tunnel and corneoscleral
• Topical Anesthesia is ideally suited for small incision
and stitchless cataract surgery. However, it is not a
advocated to perform standard/manual extracapsular
cataract extraction and IOL implantation.
• Proper selection of patient is of great importance in
this technique. It is important to have a patient who
will comply with the instructions given during surgery.
• Patients who are non-cooperative, hard of hearing,
with language problem and anxious patients are poor
candidates for surgery under topical anesthesia.
Capsulorrhexis requires the maximum cooperation Fig. 10.5: Topical anesthesia
of the patient.
• Intraocular surgery likely to be problematic in patients Apart from giving topical Anesthesia one has to give
with rigid small pupils responding poorly to dilating systemic analgesia. Besides it, surgeon should have a
drops and eyes with lenticular subluxation and high commanding hypnotic voice (vocal local Anesthesia).
Anesthesia in Microphaco 119
• Most surgeons doing corneal tunnel incision under Again its main advantages is that it provides for
topical Anesthesia prefer to do it from temporal side. immediate postoperative visual recovery.
Can one convert half way through surgery under topical
Disadvantages of Topical Anesthesia
1. Only a highly experienced surgeon can operate with
Intraoperative conversion from topical to peribulbar
topical anesthesia. The eye can move which makes
Anesthesia can definitely be achieved if surgical situation
the operation more difficult. If the eye movement
warrants it. Since corneal tunnel incision is sutureless and
occurs when capsulorhexis is being done, an
self-healing a peribulbar injection can safely be given
undesirable capsular tear may take place leading to
during the surgery.
failure of this important step of the operation.
Advantages of Topical Anesthesia 2. The chances of intraoperative complications with
topical Anesthesia can be high if the surgeon is not
1. Phacoemulsification experts feel that use of topical
highly skilled. If such complications arise surgeon
Anesthesia with a clear corneal tunnel self-healing
should be ready to convert to other methods of local
incision is a significant advancement in intraocular
Anesthesia during the intraoperative stage, because
surgery. With topical Anesthesia visual recovery is
topical Anesthesia along may not be adequate to
handle intraoperative complications. Surgeon should
2. It prevents the well known complications of
be of cool temperament who can handle such a

Section 11
retrobulbar and peribulbar injections as mentioned
situation without anxiety.
in the early part of this chapter.
3. Topical Anesthesia is not indicated in all patients
3. It lessens the time of operating room use thereby specially in anxious stressed patients, people with
lowering costs. hearing difficulties, children and very young patients.
4. There is no immediate postoperative ptosis as seen 4. As in our country a large number of patients come
in retrobulbar or peribulbar and Van Lint, O’Brien from rural areas who are illiterate and poor. Their
infiltrations lasts for 6-8 hours due to temporary compliance remains very poor and they do not
akinesia of the lids. respond adequately to the command during surgery
5. With topical Anesthesia photon laser intraocular with topical Anesthesia.
surgery can be OPD procedure. 5. The presence of very opaque cataract is a contra-
6. Faster visual recovery and ability for patients to remain indication to the use of topical Anesthesia. This is
on anticoagulation therapy. because surgeon depends on the patient ability to
7. In practice we have seen the anxiety of patients to visually concentrate on the operating microscope
peribulbar and retrobulbar injections prior to surgery. light in order to avoid eye movement during the
With topical Anesthesia this problem is over and operation. Patients, who are not able to fix the eyes,
patient compliance will be better during intraoperative may lead to complications.
period. 6. Some patients may feel pain during surgery with
8. There is no need for a qualified anesthesiologist in topical Anesthesia. One patient observed a lot more
the operating theater during the operation, although pain and felt as if a sword was being used to cut him
a number of ophthalmologists prefer an up. The pain continued postoperatively for quite
anesthesiologist by their side for local Anesthesia some time.
(retrobulbar and peribulbar Anesthesia). 7. In principle, adequate selection of patients is funda-
9. No risk of postponement of intraocular surgery as mental when considering the use of topical
seen in cases of retrobulbar hemorrhage. Anesthesia.
120 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

In spite of these hurdles topical Anesthesia will be • With the right hand, a 3.2 mm groove is made in
a safe and common technique for local anesthesia during clear-temporal cornea using a diamond knife (Fig.
intraocular surgery in the near future. 10.6).

Intracameral Anesthesia
This an adjunct method with topical Anesthesia designed
by Gills in 1995. This results in the blocking of the
sensitivity in the long ciliary nerve branches, so that the
zonular stretching and the scraping of the iris during
phacoemulsification do not produce discomfort in the
This technique consists of injecting 0.1 ml of 1 percent
preservative-free lidocaine in the anterior chamber,
avoiding the risk of intraocular toxicity and achieving
a good analgesia of the iris. Fig. 10.6: The surgeon;s right hand making a clear
Topical and intracameral anesthesia can be used in corneal tunnel incision in the temporal quardant
patients treated with anticoagulants.
• A 5.0 to 5.5 mm wide capsulorhexis is performed
Section 1

Studies by some authors comparing topical and

topical plus intracameral anesthesia have demonstrated using a 26 gauge bent needle cystotome.
that neither topical nor topical plus intracameral • Hydrodissection is performed with BSS®.
Anesthesia result in important differences in patient • Phacoemulsification is performed using the karate
complaints or in complications.11 However, the use of chop technique using less ultrasound power to avoid
intraoperative lidocaine is safe and effective in controlling excessive heating of the phaco tip, which in turn can
produce pain.
intraoperative discomfort.10
• Cortical washing. First, try to remove the subincisional
cortex as that is the most difficult.
• Viscoelastic injection in the capsular bag and a foldable
This non-pharmacological technique was first carried one-piece plate IOL is implanted.
out by Amar Agarwal (India) in 1998.1 Neither topical • The viscoelastic is removed from the anterior chamber
nor intracameral anesthetics agents are used. and the capsular bag by irrigation.
• Closure of the corneal incisions by stromal hydration.
The microscope light should begin at the lowest level
• Before performing the surgery, we must inform the and gradually increase in intensity. The intensity of the
patient that he will feel contact and that he can move light should increase to normal levels after performing
his eyes. the hidrodissection and the patient should be told to
• Use a speculum such as Castroviejo, Clarke or look at the light during surgery.
Liebermann. The skill and experience of the surgeon is one of the
• Viscoelastic Healon® is injected into the anterior most important factors for the No Anesthesia Cataract
chamber using a needle through the area where the Surgery. While using this technique, it is important to
second (paracentesis) site is made. avoid grasping the conjunctiva or sclera with tooth
• A straight rod is used to stabilize the eye with the forceps. The surgeon should use a straight and relatively
left hand. blunt rod to stabilize the eye during the entire procedure.
Anesthesia in Microphaco 121
As with topical Anesthesia, we should minimize the • Ocular asepsis before surgery is achieved using
iris-lens-diaphragm movement and iris manipulations. 5 percent povidone drops. Next, a drop of cold
No subconjunctival injections should be made methylcellulose (Celoftal™) is instilled in the eye
following surgery nor should an eyepad be placed. before placement of the ophthalmic drape to isolate
the eyelid. The cold Celoftal™ reduces the stinging
Microphaco Surgery with Cryoanalgesia sensation of the povidone.
This non-pharmacological Anesthesia technique was • The cornea is previously cooled by continuous
designed in 1999 by Francisco J. Gutiérrez-Carmona irrigation from a flask of cold BSS® in the area in
(Spain). There are no anesthethic drops used, it is a which the paracentesis will be conducted. To perform
modification of No Anesthesia Cataract Surgery. the paracentesis, the eyeball is held still with a spatula
or lens manipulator placed on the corneal periphery,
Technique opposite the area where the anterior chamber (AC)
• Before performing the surgery we must tell the is accessed using a paracentesis knife.
patient that he will feel a cold sensation in his eye • Cold viscoelastic material (Viscoat®) is injected through
and that he can move his eyes. the paracentesis into the anterior chamber, and a
• In order to perform the surgery, it is necessary lens manipulator is subsequently introduced to
previously to cool all fluids to be used in the operation stabilize the eyeball.

to around 4 degrees Celsius, except for the povidone • The cornea is then continuously cooled with BSS®

Section 11
drops, which should be at normal temperature for in the area in which the clear corneal incision is to
optimum effect. be made. Corneal tunnel incision is performed at
• Before surgery, an eye mask of cold gel (Eyes Pack™ 90º to the paracentesis with the help of a 3.2 mm
Single) is placed over the eye for about ten minutes phaco knife.
(Fig. 10.7). This will afford some degree of analgesia • Cold Viscoat® is injected into the anterior chamber.
to the eyelids, facilitating the insertion of the lid Next, the corneal incision is chilled with cold BSS®
speculum. in order to perform a continuous circular
capsulorhexis with capsular forceps.
• The lens nucleus is hydrodissected with cold BSS®
irrigation using a Binkhorst, or a straight Rycroft
cannula, inserted through the corneal incision.
• The process of phacoemulsification is performed with
cold fortified BSS® irrigation during linear and pulsed
phaco. During phacoemulsification, the cornea must
be kept chilled with cold BSS®. When the tip of the
phacoemulsifier is inserted into the anterior chamber,
the corneal incision is cooled by continuous irrigation
from a flask of cold BSS®.
• Cortical aspiration is performed with cold fortified
BSS® irrigation.
Fig. 10.7: A monolateral eye mask of cold gel is placed • Cold Viscoat® is injected into the capsular bag and
over the eye before surgery for about 10 minutes the corneal incision is extended to 4.1 mm after
122 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

chilling. Once the corneal incision is cooled with BSS®, Viscoanesthesia

a foldable IOL is implanted. This a new type of topical intracameral Anesthesia by
• Closure of the incision is performed by stromal means of a viscoelastic cohesive material which contains
hydration using cold BSS®. an anesthetic component.
An important point in this technique is the cooling The topical component used pre-operatively, consists
of the incision area before introducing any instrument of a mixture of 0.3 percent sodium hyaluronate and
into the eye. 2 percent lidocaine hydrochloride, while the intracameral
I have also found it helpful to dim the illumination component used per-operatively consists of 1.5 percent
of the operating microscope initially so that the patient sodium hyaluronate and 1 percent lidocaine
is not startled by the bright light. You can then gradually hydrochloride commercially known as VisthesiaTM (CIBA
increase the illumination as needed for visualization Vision Surgical, Switzerland).
intraoperatively. It is also very important that the The first step of the viscoanesthesia procedure
microscope light is at the lowest intensity level and to involves the preoperative application of the topical
tell the patient to fix his gaze at the microscope light. component of VisthesiaTM. Once the topical mixture is
The skill and experience of the surgeon is very important applied, the patient’s eyes are kept closed for
in order to perform this technique. approximately 1 minute to allow for optimum diffusion
of the mixture. The VisthesiaTM intracameral component
Section 1

Xylocaine Jelly is then used as a normal viscoelastic, mainly before

This method of topical anesthesia with 2 percent lidocaine capsulorhexis and before IOL implantation.
hydrochloride gel (Astra®) allows cataract surgeons to Preliminary results demonstrate the efficacy and safety
eliminate the risks associated with needle injection. The of VisthesiaTM concept as a viscoanesthetic method for
gel helps to keep the cornea moistened and increases cataract surgery. It provides a longer anesthetic effect
contact time with the ocular surface, insuring sustained when compared with the application of only an aqueous
diffusion and prolonged anesthetic effect . On the other topical anesthetic.
hand, the gel is minimally absorbed by the Researchers have evaluated the Visthesia TM
ocular mucous, reducing the risk of secondary systemic intracameral component in an in vitro animal study.
effects. Histological evaluation of the retinal and uveal tissues
In preparation for surgery, the patient received three showed no differences between the eyes receiving
doses of 2 percent Xylocaine Jelly (two doses in the VisThesiaTM injections compared to eyes in the control
holding area, and one before the eye was prepped and group receiving balanced salt solution (BSS). There also
draped for the procedure). was no histological evidence of endothelial damage or
The administration of 2 percent Xylocaine jelly has endothelial cell loss observed.
demonstrated pain scores similar to those with
intracameral anesthesia. REFERENCES
This type of topical Anesthesia is used by urologists 1. Agarwal A, Agarwal S, Sachdev MS, et al. No anesthesia
in urological explorations (cystoscopy, catheterization, cataract surgery with karate chop. In: Phacoemulsification
exploration by sound and other endourethral Laser Cataract Surgery and Foldable IOLs. Jaypee
Brothers, New Delhi, 1998; 19:144-54.
operations). Other indications are: nasal and pharyngeal 2. Arora R et al. Peribulbar Anesthesia. J Cataract Refract
cavities in endoscopic procedures such as gastroscopy Surg 1991; 17:506-8.
3. Assia EI, Pras E, Yehezkel M, et al. Topical anesthesia using
and bronchoscopy, proctoscopy and restoscopy and lidocaine gel for cataract surgery. J Cataract Refract Surg
tracheal intubation. 1999;25:635-39.
Anesthesia in Microphaco 123
4. Bloomberg L. Administration of periocular Anesthesia. J 14. Kimble JA et al. Globe perforation from peribulbar
Cataract Refract Surg 1986;12:677-79. injection. Arch Ophthalmol 1987;105:749.
5. Bloomberg L. Anterior Peribulbar Anesthesia. J Cataract 15. Koch PS. Efficacy of lidocaine 2 percent jelly as a topical
Refract Surg 1991;17:508-11. agent in cataract surgery. J Cataract Refract Surg
6. Davis DB. Posterior peribulbar Anesthesia. J Cataract 1999;25:632-34.
Refract Surg 1986;12:182-84. 16. Macky TA, Werner L, Apple DJ, et al. Viscoanesthesia Part
7. Fichman RA. Topical Anesthesia. Sanders DR, Slack II: Evaluation of toxicity to intraocular structures after
1993:1661-72. phacoemulsification in a rabbit model. J Cataract Refract
8. Furuta M et al. Limbal Anesthesia for cataract surgery. Surg 2003;29:556-62.
Ophthalmic Surg 1990;21:22-25. 17. Pandey SK, Werner L, Apple DJ, et al. Viscoanesthesia Part
9. Garg Ashok:Topical Anesthesia. Current Trends in III: Evaluation of the removal time of viscoelastic/
ophthalmology. Jaypee Brothers Publishers 1997:1-5.
viscoanesthetic solutions from capsular bag of human eyes
10. Gills JP, Cherchio M, Raanan MG. Unpreserved lidocaine
obtained postmortem. J Cataract Refract Surg
to control discomfort during cataract surgery using topical
anesthesia. J Cataract Refract Surg 1997;23(4):545-50.
18. Shriver PA et al. Effectiveness of Retrobulbar and
11. Gillow T, Scotcher SM, Deutsch J, While A, Quinlan MP.
peribulbar Anesthesia. J Cataract Refract Surg
Efficacy of supplementary intracameral lidocaine in routine
phacoemulsification under topical anesthesia. 1992;18:162-65.
Ophthalmology 1999;106:2173-77. 19. Trivedi RH, Werner L, Apple DJ, et al. Viscoanesthesia Part
12. Gutiérrez-Carmona FJ. Phacoemulsification with I: Evaluation of toxicity to corneal endothelial cells
Cryoanalgesia: A New Approach for Cataract Surgery. In: in a rabbit model. J Cataract Refract Surg 2003;29:
Phacoemulsification, Laser Cataract Surgery and Foldable 550-55.
IOLs. Jaypee Brothers Medical Publishers (2nd ed), New 20. Zahl K et al. Ophthalmol Clin North Am. Philadelphia,
Delhi, 2000;23:226-29. WB Saunders, 1990.

Section 11
13. Hay A et al. Needle perforation of the globe during 21. Zaragoza-García P. La anestesia en oftalmología. In:
Retrobulbar & peribulbar injection. Ophthalmology Monografías de la Sociedad Española de Oftalmología.
1991;98:1017-24. Madrid, 2000.
124 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Preoperative Assessment
11 of the Patient in
Bimanual Phaco

Ashok Garg (India)

In clinical practice we have seen that it is always easier

Section 1

to explain to the patient why they can not have surgery
In Bimanual Phaco (Microphaco) surgery there is
than why they have developed a significant complication.
obvious need to adequately asses the patient ophthalmic
To a greater extent criteria of a good Microphaco surgery
suitability preoperatively through ophthalmic and general
practice is the rigor of its exclusion criteria.
medical History as well as complete ocular examination
Most eye surgeon hold the general principals of good
and several special investigations. Complete ophthalmic
cataract surgery. However the exact numerical value at
check up and investigations results are analyzed to ensure
which patients are counselled not to have surgery often
that surgical plan does not breach any surgical technical
varies depending upon.
exclusions and to ensure best post operative results.
In clinical practice it is seen that many patients are
at a heightened risk of developing an intraoperative or PREOPERATIVE ASSESSMENT AND
postoperative complications, which can be, identified CONSIDERATIONS
preoperatively due to the presence of one or more risk First of all detailed history of the patients should be taken.
factors. A comprehensive history and detailed clinical
examination needs to be a part of every preoperative History
assessment to ensure any such risk factors are identified. A directed ocular and general history should be taken
Some risk factors like external ocular infections can to identify any ophthalmic instability or the presence of
be modified allowing the surgery to proceed. It is not any specific risk factors. It is necessary to exclude the
necessary that all patients with a risk factor will develop presence of serious systemic diseases like Hypertension,
a complication, however, good clinical management Diabetes Mellitus, Cardiac problems, obstructive lung,
shows that with such an visually important elective disorders and any potential source of infection in the
procedure, it is better to exclude some patients who may body like urinary tract infection (UTI), septic gums, etc.
have a successful outcome to protect those at a The necessary testing depends upon the patient age and
heightened risk of significant complications. prior medical history.
Preoperative Assessment of the Patient in Bimanual Phaco 125
A preoperative ophthalmological evaluation should ment and medicolegal problem. A few important retinal
include a complete ocular history specially related to functions are described here.
recurrent redness, pain, discharge or previous ophthalmic • Perception of light (PL) must be present for potential
treatment if any Refractive History should be taken to useful post-operative vision.
assess whether the patient is ammetropic or emmetropic • Marcus-Gunn pupillary response test should be done
at the age of +40 years. It is essential in relation to IOL routinely because in its presence visual prognosis is
power calculation and status of scleral rigidity as it is poor.
directly related to nucleus delivery during microphaco. • Projection of light (PR) is an important test for
Past ocular history is quite important specially in functions of peripheral retina and should be done
relation to previous corneal grafts, previous microbial routinely. A poor PR inference shall indicate towards
Keratitis, previous herpes simplex Keratitis or previous the poor visual prognosis.
retinal surgery, family history specially in first degree • Two light discrimination test should be done to know
about macular function. If the patient perceive two
relatives should be taken for any ocular disorder which
normal lights in this test it indicates normal macular
may hamper visual out come after microphaco.
Clinical Examination • Maddox rod test : An accurate perception of red line
indicates normal function.
Complete and thorough ocular examination is necessary
• Color perception indicates macular function is present

Section 11
to rule out comorbid conditions such as long standing
and optic nerve is relatively normal.
amblyopia, pseudo exfoliation, retinal tears or holes,
• Entopic visualization is done to know about retinal
macular lesions or optic nerve abnormalities that may
affect the visual or surgical outcome. The following useful • Laser interferometry (wherever possible) is a good
information is required before the patients is declared test for measuring the macular potential for visual
fit for microphaco. acuity in the presence of opaque media.
An accurate refraction of both eyes, measurement • Objective tests for evaluating retina are essential when
of corneal refractive power by Keratometer and some retinal pathology is suspected. These tests
measurement of axial length by A–Scan ultrasonography include.
are necessary to calculate appropriate IOL power should • B.Scan ultrasonography of the posterior segment
be done. of the eye.
Good assessment of corneal endothelium should be • Electroretinogram (ERG).
made by examining cornea by Eisner lens or by specular • Electro oculogram (EOG)
microscopy (whenever available). It helps in excluding • Visually evoked response (VER)
patients with low endothelial cell count specially in • Indirect ophthalmoscopy
conditions like glaucoma, chronic iritis, Fuch’s dystrophy, • Color Doppler ultrasonography.
trauma and old age keratic precipitates (KP) should also • Potential local source of infection should be checked
be examined. by ruling out conjunctival infections, meibomitis,
blepharitis, lacrimal sac infection and chronic
Retinal Function Tests dacryocystitis. Thorough lacrimal sac examination
The retinal functions should be thoroughly evaluated including syringing should be done. In case of
as if it is faulty even a good quality operation shall be presence of chronic dacryocystitis DCR (Dacryo-
useless from vision angle and patient must be warned cystorhinostomy) or DCT (Dacryocystectomy) should
about the prognosis to avoid unnecessary disappoint- be performed prior to microphaco.
126 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

• Complete anterior segment examination by slit lamp Patients who had undergone glaucoma filtering
biomicroscopy should be done in each case routinely surgery are not ideal for Microphaco due to hypotony
to rule out any keratic precipitate present at the back factor.
of cornea, subtle uveitis, etc. • Patients who had recurrent episodes of anterior or
• Iris pupil examination under slit lamp should be done posterior uveitis with synechiae formation are not
under mesopic condition to see for any evidence of suitable for Microphaco for the following rationale.
posterior synchiae, pigment on lens or pupil • It is difficult to perform capsulorhexis as the pupil
abnormalities. Pupil examination should also be done does not dilate full because of synechiae adhesions
after dilatation to know details about iris and pupil between Iris and capsule.
status (whether dilating easily or not). Small • Nucleus prolapse into AC becomes difficult.
contracted pupil makes capsulorhexis very difficult • Due to weak posterior capsule there are increased
and nucleus prolapse into anterior chamber become chances of vitreous prolapse and PC rent.
impossible. • Iatrogenic inflammation is more intense in uveitic
• Corneal topography is extremely important in patients.
bimanual phaco surgery. The smaller the size of • Increased chances of Zonular weakness, high IOP,
incision lesser the astigmatism and earlier stability of miosis and Cystoid macular edema.
the astigmatism shall occur. These days corneal There are certain absolute contraindications in which
topography is being done by Orbscan in which data
Section 1

Microphaco should not be performed. These include:

is collected from all four surfaces (Anterior cornea, • Fuch’s endothelial dystrophy.
posterior cornea, anterior iris and anterior lens) to • Microphthalmos
create a topographic map. • Extensive congenital anomalies
• Complete lens examination should be done by pupil • Rubella irides
dilation to ascertain the cataract grading. • Lens subluxation
• Thorough fundus examination is necessary to rule • Preoperative counseling for surgery should include
out macular degeneration, diabetic maculopathy and a full explanation of the potential risks and benefits
optic atrophy. of proposed microphaco and anesthesia as well as
• Hypotonic eye is not fit for microphaco as it is very
the technique for instilling eye drops and ointments
difficult to make corneal tunnel wound construction
and other post operative care.
in hypotonic eye. It is also difficult in nucleus prolapse
• Both out patients and indoor surgical facilities are
in AC expression of nucleus in hypotonic eye. It is
used for microphaco, with the latter reserved for
generally advised not to put pinky ball or any other
patients at risk for medical complications well
IOP lowering gadget prior to microphaco. Instead
equipped outpatients surgical facilities offer the patient
gentle massage of the eye with finger can be done
the shortest possible surgical experience and reduce
after peribulbar anesthesia.
to a minimum the disruption of the patients normal
• Age of patient is quite important because nucleus
life routine.
hardness increase with advancing age. Hence, very
old patients with very hard and big nucleus should
be avoided for microphaco.
• Preoperative IOP measurement should be done in
each case. The presence of raised IOP shall require Topical antibiotics such as Moxifloxacin(0.5%) or
a prior management before cataract surgery. tobramycin (0.3%) three to four times a day 72 hours
Preoperative Assessment of the Patient in Bimanual Phaco 127
before Microphaco should be started as prophylaxis • Some times highly anxious and nervous patients are
against infections. also given oral diazepam in small dose (2.5-5.0mg)
• Systemic antibiotics such as cipofloxacin 500 mg twice one hour before surgery to alleviate the anxiety.
daily is advised by some ophthalmic surgeons at • Mental preparation of patient for the surgery is
previous night and in the morning before surgery. essential. A written consent should be taken from
• Preparation of the eye to be operated includes the patient or from his near relative regarding full
trimming of eye lashes of upper eyelid at previous explanation of pros and cons of surgery to the patient
by the operating doctor.
night and eye to be operated should be properly
• Preoperative prepping – antibiosis is used to prevent
marked to avoid last minute confusion.
postoperative endophthalmitis. Most surgeons
• Each patient should be advised to take scrub bath
prepare the lids and facial skin with 10 percent
including face and hairwash with soap and water
povidone iodine and placing a drops of 5 percent
before surgery.
povidone – iodine into the cojunctival cul-de-sac.
• Preoperative IOP lowering is done by giving oral In summary, the key to successful small incision
acetazolamide tablety 500 mg stat 2 hours before cataract surgery is proper selection of cases, efficient
the surgery preoperative IOP reduction prevent counseling of the patients and meticulous pre-operative
operative complications such as vitreous loss, expulsive preparation of the patients. A well planned Microphaco
choroidal hemorrhage and shallowing of the anterior (Step by step) can ensure satisfactory post operative visual

Section 11
chamber. acuity to the patients without any complications.
• Mydriasis is essential for Microphaco. It is crucial that
pupil is widely dilated throughout the procedure time. REFERENCES
This is most achieved with a preoperative combination 1. Garg Ashok. Cataract in text book of ophthalmology,
of an adrenergic agent (Phenylephrine 5-10%), an Jaypee Brothers Medical Publishers (P) Ltd., 3:1620-59.
2. Singh Kamaljeet: Small incision cataract surgery, Jaypee
anticholinergic agent (tropicamide-1%) and a Brothers Medical Publishers (P) Ltd., New Delhi, 2002.
cyclooxygenase inhibitor (flurbiprofen). Intra- 3. Shah. Anil. In small incision cataract surgery, Bhalani
Publishing House, India, 2000.
operative mydriasis may also be maintained with the
4. Rozakis GW., In cataract surgery, Alternative small incision
use of dilute epinephrine in the irrigating solution. technique, Ist ed. Thordofare, Inc., 1995.
128 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Dynamics of Ocular
12 Surgical Adjuncts in
Bimanual Phaco

Ashok Garg (India)

INTRODUCTION (Precision tissue specific action, PTSA). For this purpose

Section 1

space tactics are used.

The ocular surgical adjuncts play an important role during
Space tactics is a more active protection against touch
microphaco surgery regarding control of surgery, its
by providing sufficient space for manipulation within the
quality and outcome. Fluid dynamics are responsible
eye. It is accomplished by space maintaining or enlarging
for the flowing intraocular conditions specially related
devices such as hydrodynamic flow systems or viscoelastic
to AC depth fluctuations, AC turbulence, IOP status
during surgery and fluid velocity. Thus, fluidics is directly
The viscosurgery was coined by Prof. Endre Balasz
related to clinical and surgical outcome in Microphaco
of USA to describe the use of solutions with viscous
elastic, pseudoplastic properties during and after ocular
Viscoelastic agents, irrigating solutions, enzymes, dyes,
surgery. Viscosity makes a material protective and
etc. are adjuncts as fluidics to a variety of
lubricating while elasticity provides protection from
ophthalmological procedures and surgeries. These are
vibrating instruments and other mechanical impacts.
vital components of any type of intraocular surgery.
Pseudoplasticity allows the material to deform and may
First let me discuss various viscoelastic substances used
be used to safely manipulate tissue. While we perform
in the Micro phaco surgery.
intraocular viscosurgery. We actually use a viscoelastic
agent as a fluid or soft surgical instrument because the
molecules of a true viscoelastic can deform and reform.
The development of modern ophthalmic microsurgery
has dramatically changed the facet of ocular surgery in CRITERIA FOR SELECTION OF
many ways. But the increasing number of surgical steps VISCOELASTIC MATERIAL
also involves a greater risk of involuntary tissue damage.
The field of microsurgery strategy is therefore not only Optical Properties
the desired action on the tissue but also the prevention Material suitable for intraocular use should not impair
of undesired side effects on the surrounding tissue the visibility of the operation field. Transparency is
Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco 129
primary prerequisite. A color slightly different from • To lubricate
aqueous is useful for distinction. • To protect and isolate newly created or restored tissue
Surface Tension • To prevent the formation of undesirable fibrin
The specific weight of the injected material determines coagulum
whether the bubble will raise or descend in the aqueous • Protection of corneal endothelium from mechanical
and whether it can be used to elevate or to depress the trauma
surrounding tissue. • To enable easy manipulation of tissues in the eye
• To provide coating ability to implants, instruments
Viscosity and corneal epitheial surface.
Viscous fluids are ideal surface tools since layers deposited
onto tissue implant surface will remain there. As space COMMERCIALLY AVAILABLE VISCOELASTIC
tactical tools viscous fluids are suitable in walled off cavities SUBSTANCES
with small orifices (anterior chamber). Hyaluronic Acid and Sodium Hyaluronate

Elasticity Hyaluronic acid: It is a natural compound of connective

tissue. In the ocular cavities it is a major component of
Elastic materials are resistant against deformation and
the vitreous and occurs as covering layer on the tissue

Section 1
therefore stable as to their shape. They are ideal space
surface of the anterior segment. Hyaluronic acid is not
tactical tools since their action is independent of flow
metabolized or degraded within the eye. It passes
unaltered through the trabecular meshwork as a large
molecule and is transported then with the blood flow
to the liver. Hyaluronic acid is a linear polysaccharide
The viscoelastic solutions, the viscous and elastic responses
composed of sodium glucuronate and N-acetyl
to a mechanical force depends on the velocity of the
glucosamine. The chain is unbranched and contains no
impact. The optimal solution for surgical purposes is a
intermolecular bridges.
substance with a transition from viscous to elastic
behaviour at relatively low velocities. Sodium hyaluronate: NaH, a large polysaccharide
molecule is a viscoelastic substance. It is a natural biological
Miscellaneous product present nearly in all the connective tissues in
Viscoelastic agent should be easy to inject, (inert, non- living organisms from bacteria to human tissue. It stabilizes
inflammatory, nontoxic). No particles or clumps, causes, cells and tissues and hence, protects cell from permanent
less rise of IOP with low molecular weight viscoelastics. deformation.
It must be hydrophilic enough and able to be diluted Various biological sources including the umbilical cord,
and should not prevent the movement of metabolites bovine vitreous and rooster coomb contain a large
and waste products. amount of sodium hyaluronate. Low molecular weight
sodium hyaluronate may also be produced from
streptococci by microbial fermentation. It is component
of capsular material around streptococcal organisms. In
Roles of viscoelastic substances in intraocular surgery are: the eye concentration of sodium hyaluronate is highest
• To maintain an anatomical situation created by in cortical gel and trabecular angle and low in the
surgeon and maintenance of anterior chamber. aqueous humor and covering the endothelium.
130 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Sodium hyaluronate has two fractions H3 Administration and Dosage

inflammatory (if-Na-Ha) and non-inflammatory (Nif-Na- It is available as preloaded syringe with 27 G or 30
Ha). For intraocular purpose non-inflammatory fraction G cannula containing sodium hyaluronate 10 mg/ml or
is used. 14 mg/ml strength (in 0.25, 0.50, 0.80, 2 ml and 4 ml
The molecular weight of sodium hyaluronate varies syringes). Store at 2 to 8oC and remains unaltered after
dramatically depending on the sources. The viscosity of 3-5 years at this temperature. Do not freeze. Use the
sodium hyaluronate solution is influenced by the drug at room temperature (Acclimitization at room
molecular weight, concentration and shear rate. At temperature is necessary).
higher shear rate, the resistance of flow decreases and
it remains constant at low shear rate. This typical Dosage
pseudoplasticity is exhibited by sodium hyaluronate only. For Microphaco/IOL implantation, ECCE During cataract
In 1980, Mitter and Stegmann introduced sodium surgery as soon as the anterior chamber is entered, the
hyaluronate for anterior segment surgery. role of viscoelastic begins. It fills, maintains and cushions
One percent sodium hyaluronate is true viscoelastic the anterior chamber. During anterior capsulotomy it
agent. It is highly viscous, elastic and pseudoplastic of prevents scrolling up of margins.
very high molecular weight (1.1-1.8 × 10)6 Its viscosity Hydraulic separation of nucleus and cortex, synechiae
is 100,000 to 300,000 centipoise and molecular weight (anterior or posterior) release can be easily done with
Section 1

is about 4 million Daltons. It is non-allergic and clear. sodium hyaluronate. When placed over the pupil, it gets
It is one percent solution of highly purified sodium dilated mechanically. It tamponades the bleeding vessels
hyaluronate from dermis of roster coombs. It consists on iris or in wound. After capsulotomy it helps in
of very large hyaluronic acid chains with high molecular viscoexpression of nucleus (after continuous curvilinear
weight. One of its greater advantage is that the transition capsulorhexis). It helps in plugging posterior capsule
from viscous to elastic behavior occurs even at low break and after dry aspiration. It makes bimanual
concentration and low velocities. Owing to its elasticity phacoemulsification successful by coating corneal
it can be injected through a 30 G cannula and still retains endothelial cells.
its original shape in aqueous. Besides space tactics tools, It protects anterior chamber angle during anterior
sodium hyaluronate also inhibits migration of chamber IOL insertion. It also acts as surgical instrument
lymphocytes, granulocytes and macrophages. It also during anterior, posterior or iris clip lenses.
inhibits phagocytic activity, synthesis and release of A sufficient amount is slowly introduced (using 27
prostaglandins by macrophages during phagocytosis. G cannula or needle) into the anterior chamber. Inject
Sodium hyaluronate preparation is a specific fraction either before or after delivery of the lens. Injection before
development for use in anterior segment and vitreous lens delivery protects the corneal endothelium from
procedures as a viscoelastic agent. It is non-antigenic, possible damage arising from removal of the cataractous
does not cause inflammatory or foreign body reactions lens. It may be used to coat surgical instruments and
and has a high viscosity. the IOL prior to the insertion.
Then one percent solution is transparent and remains Additional amount can be injected during surgery
in the anterior chamber for less than 6 days. It protects to replace any of the drug lost.
chamber for less than 6 days. It protects corneal Sodium hyaluronate can be easily distinguished from
endothelial cells and other ocular strucutres. It does not vitreous. Vitreous sticks to cellulose sponge and cannot
interfere with epithelization and normal wound healing. be washed out of anterior chamber.
Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco 131
Advantages of Hyaluronic Acid in Ophthalmic procedures and sequelae including enzymatic zonulysis,
Viscomicrosurgery absence of an iridectomy, trauma to filtration structure
• It ensures to maintain anterior chamber depth and and by blood and lenticular remanants in the anterior
visibility. chamber.
• It minimises interaction between tissues and acts as • Do not overfill the anterior chamber, remove some
temponade and vitreous substitute during retinal of the preparation by irrigation or aspiration at the
reattachment surgery. close of surgery (except in glaucoma surgery).
• It also preserves tissue integrity and good visibility • Carefully monitor IOP specially during immediate
when used to fill the anterior and posterior segments postoperative period. Treat significant rise in IOP
of the eye following open sky procedures. appropriately.
• It is a natural component of the tissues and is • In posterior segment surgery, monitor rise in IOP after
extremely well tolerated. injection of large amounts of the drug (specially in
• It tends to counter-balance the vitreous thrust. aphakic diabetes).
• It efficiently protects the intraocular structures. • Hypersensitivity reactions as this preparation is
• It is eliminated in relatively short time with no extracted from avian tissues and contains minute
significant increase in postsurgical intraocular pressure. amounts of protein, so potential risk of
• It does not have inflammatory reactions in the eye. hypersensitivity may exist.

Section 1
• It does not interfere with the physiological circulatory Other preparations of sodium hyaluronate available
dynamics of the aqueous humor. commercially are as follows:
• It enhances the visibility of surgical field.
• It facilitates the insertion and the implantation of Hyalectin
intraocular lenses and foldable lenses following It is highly viscous 1 percent solution of sodium
phacoemulsification. hyaluronate of lower molecular weight – 1 million
• Due to its lubricating and viscoelastic properties, Daltons. It is less viscous and less elastic than Healon.
transparency and ability to protect corneal endothelial It has special features like :
cells is maintained. • It is eliminated in relatively short time with no increase
At present there is no contraindications except for in postsurgical intraocular pressure. Therefore, there
hypersensitivity reactions to the use of sodium is no need to remove Hyalectin after the operation.
hyaluronate solution when recommended for use in • It does not give inflammatory reactions.
intraocular surgery. • It is a specialty whose active ingredient is a specific
fraction of the hyaluronic acid sodium salt which is
Adverse Reactions obtained by unique methodology based on sequential
Although well-tolerated, a transient postoperative molecular ultrafiltration stages. This procedure allows
increase in IOP has been reported. Sometimes post- the exclusion of low molecular weight fractions and
operative inflammatory reactions (iritis, hypopyon), gives a product characterized by a mean molecular
corneal edema and corneal decompensation are also weight in the range of 500000 to 730000 and with
seen. a very high degree of purity.
• The isotonic 1 percent aqueous solution of hyalectin
Precautions (20 mg / 2 ml) exhibits particular viscous characteristics
Postoperative intraocular pressure may be elevated as which make it specially suitable for intraocular
a result of pre-existing glaucoma and by operative viscomicrosurgery.
132 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

• It provides an effective protection to ocular tissues Chondroitin Sulfate

vulnerable to surgical manipulations and it allows to It is a biological polymer and is a proteoglycan.
preserve anatomical form and relationship among Chondroitin sulfate from shark cartilage was
the various structures of the eye. introduced in 1980 as a coating for intraocular lenses.
• Hyalectin favourably differentiates from hyaluronic It is a natural compound of hard connective tissue such
acid with very high molecular weight whenever such as cartilage in humans and one of the major
substances left in the anterior chamber. It does not glycosaminoglycans of the corneal stroma.
cause rise in postoperative IOP in comparison to The physical and chemical properties and molecular
hyaluronic acid with high molecular weight (which structure of chondroitin sulfate is quite similar to
cause significant rise in postoperative IOP). hyaluronic acid with the difference of presence of sulphur
• It physically shields corneal endothelium, the lens and and double negative charges per molecular subunit.
the angle structures during surgical procedures. The molecular size is 5 × 100 × 103 centistokes,
• Hyalectin sets apart from each other traumatized Thus, being much smaller than hyaluronic acid. The sugar
tissues enhancing surgical repair and preventing moieties occur as repeating disaccharide subunits
formation of anterior and posterior synechiae. consisting of glucuronic acid in B-1, 3 linkage with N-
• It helps in restoration and preservation of the ocular acetyl galactosamine for chondroitin sulfate.
volume in reconstructive surgery following eye injury. Double negative charge of chondroitin sulfate coats
Section 1

It is available as 1 percent solution in preloaded the positively charged tissue or implant surface and Thus,
disposable syringes (2 ml). decreases the electrostatic interaction between the
implant and the endothelium.
Sodium Hyaluronate and Chondroitin Sulfate Chondroitin sulfate alone has a low viscosity because
Solution of which it cannot maintain space. If concentration of
It is highly viscous but less elastic and pseudoplastic than chondroitin sulfate is increased to 50 percent, it improves
1 percent sodium hyaluronate. It is available as solution the viscosity but causes endothelial cell damage due to
of (3:1 mixture of) 3 percent sodium hyaluronate and dehydration, sticks of lens surface and does not wash
4 percent chondroitin sulfate with 0.45 mg away easily.
sodium dihydrogen phosphate hydrate, 2.65 mg Due to these problems chondroitin sulfate is generally
disodium hydrogen phosphate and 4.3 mg NaCl (in 0.5 combined with another biological polymer sodium
ml pack). hyaluronate. This formulation makes it a good viscous
It is used as surgical aid in the anterior segment substance which increases its coating ability and cell
procedures including cataract extraction and IOL protection.
implantation. The molecular weight of sodium When used alone it is available as 20 percent solution
hyaluronate is 500000 and the chondroitin sulfate which can be injected through 30 G cannula.
50000. It is produced by genetic engineering. Because Chondroitin sulfate is available in combination with
of its stickiness, it is claimed to be quite effective in HPMC which has a good coating property and does not
protecting endothelium but does not maintain anterior require refrigeration.
chamber as healon.
The disadvantage is that it is difficult to aspirate, tends Methylcelluose
to trap small air bubbles, less cohesive and requires It was introduced in 1976 for coating of intraocular
refrigeration. lenses. It is an artificial compound in the eye. Its viscosity
Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco 133
is 3000-4000 centipoise approximately and an average Presentation
molecular weight of 86000, an osmolarity of 285 mosm It is available as 2 percent HPMC solution in 2 ml vials
and a pH of 7.2. or prefilled sterilized disposable Syringes, with sterile 27
It is somewhat viscous, low cost but not truly G cannula. Administration route and technique is same
viscoelastic. It is water soluble, inert substance and as discussed in sodium hyaluronate section.
nontoxic to the endothelium, transparent and non-
pyrogenic. It is basically used as lubricant and maintain Adverse Reactions
anterior chamber but not so well. Methyl cellulose is tolerated extremely well after injection
It is 2 percent solution of hydroxypropyl
into human eyes. However, transient rise in intraocular
methylcellulose suitable for intraocular use. It is highly
pressure postoperatively has been reported.
purified brand of hydroxy propyl methyl cellulose.
Isolated incidence of postoperative inflammatory
Hydroxy propyl and methyl group increases the
reactions (Iritis, hypopyon) as well as corneal edema and
hydrophilicity of the compound. It is designed as such
corneal decompensation have been reported.
to serve as an acid in ophthalmic procedures of the
The main advantage of methyl cellulose is its availability
anterior segment.
at a very low cost in comparison to sodium hyaluronate
Injection of methyl cellulose serves to support a deep
specially in, developing countries. HPMC main
anterior chamber during intraocular surgery and allows
advantages are its availability, ease of preparation, storage

Section 1
through manipulation with less trauma to corneal
at room temperature, ability to withstand autoclaving
endothelium and other surrounding tissues. It impedes
and potential for low cost.
vitreous leakage into the anterior chamber thereby
The disadvantage of this viscoelastic substance is its
decreasing the possibility of postoperative flat chamber.
low viscosity because of which it is not able to maintain
Precautions anterior chamber and requires large bore cannula.
• Do not overfill the anterior chamber with methyl
It is a linear, long chain and high molecular weight
• Remove as much possible of methylcellulose by
irrigation/aspiration at the close of surgery for synthetic polymer. It has repeated acrylamide units
preventing corneal endothelial cell loss as a result of without protein or other molecular contamination.
performed procedure. Acrylamide monomer are highly reactive and toxic
• Carefully monitor IOP specially during the immediate substances but in polymer form it is highly stable and
postoperative period. nontoxic. Polyacrylamide has a low contact angle because
• Instillation of methyl cellulose should be done so as of which it possesses good surface wetting and coating
to avoid trapping of air bubble behind methyl properties.
cellulose. Orcolon (Low concentration polyacrylamide 4.5 mg/
• Carefully examine the solution for rubber particles ml) is commercially available.
that may have been aspirated with repeated washing It has molecular weight of one million dalton and
of sterile water for injection high and stable viscosity of approximately 40000 cps
• Concurrent presence of medication in the chamber with good elastic and pseudoplastic properties. The
or associated ocular structures should be avoided as osmolality is 340 mOsm and the pH is 7.2. It is injected
it may interact with methyl cellulose to cause through 27 G cannula and can be stored at room
clouding. temperature.
134 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Delayed sustained increase in intraocular pressure and death when the tissues have been exposed to
secondary to the use of polyacrylamide in the anterior prolonged period of time.
chamber has been reported. The cause may be related Two types of irrigating solutions are available for use
to presence of small particles of viscoelastic which could in ophthalmology. However, only intra ocular irrigating
lead to compromised trabecular meshwork. solutions are used in Microphaco surgery.

Collagen Intraocular Irrigating Solutions

Collagen constitutes an important bulk of connective The commercially available intraocular irrigating solutions
tissues. There are different types of collagen, i.e. I, II, (e.g. BSS and BSS plus) are used during ocular surgery
III and IV, etc. Collagel (1.4% collagen type IV) was to protect the lens and cornea in patients. Unlike
viscoelastic introduced in 1990. It is obtained from physiological saline and Ringer lactate solution, these
human placental tissue. balanced salt solutions provide magnesium and calcium
It has a molecular weight of approximately one million ions as cellular nutrients.
daltons and a viscosity of 500,00 centipoise (Zero shear These nutrients are required for intercellular and
rate), an osmolality of 300 mosm and a pH of 6.2. intracellular function during prolonged ocular, surgery.
It has been clinically compared with healon and no In addition to magnesium and calcium, bicarbonate,
significant difference in IOP, corneal thickness, endothelial glucose and glutathione are present in these perfusion
solutions (BSS plus). These components help to maintain
Section 1

cells and postoperative visual acuity have been observed.

a deturgesced or thin cornea by avoiding corneal
It is commercially available for use.
clouding. Various commercially available intraocular
irrigating solutions are :
A new polymer, poly-TEGMA 40 percent (triethylenglycol BSS Solution Containing
monomethacrylate) and poly-GLYMA (Glycerol 0.64 percent sodium chloride, 0.075 percent potassium
monomethacrylate) have been evaluated in rabbits and chloride, 0.03 percent magnesium chloride, 0.043
pre-clinical studies as potential viscoelastic substances for percent calcium chloride, 0.39 percent sodium acetate,
intraoperative use in anterior segment surgery. These 0.17 percent sodium citrate and sodium hydroxide or
are highly swelling and hydrophilic polymers. Poly- hydrochloric acid in (15,30,300 and 500 ml sterile
GLYMA and poly-TEGMA 40 percent are characterized packs).
by high biological tolerance after its implantation into
BSS plus - (Mix aspastically just prior to use)
the anterior chamber. Poly-TEGMA 40 percent is
potential viscoelastic substance and shall be commercially Part I : 480 ml containing 7.44 mg NaCl, 0.395 mg
available in short future. KCl, 0.433 mg sodium phosphate , 2.19 mg
Provisc has been recommended as a safe and effective sodium bicarbonate, hydrochloric acid or
viscoelastic substance in modern surgery of cataract. sodium hydroxide/ml.
Part II : 20 ml containing 3.85 mg calcium
chloridedihydrate, 5 mg magnesium chloride
IRRIGATING SOLUTIONS hexahydrate, 23 mg dextrose and 4.6 mg
Irrigating solutions are aqueous solutions used to cleanse glutathione disulfide/ml.
and to maintain moisture of ocular tissues. Ideally these It is preservative free (500 ml pack) and 30 ml pack.
solutions are isotonic. The optimum pH is 7.4. A pH Its pH is at or near the optimal 7.4 level (pH of human
less than 7 or greater than 8 has caused cellular stress aqueous humor).
Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco 135
Salient Features of BSS Plus Solution hemorrhage for hasten re-absorption and for cortisone
• It is iso-osmotic with intraocular tissues. therapy when given subconjunctivally for early
• BSS plus solution provides uncompromised pterygium resolution. The advantages it brings to local
endothelial nourishment even during Microphaco. injection are:
• In addition to supplying five essential ions (Sodium, 1. Quicker diffusion and more effective action of
potassium, magnesium, calcium and chloride) this lignocaine and adrenaline in promoting akinesia of
solution provides the endothelium with three orbicularis oculi and extraocular muscles.
additional constituents. 2. The swelling at the site of injection is appreciably
• Sodium bicarbonate for normal endothelial pump lessened by its presence. The duration of anesthesia
function to help reduce corneal swelling. It is vital is about the same as without the use of hyaluronidase
for maintaining endothelial barrier integrity and is provided that adrenaline is used.
activating agent for endothelial cell metabolic pumps The effect of the injection is hastened by the massage
for maintaining corneal clarity. of the infiltrated area.
• Dextrose is an energy source for endothelial cell 3. Hyaluronidase increases the area of anesthesia by
metabolism and is essential for acrobic metabolism 40 percent.
of endothelial cells and helps to maintain transparency 4. It s nontoxic to the ocular tissues.
of cornea and lens.

Section 1
• Oxidized glutathione to protect cell against oxidative Dosage
stress and maintain integrity of the blood aqueous It is available as an odorless, fluffy powder containing
barrier to minimise inflammation. It maintains 300 units of activity per mg.
functional complexes of endothelial cells. It is freshly prepared just before use. For local
• BSS plus solution does not contain alien ingradients anesthesia it is directly reconstituted in 2 percent lidocaine
such as acetate or citrate which can chelate free solution 1 ampoule of hyaluronidase containing 1500
calcium ions. Calcium ions help to maintain the IU (each ml) is directly mixed into 30 ml vial of 2 percent
corneal endothelium’s vital barrier function. lidocaine and adrenaline. Hyaluronidase can also be
Compound sodium lacetate or citrate which can obtained by dissolving the contents of one ampoule in
chelate (in 500 ml pack) Compound sodium chloride 10 ml sterile distilled water and withdrawing 1 ml of it.
solution (in 5 ml and 500 ml packs)
Adverse Reactions
Generally there are no signs of local or systemic tissue
Hyaluronidase Hyaluronidase is antigenic and may sometime
This enzyme is prepared from mammalian testes and produce allergic reactions. Because of danger of
acts by depolymerising hyaluronic acid an essential spreading the infection, the enzyme should not be
component of the intercellular ground substance which injected into or around an infected area.
determines the permeability of tissue. Ocular malignancy is also considered a
The enzyme hyaluronidase is commonly used in contraindication for Hyaluronidase for similar action.
conjunction with local anesthetics lignocaine (2%) with Solutions of hyaluronidase rapidly lose their viscosity
adrenaline for infiltration and regional local anesthesia. reducing activity at room temperature. Fresh solution
Hyaluronidase is also indicated for subconjunctival should be used certainly within 12 hours.
136 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)


Trypan Blue Trypan blue is indicated for facilitating surgical procedures
for cataract extraction (IOL surgery and micro
Trypan blue is a dye which safely stains the anterior lens
phacosurgery) and as a staining agent.
capsule and is mainly used in cataract surgery (ECCE,
IOL surgery phacosurgery and microphaco surgery). Administration and Dosage
Trypan blue is a capsule stainer which reduces the
It is available as 1 ml single use ampoule commercially.
risk of complication due to unrecognised radial capsule
Each ml contains 0.6 mg trypan blue, 1.9 mg of sodium
by facilitating the performance of the capsulorhexis in
mono-hydrogen orthophosphate, 0.3 mg of sodium
the absence of red fundus reflex specially in the cases dihydrogen orthophosphate, 8.2 mg of sodium chloride
of matured cataract. Special feature of trypan blue is and sodium hydroxide for adjusting the pH and water
that it stains the anterior capsule without affecting the for injection.
corneal endothelium. So, blue stained capsule can be For trypan blue administration, first step of procedure
easily identified from the underlying unstained lenticular is to inject air into the anterior chamber using a 26 guage
tissue. It helps the eye surgeon to see capsule clearly needle in the area where the second site is made. This
Thus, eliminates the chances of hitting the outline with prevents the water like dilution of the trypan blue. Then
the phacotip during phacoemulsification. trypan blue is withdrawn from the ampoule into the
tuberculin syringe and is injected by needle into the
Section 1

Mechanism of Action anterior chamber between the air bubble and the lens
Trypan blue is used to enhance the visualization of the capsule. Use the bevel down of the needle and see to
anterior lens capsule of the eye during removal of it that the injection is made in a drop format so that
cataractous lens replacement procedures. Trypan blue the whole capsule gets stained. If some portion is left
provides a clear, visible staining at low amounts without unstained, inject a drop in that area till it gets stained.
diffusing into or through concerned tissues. So, it facilitates It is kept lie in this position for a minute for complete
the controlled opening of anterior capsule and reduces staining of the anterior capsule to occur. Thereafter
the risk of inadvertent damage to the capsule specially viscoelastic is injected into the anterior chamber. This
will distend the eye so that during clear corneal incision
radial tear towards or beyond the equator of the lens.
eye shall be tense and one can create a good valve.
Besides, it has low toxicity profile.
Now one can use a straight rod to stabilize the eye with
the left hand and with the right hand clear corneal or
scleral incision can be made. Inject viscoelastic inside
Trypan blue solution concentration is more preferred the eye to remove the air bubble and trypan blue. Now
in the range of 0.01-0.1 percent. In this range an optimal rhexis can be started with a needle or Forceps (Surgeons
staining effect is achieved, while at the same time the choice). One can see the contrast between the capsule
risk of possible damage to the eye or any part there which has been stained and the cortex which is unstained.
of due to the toxicity of the dye is minimised. After few The rhexis is continued and finally completed. After
drops instillation of typan blue due on to anterior lens rhexis completion we can see the stained anterior capsule
capsule, it selectively stains the anterior lens capsule, lying in the anterior chamber.
whereas the lenticular material beneath the anterior lens
capsule is not stained. No traces of the dye are present Contraindication
in ocular tissues shortly after the cataract extraction Trypan blue is contraindicated in patients with a
procedure has been completed. hypersensitivity to the dye or any of its components.
Dynamics of Ocular Surgical Adjuncts in Bimanual Phaco 137
Adverse Reactions Indications and Administration
• Clinical literature reports are not certain if extended Perfluorocarbons are heavier than intraocular lenses.
contact of trypan blue with the corneal endothelium Hence, these liquids can be used to float a displaced
produces corneal damage or not. At present no case intraocular lens off the posterior retina making it safer
has been reported as the trypan blue is washed off and easier to reposition or remove. The injection of
with the viscoelastic and the BSS fluid. perfluorocarbon may be useful when there is a
• Mild postsurgical inflammatory reactions and some concomitant retina detachment as it will simultaneously
bullous keratopathy have been reported to occur push the retina against the back of the eye holding it
after using Trypan blue in certain cases.
away from IOL instruments and lift the intraocular lens
• Trypan blue solution should be given to a pregnant
woman only if the benefits clearly outweigh any
possible risks. Povidone Iodine (Halogens)
• On the whole trypan blue is well tolerated following
Iodine is aqueous and alcoholic solutions have been used
injection into the anterior chamber of the eye during
as skin disinfectant. It is an active bactericidal agent with
cataract surgery.
a moderate activity against spores. Chlorine and its
Liquid Perfluorocarbons compounds have been used as disinfectants.
Commercially it is available as 5 percent sterile ophthalmic

Section 1
Dr Stanley Chang (USA) introduced a heavier than water
liquid for tamponading the retina and it was N- prep solution. It contains 5 percent povidone iodine
perfluorocarbon amine. The basic principle to these (0.5% available iodine) stabilized by glycerine.
liquids is that they are heavier than water, so they would It is indicated in the eye for prepping of the periocular
flatten the retina or unfold a giant tear. region (lids, brow and cheek) and irrigation of the ocular
There are 4 types of perfluorocarbon liquids being surfaces (cornea, conjunctiva and palpebral fornices) prior
used in posterior segment surgery. to microphaco surgery.
a. Perfluoro-N- Octane This topical solution is an isotonically balanced
b. Perfluoro-Decaline preoperative microbicidal solution that can safely be used
c. Perfluoro-Tributylamine directly on the cornea and conjunctival cul-de-sac as well
d. Perfluoro-Phenanthrene as on periocular region. This solution is strictly used for
Liquid perfluorocarbons are heavier than water. external use only. It is not used for intraocular injection
These are generally used to push the retina against the or irrigation.
back of the eye with the patient lying in the supine
Salient features of this topical solution are :
position and to retrieve the dislocated IOL in the posterior
• Assure asepsis in less than 60 seconds and stained
segment. These liquids are clear, with low viscosity and
skin is virtually impossible to reinfect for at least 1
surface tension and are immiscible with water liquid
perfluorocarbons have refractive indices very close to hour.
aqueous so it is difficult to see the interface between • It is nontoxic, has excellent skin tolerance and does
perfluorocarbon and the aqueous. However, a clear not burn the skin.
miniscus is visible between the perfluorocarbon and the • It has broad spectrum of action sporicidal,
intraocular fluids or BSS. Some perfluorocarbons are bactericidal, antimycotic, viricidal and protozocidal.
intended for intraoperative use only while others are left • It decreases the incidence of postoperative
in eyes for a prolonged period of time. endophthalmitis.
138 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

How to Use this Solution 0.2 percent BPL solution is used for sterilization of
• First squeeze the entire content of bottle into a sterile biological products. It is capable of killing all micro-
prep cup. organisms and is very active against viruses.
• Saturate sterile cotton tipped applicator or sponge
to prep lashes and lid margins using one or more BIBLIOGRAPHY
applicators per lid. Repeat once. 1. Agarwal A. Textbook of Ophthalmology, ed. 1, New Delhi;
• Saturate sterile prep sponge to prep lids, brow and Jaypee Brothers Medical Publishers, 2002.
2. Bartlett JD. Clinical Ocular Pharmacology, 4th ed, Boston:
cheek in circular ever expanding fashion until the
Butterworth-Heinemann, 2001.
entire field is covered. Repeat prep three times. 3. Bartlett JD. Opthalmic Drug facts, Lippincott-William and
• Irrigate the cornea, conjunctiva and palpebral fornices Wilkins, 2001.
4. Buratto. Viscoelastics in Ophthalmic Surgery, Slack. Inc.,
with this solution using a sterile disposable syringe. 2000.
• After the prepping solution has been left in contact 5. Crick RP, Trimble RB. Textbook of Clinical Ophthalmology,
for two minutes. Sterile saline solution in a syringe Hodder and Stoughton, 1986.
6. Dich. Viscoelastics in Ophthalmic Surgery, Springer-Verlag,
should be used to flush the residual prepping solution 2000.
from the cornea, conjunctiva and palpebral fornices. 7. Duane TD. Clinical Ophthalmology, ed. 4: Butterworth-
Heinemann, 1999.
Topical local sensitivity reaction has been reported.
8. Duvall. Ophthalmic Medications and Pharmacology, Slack
Povidone-iodine is effective against bacteria, spores, Inc, 1998.
Section 1

fungi, some viruses including AIDS virus but not entero 9. Ellis PP. Ocular Therapeutics and Pharmacology, ed. 7: CV
Mosby, 1985.
or adenovirus.
10. Fechner. Ocular Therapeutics, Slack Inc., 1998.
It is also available commercially as following: 11. Fraunfelder. Current Ocular Therapy, ed., 5: WB Saunders,
i. Betadine antiseptic solution 10 percent for 2000.
12. Garg A. Current Trends in Ophthalmology, ed. 1, New
prepping skin sites. Delhi: Jaypee Brothers Medical Publishers, 1997.
ii. Betadine surgical scrub 7.5 percent – a soap used 13. Garg A. Manual of Ocular Therapeutics, ed. 1. New Delhi:
for hand scrubbing. Jaypee Brothers Medical Publishers, 1996.
14. Garg A. Textbook of Ocular Therapeutics, ed. 2, New Delhi:
Jaypee Brothers Medical Publishers, 2003.
Phenols 15. Garg A. Advances in Ophthalmology, ed. 1, New Delhi,
Jaypee Brothers Medical Publishers, 2003.
Phenols cause cell membrane damage causing lysis and
16. Goodman LS, Gilman A. Pharmacological Basis of
are powerful microbial substances. Lysol and cresols are Therapeutics, ed. 7, New York: Macmillan, 1985.
good general disinfectants. 17. Havener’s. Ocular Pharmacology, ed. 6: C.V. Mosby, 1994.
18. Kanski. Clinical Ophthalmology, ed. 4: Butterworth –
Heineman, 1999.
Acetone 19. Kershner. Ophthalmic Medications and Pharmacology,
Acetone is one of the most commonly used potent Slack Inc, 1994.
20. Olin BR et al. Drugs Facts and Comparisions: Facts and
bactericidal agent. It is used for sterilization of sharp Comparisions, St Louis, 1997.
cutting instruments. It has wide action against gram- 21. Onofrey. The Ocular Therapeutics, Lippincott-William and
positive and gram-negative microorganisms. Wilkins, 1997.
22. Rhee. The Wills Eye drug Guide, Lippincott-William and
Wilkins, 1998.
Betapropiolactone (BPL) 23. Steven Podos. Textbook of Ophthalmology, New Delhi:
Jaypee Brothers Medical Publishers, 2001.
It is condensed product of Ketane and formaldehyde 24. Zimmerman. Textbook of Ocular Pharmacology, Lippincott
with a boiling point of 163oC. It has rapid biocidal action. and William and Wilkins, 1997.
Bimanual Microincision Phacoemulsification 139

Bimanual Microincision
13 Phacoemulsification:
Instrumentation and
I Howard Fine
Richard S Hoffman
Mark Packer (USA)

Section 1
The first person to perform bimanual microincision phaco
in a way that is reminiscent of what we are currently
doing today is Steve Shearing, MD, of Las Vegas. In
an article published in the January 1985 issue of the
International Journal of Cataract Surgery, the cover story
involved the use of this technique (Fig.13.1). 1
Subsequently, Dr. Tsutomu Hara from Japan published
a paper in 1989 on his experience with bimanual
microincision phaco.2 Amar Agarwal, MD, renamed the
procedure phakonit in a 1998 publication.3 Others
including Hiroshi Tseunoka, MD4 from Japan, Randall
Olson, MD5 and David Chang, MD6 from the United
States, Jorge Alió, MD7 from Spain, and Drs. Fine,
Hoffman and Packer 8 all have added to the discussion
of the value of this technique.
We believe that this technique is better because it
Fig. 13.1: Cover page picture of the January 1985 issue of
involves smaller and quite possibly safer incisions. It is the journal, cataract Dr. Shearing performing early bimanual
closer to the ideal procedure than coaxial phacoemulsi- microincision phacoemulsification
fication in that there is dramatic reduction of fluid through
the eye and the ideal procedure would be a completely tissue with the incoming stream of fluid and we have
closed system. With bimanual microincision phaco we a much more stable chamber because all of the fluid
have improved followability, we are able to manipulate is entering through one side of the eye and leaving
140 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

through the other side so we do not have competing

currents of fluid around the phaco needle. Of course,
bimanual irrigation and aspiration of cortex has been
known for a longtime to be advantageous.
We began bimanual microincision phacoemulsifica-
tion over two years ago because we were told we would
be in the first wave of investigators in the United States
on the ThinOptX IOL and we thought we should learn
this technique in advance of the commencement of that
study. However, we soon recognized that this was a
superior procedure and therefore have limited our
cataract surgeries and refractive lens exchanges to this
technique over the past two years. We are frequently
Fig. 13.2: Mastel (Rapid City, South Dakota) Fine-
confronted by criticisms saying that it seems to be not Paratrap™ blade
worthwhile in that at this time we still have to make an
incision between our two microincisions for implantation
of an IOL. This is reminiscent of the criticism of
Section 1

phacoemulsification in the early 1980s before the

availability of foldable IOLs. People felt that it was not
worthwhile because the phaco incision had to be
enlarged to implant an IOL. However, we persisted
saying that phacoemulsification was a better procedure
than extracapsular cataract extraction and for the same
reason—the belief that microincision cataract surgery is
Fig. 13.3: Rhein (Tampa, Florida) 3D Blade®,
a better procedure even in the absence of an IOL angled Handle
insertable through these microincisions.
MicroSurgical Technology’s (Redmond, Washington)
INCISIONS Duet Bimanual set (Fig. 13.5). We routinely separate
We have a strong preference for diamond knives because our microincisions by 60° to 90°. We like them to be
they are very reproducible and they do not stretch tissue. approximately 1.5 mm long and our strong preference
Knives we use include the Mastel (Rapid City, South for trapezoidal blades is due to the ease through which
Dakota) Fine-Paratrap™ blade (Fig. 13.2), which when we can rotate instruments within the incision without
inserted to the end of the bevel produces incision sizes being oar-locked.
of 1.1 to 1.2 mm internally and 1.3 to 1.4 mm externally,
the Rhein (Tampa, Florida) 3D Blade® (Fig. 13.3) which CAPSULORHEXIS
produces incisions of 1.2 mm internally and 1.4 mm Following incision construction, we exchange aqueous
externally and is an excellent blade because it is self- for viscoelastic (Viscoat, Alcon Laboratories, Fort Worth,
directed, the ASICO (Westmont, Illinois) Packer bimanual Texas) by injecting viscoelastic into the distal angle
phaco diamond knife (Fig. 13.4), as well as a variety through one of the microincisions which allows for
of metal blades including the metal blade from extrusion of aqueous and allows us to achieve a stable
Bimanual Microincision Phacoemulsification 141

Fig. 13.5: MicroSurgical Technology (Redmond,

Washington) Duet bimanual metal blade

Section 1
Figs 13.6A and B: MicroSurgical Technology (Redmond,
Washington) Fine-Hoffman capsulorhexis forceps

Figs 13.4A and B: ASICO (Westmont, Illinois) Packer

bimanual phaco diamond knife

anterior chamber. We then perform a capsulorhexis

utilizing one of several instruments. We have strong
preferences for the MicroSurgical Technology (Redmond,
Washington) Fine-Hoffman Capsulorhexis forceps (Fig.
13.6), the Fine-Ikeda forceps by ASICO (Westmont,
Illinois) (Fig. 13.7), or the fine capsulorhexis forceps by
Katena (Denville, New Jersey). Each of these allows
us to make a very precise capsulorhexis through a 1
mm incision and the MicroSurgical Technology
(Redmond, Washington) instrument allows for
exchanging the capsulorhexis forceps for intraocular
scissors or intraocular tying forceps as each type can snap
on and off the same handle.
It is interesting that the size and shape of these
capsulorhexes are much more accurate than they
were with traditional capsulorhexis forceps through a 2.5
mm incision. We believe this is due to the fact that one Figs 13.7A and B: ASICO (Westmont, Illinois)
cannot use the wrist in making a capsulorhexis through Fine-Ikeda forceps
142 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

a microincision and so we are limited to just finger

movements. This is analogous to the accuracy with which
we write when we rest our wrist and use only our fingers
compared to using both our fingers and wrist in the use
of a fountain pen. We aim for a round capsulorhexis
sized between 4.5 and 5.5 mm in diameter.

We perform cortical cleaving hydrodissection in
100 percent of our cases.9 One does not have to remove
viscoelastic when injecting through these microincisions Fig. 13.8: Demonstration of vertical chopper being inserted
into the eye. Image provided by MicroSurgical Technology
because a little bit of posterior pressure on the incision (Redmond, Washington).
will allow egress of some of the viscoelastic during the
cortical cleaving hydrostep. Following cortical cleaving in our paper on the use of power modulations and the
hydrodissection we spin the lens to be sure that the cortical choo-choo chop and flip technique. 10 We utilize
connections to the capsule have been severed, after horizontal chopping for softer nuclei, grades 1 or 2+
Section 1

which we then do two hydrodelineation injections as we and vertical chopping for nuclei of grades 3 and 4+.
have previously described.9 We then rock the nucleus We have designed chopping instruments with
from side to side to be sure that we have severed the MicroSurgical Technology (Redmond, Washington) (Figs
epinuclear-endonuclear connections. 13.9 and 13.10), Katena (Denville, New Jersey) (Fig.
13.11), Rhein Medical (Tampa, Florida) and ASICO
CHOPPING (Westmont, Illinois). They all work very well. We went
through many prototypes in the development of the
We allow for continuous flow throughout the procedure choppers produced by MicroSurgical Technology
including flow when inserting the chopper. The irrigating (Redmond, Washington). These have some unique
chopper is held vertically and the tip is inserted beyond advantages in that they are thin-walled and short so that
the internal lip of the incision, the handle is rotated there is a decreased resistance to flow through them and
horizontally and the open end of the chopper is brought they are bent slightly so that the placement of the
into the eye (Fig. 13.8). This prevents snagging of microincisions, which force us to work over the brow
Descemet’s membrane. For horizontal chopping and check, does not necessitate an upward pull on our
maneuvers we have a strong preference for the choppers instrumentation in order to get over the brow or check.
we designed in conjunction with MicroSurgical
Technology (Redmond, Washington), all of which are
front irrigating so they deepen the anterior chamber as
soon as the open end touches the microincision thus
avoiding injury to intraocular structures. Also, the We have been able to perform bimanual microincision
irrigation remains constant in direction with rotation of phacoemulsification with most of the machines available
the instrument during the operation. The maneuvers in America and Tables 13.1 to 13.5 show the optimized
utilized in this technique are exactly the same with an phacoemulsification parameters and power modulations
irrigating instrument that we have described previously that we prefer.
Bimanual Microincision Phacoemulsification 143
Table 13.1: Parameters for bimanual phaco Infiniti™
Chop Epinucleus
Power % Linear 35 Linear 15
Flow 36 Fixed 35 Linear
Modulation 50 pps, 35% on, 30 pps, 25%
Neo: Amp 20 No Neo
Threshold 5
Vacuum 360 fixed 300 linear No
Dynamic Rise 1 dynamic rise
Bottle Height (cm) 110 110

Table 13.2: Parameters for bimanual phaco Legacy®

Chop Epinucleus
Power % Linear 40 15
Fig. 13.9: MicroSurgical Technology (Redmond, Flow 32 32 (linear)
Washington) fine horizontal chopper Modulation NeoSoniX, NeoSoniX
2 pps. Ampl. Burse, 30 msec.
80% Threshold Amplitude 40%
Vacuum (mmHg) 220 (linear) 220
Bottle Height (cm) 132 132

Section 1
Table 13.3: Parameters for bimanual phaco Millennium®
Chop Epinucleus
Power % 15 Fixed 0-3 Linear
Flow cc/min 46 Fixed 38 Fixed

Fig. 13.10: MicroSurgical Technology (Redmond, Modulation Burst 200 ms Pulses 3/sec.
Washington) Fine-Olson vertical chopper (Pulse: pps or
Vacuum (mmHg) 220 (linear) 220
Linear Yaw
Infusion Pressure 35 35
Bottle Height (cm) 132 132

Table 13.4: Parameters for bimanual phaco Sovereign®

with WhiteStar Technology
Chop Trim Flip
Power % Linear 40 20 20
Flow Unocc/occlude 36 22/16 24/16
(panel except
where indicated)
Fig. 13.11: Katena (Denville, New Jersey) Modulation CL CL CL
irrigating chopper
Vacuum (mmHg) 350(panel) 200/50 200/80
The major difference between coaxial phacoemulsifi- Unocc/occlude (linear) (linear)
Ramp (%) 30 30 30
cation and bimanual microincision phacoemulsification
Bottle Height 38 38 38
resides in the way in which the instruments are
coordinated. In coaxial phacoemulsification, we tend
144 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Table 13.5: Parameters for bimanual phaco STAAR wave

Chop Trim Flip
Power % 55 Linear 20 Linear 55
Flow 30 23 26
Modulation Sonic Sonic Sonic
Random 2 pulses per second
Vacuum (mmHg) 500 300 200
Bottle Height 45 45 45

to use our second hand instrument, the chopper, very

close to the phacotip, sometimes being a little below it,
sometimes a little above, but most frequently just directly
in front of it. We have to be very careful in bimanual Fig. 13.12: Demonstration of working with the phacotip slightly
below and behind the chopper. Image provided by
microincision phacoemulsification to not irrigate material
Microsurgical technology (Redmond, Washington)
purchased at the phacotip off the tip by the incoming
stream of fluid. As a result we tend to work with our hands with a little upward movement of the phacotip
phacotip slightly below and behind the chopper and can and a downward diagonal movement of the chop
approach it from below and behind as we need to use instrument. This usually results in an immediate division
Section 1

the chopper. (Fig. 13.12) Our chop maneuvers are those of the endonucleus into two. We then rotate it in such
previously described. For horizontal chopping, we touch a way as to purchase the largest hemi-nucleus for
the center of the endonucleus and with the vertical rechopping and then, once again with the second chop,
element of the chop instrument in a vertical orientation, we have a pie-shaped segment attached to the phacotip,
slide it to the distal left periphery until it drops into the which can be mobilized or chopped in additional time.
golden ring created by hydrodelineation. We then lift We have not found utilizing the parameters in the
the endonucleus up and toward the incision and then, above tables that we have had any problems with any
using power modulations and high vacuum, we imbed of the instrumentation herein described with respect to
the phacotip. Once the tip is imbedded, we draw the maintaining a stable anterior chamber. In fact, we have
chop instrument toward the side of the phacotip and found our chamber to be very much more stable than
then separate our hands with a little downward force with coaxial phacoemulsification.
on the chop instrument and an upward force on the In some instances in which during the procedure we
phacotip. This results in a complete division of the have blown a hole in the posterior capsule with the
endonucleus to hemi-nuclei. We then rotate clockwise phacotip, we have been able to continue the procedure
and in a similar manner, chop the second heminucleus. by maintaining irrigation high in the anterior chamber
At the completion of the second chop, we have a pie- and reaching down into the capsular bag to mobilize
shaped segment that is attached to the phacotip in its nuclear material. This would be impossible with coaxial
bevel down configuration and we can mobilize it, if it phacoemulsification because as we brought the phacotip
is soft enough, or chop it a second time to reduce the down, we would be bringing a forceful stream of fluid
size of the pie-shaped segment. with fluctuating direction into the capsular bag which
For vertical chopping, we imbed the phacotip first would almost certainly extend any pre-existing tear.
and then drive the vertical chop instrument diagonally We chop the endonucleus as previously described
downward above the phacotip and then separate our and then mobilize epinucleus at the level of the
Bimanual Microincision Phacoemulsification 145
capsulorhexis. We have a very strong preference for
straight, 30° phacoemulsification tips used bevel down.
The bevel down configuration has several advantages.
The approach to the endonucleus through a clear corneal
incision is approximately 30° so with the 30° bevel down Fig. 13.13: MicroSurgical Technology (Redmond, Washington)
Duet bimanual irrigation and aspiration instrumentation
tip, as soon as we touch the endonucleus we can begin
to evoke vacuum which helps us bury the tip and to and removing residual cortex, we then remove the
stabilize the nuclear material. Second, all of the energy, aspirator and inject viscoelastic prior to removing the
both ultrasound and cavitational, is directed toward the irrigator.
nucleus rather than toward the corneal endothelium or
the trabecular meshwork. Finally, we can mobilize STROMAL HYDRATION AND IOL
nuclear material from the level of the capsulorhexis up IMPLANTATION
rather than having to go deeply into the endolenticular
We can then stromally hydrate the two side-port incisions
space to achieve mobilization of these pie-shaped
and make an incision between them for the implantation
of our IOL. We do not enlarge one of the microincisions
When all of the endonucleus has been removed, we
for IOL implantation because the manipulation through
then turn the chop element on our chopper horizontally
these incisions distorts them somewhat and they seal less

Section 1
and rotate the phacoemulsification needle to a bevel up
well if we enlarge them. For most IOLs we use a
position in order to mobilize the epinucleus. This has
2.7–2.8 mm wide incision that is 2 mm long. Some IOLs
previously been described.10 We rotate the epinucleus
require larger incisions and we use a trapezoidal knife,
with the phacotip in zero foot position, rather than with
the Rhein (Tampa, Florida) 3D diamond blade for all
the chop instrument in order to provide added safety.
of these incisions. After implantation of the IOL we
This is analogous to the way we rotated nuclear material
usually perform coaxial removal of viscoelastic in front
in the days of one-handed phacoemulsification with the
of and behind the IOL and then do stromal hydration
phacoemulsification tip in either foot position zero or
on both side-port incisions as well as the implantation
foot position one.10 After we trim and flip the epinucleus,
incision. We continue to test all incisions utilizing
we then will remove our instruments and bring a straight
fluorescein dye and pressure on the incision to document
irrigating handpiece through the left incision and an
that sealing has been achieved after stromal hydration
aspirating instrument through the right. We prefer the
and reconstitution of the anterior chamber with Miochol
MicroSurgical Technology (Redmond, Washington)
to bring the pupil down and allow for immediate clear
bimanual irrigation and aspiration instrumentation and
feel that it is extremely important that the port be highly
polished. (Fig. 13.13) We are aware that those made
by Mastel (Rapid City, South Dakota), Rhein Medical BIMANUAL MICROINCISION
(Tampa, Florida), ASICO (Westmont, Illinois), and PHACOEMULSIFICATION
Katena (Denville, New Jersey) all work very well. We The results of our bimanual compared to coaxial
usually use a 0.2 mm aspiration port because following phacoemulsification are seen in tables. (Tables 13.6 and
cortical cleaving hydrodissection, most of the cortex is 13.7). We see that in all instances they were the same.
removed and what is left are wispy strands which occlude There was no statistically significant difference in any of
a 0.2 mm aspiration tip much better than a 0.3 mm these results compared to coaxial phacoemulsification
aspiration tip. After polishing the posterior capsule with the possible exception of the STAAR wave system.
146 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

We believe bimanual microincision phaco-

Table 13.6: Comparison of outcome results bimanual vs
coaxial data. emulsification represents the future of cataract surgery
Percentage of eyes with clear corneas 2-24 hours post- and refractive lens exchange. We know there will soon
op. Chi-square analyses on all machines indicate no
be available small incision lenses that will go through
significant differences between coaxial and bimanual
phaco in percentage of patients with clear corneas. these microincisions and the full promise of increasingly
smaller incisions will be realized.
Machine Coaxial Bimanual
Results Results
Legacy with NeoSoniX 98% 100% REFERENCES
Millennium with phaco burst 100% 100%
STAAR sonic/ultrasonic wave 95% 100% 1. Shearing SP, Relyea RL, Loaiza A, Shearing RL. Routine
Sovereign with WhiteStar 100% 97% phacoemulsification through a one-millimeter non-sutured
p > 0.05 for all comparisons incision. Cataract 1985; 2(2):6–10.
2. Hara T, Hara T. Endocapsular phacoemulsification and
aspiration (ECPEA) – recent surgical technique and clinical
Table 13.7: Comparison of outcome results bimanual vs results. Ophthalmic Surgery 1989; 20(7):469–75.
coaxial data. 3. Agarwal A, Agarwal S, Agarwal A. No anesthesia cataract
Percentage of eyes with UCVA of 20/40 or better 2-24 surgery. In Agarwal S, et al (Ed). Phacoemulsification, Laser
hours postoperative Cataract Surgery, and Foldable IOLs. New Dehli, India,
Chi-Square analysis indicates that the STAAR sonic wave Jaypee Brothers 1998:144–54.
showed significant improvement in UCVA with bimanual 4. Tseunoka H, Shiba T, Takahashi Y. Feasibility of ultrasound
over coaxial phaco. cataract surgery with a 1.4 mm incision. J Cataract Refract
Section 1

All other analyses indicate no other significant Surg 2001; 27:934–40.

differences between coaxial and bimanual phaco in 5. Olson RJ. Microphaco chop. In Chang D (Ed): Phaco
percentage of patients with a UCVA of 20/40 or better. Chop: Mastering Techniques, Optimizing Technology, and
Avoiding Complications. Thorofare, NJ, SLACK Inc;
Machine Coaxial Results Bimanual 2004:227–37.
Results 6. Chang D. Bimanual phaco chop. In Chang D (Ed): Phaco
Legacy with NeoSoniX 96% 93% Chop: Mastering Techniques, Optimizing Technology, and
Millennium with phacoburst 100% 95% Avoiding Complications. Thorofare, NJ, SLACK Inc.;
STAAR sonic/ultrasonic wave* 74% 100% 2004:239–50.
sovereign with WhiteStar 94% 95% 7. Alio J. What does MICS require. In Alio J. MICS. Panama:
*p < 0.01 Highlights of Ophthalmology; 2004:1.
8. Fine IH, Hoffman RS, Packer M. Optimizing refractive lens
exchange with bimanual microincision phaco-
emulsification. J Cataract Refract Surg 2004; 30:550–4.
9. Fine IH, Packer M, Hoffman RS. Hydrodissection and
hydrodelineation. In Cataract Surgery: Technique,
This result may have been due to that we combined Complications and Management (2nd edn), R Steinert,
(Ed): IH Fine, HV Gimbel, DD Koch, RL Lindstrom, TF
within these techniques the use of both sonic and Neuhann, RH Osher, associate (Eds): Saunders,
ultrasonic depending on the density of the particular Philadelphia, PA, 2004.
portion of the nucleus on which we were working and 10. Fine IH, Packer M, Hoffman RS. Use of power modulations
in phacoemulsification: Choo-choo chop and flip
that combination seems to have advantages over either phacoemulsification. J Cataract Refract Surg February 2001;
the ultrasound or sonic system alone. 27: 2, 188–97.
Air Pump in Phakonit 147

Air Pump
14 in Phakonit
Amar Agarwal, Sunita Agarwal
Athiya Agarwal, Ashok Garg (India)


Section 1
Various methods have been used to combat surge during
phacoemulsification. We describe a simple device that
can be used with any phacoemulsification machine to
minimize surge during phacoemulsification. An
automated air pump is used to push air into the infusion
bottle thus increasing the pressure with which the fluid
flows into the eye. This increases the steady-state pressure
of the eye making the anterior chamber deep and well
maintained during the entire procedure. It makes
phakonit and phacoemulsification a relatively safe
procedure by reducing surge even at high vacuum levels.

Fig. 14.1: Diagrammatic representation of the connection

HISTORY of the air pump to the infusion bottle

The main problem in phakonit we had was the

destabilization of the anterior chamber during surgery. INTRODUCTION
We solved it to a certain extent by using an 18-gauge Since the introduction of phacoemulsification by
irrigating chopper. Then one of us (S.A.) suggested the Kelman,1 it has been undergoing revolutionary changes
use of an antichamber collapser, which injects air into the in an attempt to perfect the techniques of extracapsular
infusion bottle (Fig. 14.1). This pushes more fluid into cataract extraction surgery. Although advantageous
the eye through the irrigating chopper and also prevents in many aspects this technique is not without it’s attending
surge. Thus, we were able to use a 20 gauge or 21 gauge complications. A well maintained anterior chamber
irrigating chopper as well as solve the problem of without intraocular fluctuations is one of the prerequisites
destabilization of the anterior chamber during surgery. for safe phacoemulsification and phakonit.2
148 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

When an occluded fragment is held by high vacuum approximately 10 oscillations per second. The
and then abruptly aspirated, fluid rushes into the phaco- electromagnetic motor is weak enough to stop once the
tip to equilibrate the built up vacuum in the aspiration pressure in the closed system (i.e. the anterior chamber)
line, causing surge.3 This leads to shallowing or collapse reaches about 50 mmHg. The rubber cap ceases to
of the anterior chamber. expand at this pressure level. A micropore air filter is
Different machines employ a variety of methods to used between the air pump and the infusion bottle so
combat surge. These include usage of noncomplaint that the air pumped into the bottle is clean of particulate
tubing,4 small bore aspiration line tubing,4 microflow tips,4 matter.
aspiration bypass systems,4 dual linear foot pedal control4
and incorporation of sophisticated microprocessors4 to METHOD
sense the anterior chamber pressure fluctuations.
1. First of all, the BSS bottle is taken and put in the
The surgeon dependent variables to counteract surge
IV stand.
include good wound construction with minimal leakage,5
2. Now we take an air pump. This air pump is the same
and selection of appropriate machine parameters
air pump, which is used in fish tanks (aquariums)
depending on the stage of the surgery.5 An anterior
to give oxygen to the fishes. The air pump is plugged
chamber maintainer has also been described in literature
on to the electrical connection.
to prevent surge, but an extra side-port makes it an
3. An IV set now connects the air pump to the infusion
Section 1

inconvenient procedure.
bottle. The tubing passes from the air pump and the
We herein describe a simple and effective method
end of the tubing is passed into one of the infusion
to prevent anterior chamber collapse during
phacoemulsification and phakonit by increasing the
4. What happens now is that when the air pump is
velocity of the fluid inflow into the anterior chamber.
switched on, it pumps air into the infusion bottle.
This is achieved by an automated air pump which pumps
This air goes to the top of the bottle and because
atmospheric air through an air filter into the infusion
of the pressure, it pumps the fluid down with greater
bottle thereby preventing surge. We stumbled upon this
force. With this, the fluid now flows from the infusion
idea when we were operating cases with phakonit7 where
bottle to reach the phaco handpiece or irrigating
we wanted more fluid entering the eye, but now also
chopper. The amount of fluid now coming out of
use it in all our phaco cases.
the handpiece is much more than what would
normally come out and with more force (Figs 14.2
and 14.3)
A locally manufactured automated device, used in fish 5. An air filter is connected between the air pump and
tanks (aquariums) to supply oxygen, is utilized to the infusion bottle so that the air which is being
forcefully pump air into the irrigation bottle. This pump pumped into the bottle is sterile.
is easily available in aquarium shops. It has an 6. This extra-amount of fluid coming out compensates
electromagnetic motor which moves a lever attached to for the surge which would otherwise occur.
a collapsible rubber cap. There is an inlet with a valve,
which sucks in atmospheric air as the cap expands. On
collapsing, the valve closes and the air is pushed into
an intravenous (IV) line connected to the infusion bottle Before we enter the eye, we fill the eye with viscoelastic.
(Fig. 14.1). The lever vibrates at a frequency of Then once the tip of the phaco handpiece in phaco or
Air Pump in Phakonit 149
1. With the air pump, the posterior capsule is pushed
back and there is a deep anterior chamber.
2. The phenomenon of surge is neutralized. This
prevents the unnecessary posterior capsular rupture.
3. Striate keratitis postoperatively is reduced, as there
is a deep anterior chamber.
4. One can operate hard cataracts (Fig. 14.4) also quite
comfortably, as striate keratitis does not occur post-
5. The surgical time is shorter as one can emulsify the
nuclear pieces much faster as surge does not occur.
6. One can easily operate cases with the phakonit
technique as quite a lot of fluid now passes into the
Fig. 14.2: Flow of fluid through the irrigating chopper eye. Thus, the cataract can be removed through a
without an air pump smaller opening.
7. It is quite comfortable to do cases under topical or
no anesthesia.

Fig. 14.3: Flow of fluid through the irrigating chopper with an

air pump. Note when the air pump is on the amount of fluid
Section 1
coming out of the irrigating chopper is much more Fig. 14.4: Phakonit being performed in a mature brown
cataract. Such difficult cases can be operated upon by
phakonit because of the air pump. It deepens the chamber
irrigating chopper in phakonit is inside the anterior and prevents any surge
chamber we shift to continuous irrigation. This is very
helpful especially for surgeons who are starting phaco TOPICAL OR NO ANESTHESIA CATARACT
or phakonit. This way, the surgeon, never comes to SURGERY
position zero and the anterior chamber never collapses. When one operates under topical or no anesthesia, the
Even for excellent surgeons this helps a lot. main problem is sometimes the pressure is high especially
150 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

if the patient squeezes the eye. In such cases, the

posterior capsule comes up anteriorly and one can
produce a posterior capsular rupture. To solve this
problem, surgeons tend to work more anteriorly,
performing supracapsular phacoemulsification/phakonit.
The disadvantage of this is that striate keratitis tends to
With the air pump, this problem does not occur.
When we use the air pump, the posterior capsule is quite
back, as if we are operating a patient under a block.
In other words, there is a lot of space between the
posterior capsule and the cornea, preventing striate
keratitis and inadvertent posterior capsular rupture. If
one is operating on a patient with a small pupil (Fig.
14.5) and shallow anterior chamber once again one can Fig. 14.6: Iris hooks used to dilate the pupil
use iris hooks (Figs 14.6 and 14.7) to dilate the pupil
and then perform phakonit with the air pump on (Fig.
Section 1

14.8). This will help deepen the chamber and one can
complete the case. Such cases cannot be operated
comfortably without the air pump.

Fig. 14.7: Four iris hooks are in place. This way the pupil is
well dilated. It is better to do phakonit than phaco in such
cases as four areas have already been blocked by the iris
hooks. As there is little space left phakonit has an advantage.
But one should use the air pump as it makes life easier

handpiece tip is occluded, flow is interrupted and vacuum

Fig. 14.5: Miotic pupil
builds up to its preset values. Additionally the aspiration
tubing may collapse in the presence of high vacuum
DISCUSSION levels. Emulsification of the occluding fragment clears
Surge is defined as the volume of the fluid forced out the block and the fluid rushes into the aspiration line
of the eye into the aspiration line at the instant of to neutralize the pressure difference created between
occlusion break. When the phacoemulsification the positive pressure in the anterior chamber and the
Air Pump in Phakonit 151
by 10 mmHg for every 15 centimeters increase in bottle
height above the eye.5
High steady-state IOPs increase phaco safety by
raising the mean IOP level up and away from zero, i.e.
by delaying surge related anterior chamber collapse.2
Air pump increases the amount of fluid inflow thus
making the steady-state IOP high. This deepens the anterior
chamber, increasing the surgical space available for
maneuvering and thus prevents complications like posterior
capsular tears and corneal endothelial damage. The
phenomenon of surge is neutralized by rapid inflow of
fluid at the time of occlusion break. The recovery to steady-
state IOP is so prompt that no surge occurs and this
enables the surgeon to remain in foot position3 through
Fig. 14.8: Phakonit started. Note the irrigating chopper in the the occlusion break. High vacuum phacoemulsification/
left hand and a sleeveless phaco needle in the right hand phakonit can be safely performed in hard brown cataracts
using an air pump. Phacoemulsification or phakonit under
negative pressure in the aspiration tubing. In addition,

Section 1
topical or no anesthesia6,7 can be safely done neutralizing
if the aspiration line tubing is not reinforced to prevent the positive vitreous pressure occurring due to squeezing
collapse (tubing compliance), the tubing, constricted of the eyelids.
during occlusion, then expands on occlusion break.
These factors cause a rush of fluid from the anterior
chamber into the phaco probe. The fluid in the anterior
chamber is not replaced rapidly enough to prevent The air pump is a new device, which helps to prevent
shallowing of the anterior chamber. surge. This prevents posterior capsular rupture, helps
The maintenance of intraocular pressure (steady-state deepen the anterior chamber and makes phaco-
IOP)2 during the entire procedure depends on the emulsification and phakonit safe procedures even in hard
equilibrium between the fluid inflow and outflow. The cataracts.
steady state pressure level is the mean pressure
equilibrium between inflow and outflow volumes. In most KEY POINTS
phacoemulsification machines, fluid inflow is provided 1. The air pump is a simple and effective method to
by gravitational flow of the fluid from the balanced salt prevent anterior chamber collapse during
solution (BSS) bottle through the tubing to the anterior phacoemulsification and phakonit by increasing the
chamber. This is determined by the bottle height relative velocity of the fluid inflow into the anterior chamber.
to the patient’s eye, the diameter of the tubing and most 2. This is achieved by an automated air pump which
importantly by the outflow of fluid from the eye through pumps atmospheric air through an air filter into the
the aspiration tube and leakage from the wounds.2 infusion bottle thereby preventing surge.
The inflow volume can be increased by either 3. A micropore air filter is used between the air pump
increasing the bottle height or by enlarging the diameter and the infusion bottle so that the air pumped into
of the inflow tube. The intraocular pressure increases the bottle is clean of particulate matter.
152 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

4. Surge is defined as the volume of the fluid forced phacoemulsification systems. J Cataract Refract Surg
out of the eye into the aspiration line at the instant 3. Seibel SB. Phacodynamics. Thorofare, NJ, Slack Inc,
of occlusion break. 1995;54.
4. Fishkind WJ. The Phaco Machine : How and why it acts
5. The air pump is a new device, which helps to prevent
and reacts? In: Agarwal’s Four volume textbook of
surge. This prevents posterior capsular rupture, helps Ophthalmology. Jaypee Brothers: New Delhi; 2000. (In
deepen the anterior chamber and makes print).
5. Seibel SB. The fluidics and physics of phaco. In: Agarwal’s
phacoemulsification and phakonit safe procedures et al (Eds): Phacoemulsification, Laser Cataract Surgery and
even in hard cataracts. Foldable IOLs. Second edition. Jaypee Brothers: New
Delhi; 2000;45–54.
6. Agarwal et al. No anaesthesia cataract surgery with karate
REFERENCES chop; In: Agarwal’s et al (Eds): Phacoemulsification, Laser
Cataract Surgery and Foldable IOLs. Second Edition.
1. Kelman CD. Phacoemulsification and aspiration: a new Jaypee Brothers: New Delhi; 2000;217-26.
technique of cataract removal; a preliminary report. Am J 7. Agarwal et al. Phakonit and laser phakonit. In: Agarwal’s
Ophthalmol 1967;64:23–25. et al (Eds): Phacoemulsification, laser cataract surgery and
2. Wilbrandt RH. Comparative analysis of the fluidics of the foldable IOLs. Second Edition. Jaypee Brothers: New Delhi;
AMO Prestige, Alcon Legacy, and Storz Premiere 2000;204-16.
Section 1
Internal Forced Infusion for Phakonit 153

Internal Forced Infusion

15 for Phakonit

Arturo Pérez-Arteaga (Mexico)

INTRODUCTION of the millennium microsurgical system; nevertheless any

Section 1
phaco system that contains an air exit (air pump) for
As phakonit started, one of the main problems to solve
any purpose can be used to create IFI.
was to the amount of irrigation incoming into the eye.
The advantage of this technique is that the surgeon
As was described by Amar Agarwal, simply separating
has into the same machine all the parameters to perform
the infusion from the phaco probe was not enough to
phakonit (Amount of infusion, ultrasonic power
perform this technique because the amount of fluid
modulation and vacuum control), increasing with this
incoming the eye is less that with the sleeve in coaxial
the safety of the procedure and avoiding the creation
phacoemulsification; to solve this Sunita Agarwal
and use of an external air pump. The disadvantage is
described the use of an external air pump (External
that not all phaco machines contain an air pump (i.e.
Forced Infusion).
Legacy, Infinity, Universal…)
The first description of an air pump included two
bottles connected in a “Y” intersection and a transuretral
tubing instead the traditional intravenous set.1 Later the SURGICAL CONCEPTS
air tubing was connected into the drip chamber of the The traditional phakonit technique uses an irrigating
same intravenous tubing, making so simple the system chopper or cannula and a ultrasonic tip with the sleeve
and more reproducible by any surgeon. It was in this cut;2 unfortunately the amount of irrigation fluid that
point when the air pump of the same phaco machine goes trough the irrigating choppers is by far less in
was also used to create this forced infusion; so internal comparison to coaxial phacoemulsification.3 Sunita
forced infusion (IFI) was born. IFI is the use of the air Agarwal solved this problem by the use of an air pump.4
pumps included in the phacoemulsification surgical The purpose of this pump is to push more fluid into
systems as the source of air to create the forced infusion the eye; the air is generated by an external pump, so
for phakonit. the air fill the bottle of intraocular solution and so it
The air pump systems to create IFI described here actively pushes the fluid outside the bottle trough the
are the anterior vented gas forced infusion tubing of infusion line and so actively reaches the eye;5 it is the
the Accurus surgical system and the bottle infusion tool external forced infusion (EFI).
154 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

The advantages of this air pump system are: The advantages of the internal forced infusion over
• It actively pushes fluid into the eye so the system is the external are:
independent of gravity forces and/or bottle height. • The surgeon does not have to incorporate an external
• The amount of fluid controlled with the air force of air pump to the surgical system to obtain the
the air pump. advantages of the forced infusion. The creation of
• The amount of fluid that reaches the eye can have the irrigation force is inside the same machine.
varieties depending the irrigating chopper’s flow-rate • The surgeon can control all the parameters (forced
the surgeon is using, so it can be regulated. infusion rate, ultrasonic power modulations and
• The increase of fluid avoids surge and it’s surgical vacuum settings) in the panel of the same surgical
consequences. system (Fig. 15.1).
• The continuous maintenance of the anterior chamber • The forced infusion rate can be actively and digitally
allows the surgeon to free manipulate the instruments controlled during the surgery, adjusting so the
and tissues inside the eye, making easy the surgery. parameters to the conditions and/or the surgical steps
of the surgery.
• The positive pressure creates a tense zonnule and
so a firm capsular bag facilitating the chop maneuvers. • The surgeon increases the confidence to the surgical
system he or she is working with.
• The endothelium is pushed forward while the posterior
capsule is pushed back, protecting both structures.
Section 1

• The continuous irrigation outgoing through the

phaco-tip incision cools continuously the tip and the
cornea, decreasing the thermal burns.6 Mechanical of Fluidics in Phakonit
In the case of the IFI the surgeon uses the air pump As was described by Felipe Vejarano the amount of fluid
contained in the same phaco machine he is using.7,8 incoming to the eye must be superior to the outgoing

Fig. 15.1: Forced infusion through the irrigating chopper created with the millennium and the Accurus surgical systems
Internal Forced Infusion for Phakonit 155
one. If the surgeon follows this simple rule, surge will of the irrigation line and irrigation cannula, level above
never occur and the surgery will be safe. the sea where the surgeon is working (atmospheric
The amount of fluid incoming the eye is only pressure) and the amount of fluid remaining inside the
determined by the flow rate, it means the cubical bottle as the case consumes solution. We believe that
centimeters of water that can go by the infusion line in coaxial phacoemulsification, because of the sleeve and
through a specifically diameter of tubing and irrigating because the wound size, the factors that are influencing
chopper or cannula in a specifically period of time (cc. the passive infusion are inside a range of good
per minute). Unfortunately, the amount of outgoing fluid management and so not very important, but in phakonit,
is not so simple to measure, because it is dependent of with smaller irrigation diameters of the cannulas and the
more variables: cohoppers and because it is an almost closed system,
1. The vacuum and aspiration rate settings in the phaco the principle of increase the amount of irrigation to
machine. compensate the outgoing fluid, cannot be achieved only
2. The diameter of the phacotip and the aspirating with passive infusion, but as a counterpart, it is very easy
cannula. to reach with forced infusion.
3. The desired insensible lost of fluid: It means the
amount of fluid that goes outside the eye through Basic Principles to Create
the incisions during the procedure. Some filtration Internal Forced Infusion

Section 1
is desired to cool the cornea. The surgical equipments that contain an air pump are
4. The undesired insensible lost of fluid: It happens when those with the capability to perform both, anterior and
the incision size is larger than the needed for the posterior segment surgery. The air pump is included in
specifically irrigation and aspiration system, so more these systems for the fluid interchange in vitreoretinal
quantities of fluid (more than the desired) are lost surgery; it is used to pressurize the eye in posterior
trough one or both incisions. segment surgery. This air pump is the main element to
5. The use of some aspiration controllers.9 create IFI. The control of the air pump system is in the
6. The aspiration system used (ventury, peristaltic or
panel or in the digital controls of the phaco system, so
the surgeon can turn on/off the pump and increase or
At this time many manufacturers of choppers and
decrease the amount of desired air as the surgery starts
cannulas are understanding this issues and are doing
and is ongoing.
specifically knives for each handpiece, phacotips and
The elements to create IFI are as follows (Fig. 15.3):
irrigating and aspirating choppers or cannulas; they are
also taking care of the internal and external diameters 1. The air pump of the phaco system functioning.
of their irrigating and aspirating devices. But even with 2. The line to connect the air pump to the drip chamber
this important advances, we must remember that the of the irrigation administration set: This line is
amount of fluid that reaches the eye concerns only to provided by each manufacturer; in the end that is
the surgeon. connected to the air pump this line must have an
The passive infusion (not-forced) depends only of air filter (to be sure the air is clean) and in the another
the gravity force and many variables are influencing how end the adapter to the drip chamber. It is also possible
it works, like the material containing the solution (glass, to create this line if it is not available with the
plastic, rigid, solid), the possibility to increase the bottle manufacturer, only is needed to adapt the air filter
level (extension in the elevation arm, height of the OR to one compatible with the air pump of each phaco
roof), the amount of fluid inside the bottle, the diameter system (Figs 15.1 and 15.2).
156 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 15.2: Air pump exit and air filter at the start of the airline

3. The bottle of intraocular solution: To create always

a standard positive pressure my suggestion is to use
always a 500 cc glass bottle; the height of the bottle
Section 1

now is not important. Once the active column of air

has reach the drip chamber, the air will go over the
Fig. 15.3: Air tubing connected into the drip chamber of the
water inside the bottle creating so the positive pressure
irrigation administration set with a needle to avoid the
needed within the bottle; this is the reason why a creation of bubbles
plastic bottle or a bag containing the intraocular
solution are not a good option; if you have a material The AVGFI Tubing System of the
with low compliance like glass, you can be sure to Accurus Surgical System
obtain the desired pressure. The AVGFI from Alcon, The anterior vented gas forced infusion tubing of the
contains a needle to reach the air cushion over the accurus surgical system (AVGFI) is an air pump with a
water level, avoiding bubbles. regulator integrated inside the machine designed by the
4. The irrigation administration set: It will connect the Alcon engineers to pressurize the infusion line for anterior
pressurize bottle to the irrigating chopper or cannula, and posterior segment surgery. The main application,
but also is able to keep pressure inside, because it until now, has been in vitreoretinal surgery for the
has to go through a roller clamp (in some systems interchange between air and fluid and has not been too
outside and in others inside the cassette) that will be much used in anterior segment surgery, because the
controlled by the footswitch; so when the roller clamp passive infusion has been enough to perform a coaxial
is closed the pressure is keeping inside but when it phacoemulsification. But now in phakonit, for the users
is open by the foot of the surgeon the predetermined of this machine, the AVGFI system has found a precise
pressure is liberated and the forced infusion reaches application.
the eye. This system contains all the elements described to
5. The control panel: It will be different in each surgical create IFI and the surgeon can have them directly from
system but it is very easy to find if the surgeons knows the manufacturer. These elements are the filtered line
that it is the part of the system that controls the pre-connected to the drip chamber with a needle (to
amount of air outgoing the internal air pump. avoid bubbles) and the irrigation administration set that
Internal Forced Infusion for Phakonit 157
will be connected to the cassette (the Accurus system The adequate positive pressure for phakonit is at the
contains an internal clamp that is controlled by the range from 80 to 140 cm H2O; the variation will depend
surgeon trough the footswitch or via panel) (Fig. 15.4). upon the diameter of the irrigation line and the kind
of irrigating chopper in use, the behavior of the anterior
chamber during the procedure (factors influencing like
the incision size) and the above mentioned factors that
can decrease or increase the outgoing fluid. We start
with the preset in the Accurus system with 110 cm H2O
of positive pressure, 20 to 30 percent of ultrasonic power
and 180 mm Hg of vacuum for microtips (0.9) and 120
mm Hg for high rate tips (like angled Kelman); from
this point the surgeon can move up and down depending
the individual case; for irrigation/aspiration the forced
infusion remains the same and the vacuum can be at
400 mm Hg.

The Bottle Infusion Tool of the

Fig. 15.4: AVGFI of the Accurus ready

Section 1
Millennium Microsurgical System
This system is also an air pump integrated in the posterior
The control of the AVGFI system is in the digital panel
segment module of this surgical system. It was designed
and once it is on the display will show 65 cm H2O of
by the interchange air/fluid and the pressurize the eye
positive pressure as a basal measure. Now, the surgeon
during vitreoretinal surgery. Not all millenniums machines
can increase or decrease the desired pressure as needed;
contain this posterior segment surgery module, so the
also the surgeon can preset two different values of
surgeon must be sure it is integrated in the machine he
pressure at the footswitch and reach them easily any
or she is working with.
time during the surgery by a simple movement of the
The surgeon will obtain from Bausch and Lomb only
foot. The display can also be in mmHg if the surgeon
the air line ready to connect at the air filter by one side
wants to use this measure.
to the air pump module and by the other to the drip
chamber; it is not preconnected like the AVGFI system
and also has not a needle to go inside the bottle, so
the surgeon must have an independent irrigation
administration set to make this system work. The line
the is connected to the drip chamber, the drip chamber
of the irrigation administration set is connected to the
bottle and this irrigation administration set must go
through the roller clamp (this system uses an external
clamp) and so now the surgeon can control the forced
infusion with the footswitch. Finally the irrigating chopper
or cannula is connected to the end of the irrigation line.
The bottle infusion tool control is in the panel of the
Fig. 15.5: AVGFI control panel millennium system; the surgeon must press first Tools
158 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 15.6: Control of positive pressure in the Millennium´s panel

and then choose Bottle Infusion; when it is on the air 3. Connect a line with an air filter to the air pump and
will start to flow trough the air pump; the measure in the extreme to the drip chamber to the irrigation
Section 1

this machine is display in mm Hg. Our settings in the administration set (with or without needle).
Millennium are 80 mm Hg of positive pressure, 15 to 4. Connect the irrigation administration set to the 500
30 percent of phaco power and 130 to 150 mm Hg cc. glass bottle and pass the line trough the internal
of vacuum (the phacotip of the Millenniun is 1.1 mm).9 (in the cassette) or external clamp of the phaco
During the surgery the surgeon can increase or machine managed with the footswitch.
decrease the forced infusion according the case conditions 5. Start with a positive pressure between 70 to 90 mm
and instrumentation used. In this system the surgeon Hg or 100 to 120 cm H2O (according the machine
cannot program different positive pressures in the measures) and increase or decrease depending the
footswitch like in the Accurus machine, so each change case.
required during the surgery must be done in the panel.
6. If the surgeon does not want to have bubbles in the
Remember that in this system there is not rigid line
bottle an AVGFI system can be used; just look for
to connect the drip chamber with the bottom of the
a compatible air filter and switch it if needed.
bottle (needle), so bubbles within the solution are
The air incoming inside the bottle actively push the
common. If the surgeon does not want bubbles, a sterile
fluid into the eye at the desired pressure. As the irrigation
AVGFI system can be used and only the air filter must
be changed because is not compatible with the fluid is consuming, the air cushion inside the bottle is
Millennium´s air pump (see Fig. 15.2). increasing and the compliance inside the system is also
increasing, so a good recommendation for the surgeon
Internal Forced Infusion with Other Machines is to remember to change to a new bottle when
All phaco machines capable to perform phacoemusifi- approximately 150 cc of solution are remaining inside
cation and posterior vitrectomy, are good to develop it. This precaution has two reasons:
IFI for phakonit. The surgeon must follow this steps: • As the air column grows the capacity of response of
1. Find the air pump in the phaco system. the system becomes slow.
2. Find the tool to control the air pump at the panel • It avoids creating forced infusion of “air” inside the
(on/off and increase or decrease the fluid). eye when the bottle gets empty.
Internal Forced Infusion for Phakonit 159
Internal Forced Infusion in Vitreous Loss are aspirating is much better for control that get both
The management of the posterior capsule rupture with functions in one instrument managed with the same
or without vitreous loss is another important advantage hand as we were doing in coaxial phacoemulsification.
of the use of a bimanual technique. In traditional phacoemulsification the size of the
The variations in the forced infusion when it occurs wound and the use of one hand for both functions
are as follows: (irrigation and aspiration) decrease the effect of the water
1. If the hyaloids face remains intact and there is not loss trough the incision; it is not a total enclosed
vitreous loss, do not change the parameters of forced environment and so a passive infusion is enough.
infusion, because the force of the water will push In phakonit the environment is much more closed
away the entire vitreous body and vitrectomy will (even not by complete) and the maneuvers are
not be needed. If the surgeon has not forced infusion, performed with both hands; these two factors make this
surge can occur a then the damage to the hyaloids surgery to appear more as a posterior vitrectomy
face. surgery. This is why the mechanical of fluids in phakonit
2. If the surgeon is quite sure that vitreous loss is present is by far more demanding rather than in coaxial phaco,
then the forced infusion must be reduced at the and this is why a positive pressure is effective. Furthermore
control panel to 60 to 80 cm H2O. This is because the decrease amount of irrigation fluid in phakonit in
two reasons: comparison to a traditional sleeve phacoemulsification
• Excessive force of fluid will push the vitreous body

Section 1
and the behavior of the cornea tissue (where the incisions
away the vitreous cavity. are located) increase the need of this positive pressure.
• The aspiration rate during a vitrectomy is by far The advantage to have both hands in use and the
less that during phacoemulsification and irrigation/ irrigation and aspiration in separate lines increases the
aspiration, because the small diameter of the importance of forced infusion. The force of the water
vitrectomy handpiece. becomes a “third hand” for the surgeon inside the eye;
Never forget to change the position of the irrigating this water force can drive the tissues where the surgeon
cannula to a horizontal direction to avoid push more wants; the posterior capsule far away from the phacotip,
vitreous to the anterior chamber. Also never think to the endothelial cells far from the instruments, the nuclear
perform anterior vitrectomy with an anterior vitrectomy pieces to the phacotip, even a complete luxation of the
set (irrigation and aspiration in the same hand); always nucleus to iris plane can be done with the force of the
a posterior vitrectomy set must be use to obtain the water. Of course with forced infusion the spaces (anterior
advantages of bimanual surgery. and posterior chambers and capsular bag) increase in
amplitude and this is another advantage of bimanual
With this new phacoemulsification techniques the Perhaps many surgeons around the world are
surgeons understand new concepts in the mechanical performing phakonit without forced infusion, but I think
of fluids inside the eye. Too much we have learned from for all those reasons that the security margin is by far
the posterior vitrectomy system: it is an enclosed one, less.
with irrigation and aspiration and with small incisions; To create forced infusion as the reader surgeon can
the retinal surgeons are able to pressurized the eye in see is very easy and it is not a real increase the cost of
order to avoid bleeding, attach the retina and even the surgery. It is a measure of safety for the surgeon
produce intentional ischemia. Also we have learned from and for the patients. It do not cause damage at the
them that to irrigate since another port from which we endothelial cells, posterior capsule or the zonnula if the
160 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

surgeon remains at the recommended values. Each 2. Agarwal A. Agarwal A. et al. Phakonit: Lens removal trough
a 0.9 mm incision. J Cataract Refract Surg. 2001;27:1531-
phaco machine has an own measure of the positive 32.
pressure; just remember that 100 cm H2O are equivalent 3. Agarwal A. Agarwal S. Agarwal A. Phakonit and laser
to 76 mmHg depending the scale your machine uses. phakonit: lens removal trough a 0.9 mm incision.
Phacoemulsification, laser cataract surgery and foldable
In some cases the surgeon can work with the phaco IOL´s. New Delhi, India: Jaypee; 2000; 204-16.
machine that really wants; but it is not always so, and 4. Tsuneoka H. Shiba T.Feasibility of ultrasound cataract
daily, all around the world, many surgeons are working surgery trough a 1.4 mm incision. Journal Cataract and
Refractive Surgery, 2001; 27, 934-40.
only with the machine they can have. It is not true that 5. Agarwal, Amar. Bimanual 0.9 mm approach to phaco
there is a specifically machine to perform phakonit (as promises astigmatic neutral cataract surgery and faster
has been demonstrated by Amar Agarwal); any machine rehabilitation. Eurotimes, February 2003.
6. Alió, Jorge. MICS ready to go. Ocular Surgery News, March,
can be useful to perform this technique. Also there is 2003.
not any special machine to create IFI for phakonit; any 7. Pérez-Arteaga, Arturo. Accurus Forced Infusión good for
machine with air pump can be used. So I strongly believe MICS. Ocular Surgery News, 6/15/03.
8. Pérez-Arteaga, Ar turo. Bottle Infusión Tool of the
that if your phaco machine has not an air pump, then Millennium Surgical System for Phakonit. Ocular Surgery
you have to create one (External Forced Infusion); but News; 09/15/03.
if you have a machine that has air pump, then you have 9. Pérez-Arteaga, Arturo. Anterior vented gas forced infusion
of the accurus surgical system for phakonit. J Cataract
to use it. Refract Surg. April 2004.
10. Chang, David. High vacuum bimanual phaco attainable
Section 1

with STAAR Cruise control. Ocular Surgery News, 8/1/03.

REFERENCES 11. Prakash D. P. Cutting phaco sleeve permits ultra-small
1. Agarwal A. Agarwal A. et al. Phakonit phacoemulsification incision surgery. Ocular Surgery News, June, 2003.
trough a 0.9 mm corneal incision. J Cataract Refract. Surg. 12. Agarwal A. et. al. Bimanual Phaco. Mastering the Phakonit/
2001;27:1548-52. MICS Technique. SLACK Inc. New Jersey, 2004.
Phakodynamics of Microincision Phako 161

Phakodynamics of
16 Microincision Phako

Dipan Desai (India)

INTRODUCTION different types and grades of cataracts. All these factors

are highly dependent on one another and will not yield

Section 1
Phakoemulsification, in order to be performed well,
requires a good understanding of fluid mechanics as results individually. They are deeply intertwined and each
well as of the ultrasonics of the machine. With the advent has to be adjusted in context with the others. A true
of micro-phako, the learning curve has become even understanding of this will help in the logical setting of
steeper. Basically the dynamics of phako in both the machine parameters in adaptation to different surgical
conventional and micro phako remain the same. In techniques. Even the most modern feature-rich machine
micro-phako irrigation is through the side-port rather will not give adequate results as compared to an older
than through the irrigation sleeve. With this one of the machine if the principles of phakodynamics are not
major problems encountered is that not enough fluid adhered to.
is going into the eye through the side-port irrigating Microincision phako has been well accepted because
chopper. In conventional phako the silicon sleeve delivers of several advantages over conventional phako. Some
up to 80 to 90 cc./minute of fluid into the eye, whereas of the obvious advantages are decreased incision size,
the best irrigating choppers cannot deliver more than improved surgical control, more physiological phako-
45 cc./minute. Keeping this basic fact in mind, one has dynamics, good anterior chamber maintenance, less
to work around it in terms of surgical maneuvers, fluid astigmatism, reduced risk of endophthalmitis and faster
management, ultrasonics and type and grade of cataract. visual rehabilitation. Because irrigation is separated from
In order to achieve best surgical results and patient aspiration the added advantage is that all the fluid comes
outcomes, it is essential to understand the basic principles in through one incision and exits through the other. The
of phakodynamics. This is even more relevant to micro- irrigation fluid in conventional phako has a tendency
phako and is mandatory for the evolution of this to push the fragments away from the aspiration tip,
technique. Phakodynamics is defined as the study of whereas the incoming stream of fluid in micro phako
the fundamental principles of flow rate, vacuum, phako assists in mobilising lens fragments to the phako tip
power modulations (machine parameters), along with without inducing competing currents around it. This is
individual micro surgical maneuvers in context to a definite advantage over conventional phako.
162 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

Phakodynamics of micro-phako can be discussed was inability to control the pressure of the fluid
under three main headings: entering the eye along with extremely high intra-
1. Fluidics. ocular pressure. An additional concern was
2. Phako power modulations. contamination. This system still works satisfactorily
3. Surge prevention. and Dr Agarwal has been using it since 1998.
2. Bottle height extenders: The irrigation pole, which
FLUIDICS normally has a maximum height of thirty inches, is
extended by an additional twelve inches.
Fluidics is of paramount importance in the performance
3. Use of additional anterior chamber maintainer: The
of modern day phako, and especially so for microincision
author has used this method since 1998 and has
phako. An understanding of fluidics is mandatory for
named it “Three Port Phakectomy”. Here a third port
the normal evolution of the technique of microincision
is made to allow an anterior chamber maintainer to
phako. Intra and extracapsular cataract extraction were
be introduced. A 22 guage irrigating chopper is used
open chamber methods. Here fluidics was not of such
along with it. The author has obtained very satisfactory
importance. Phakoemulsification is a closed chamber
method, whereas in microincision phako the chamber results with this technique. A capsulorhexis can be
is, so to speak, closed even more efficiently. In such a performed without viscoelastics. Details of this
closed chamber, one must monitor the inflow (irrigation) technique and CD are available in the chapter on
Section 1

and the outflow (aspiration). These are the two main Three Port Phakectomy in this book.
components of fluidics. 4. Desai’s pressurized bottle: The author has devised
this simple method and has been using it to great
Irrigation advantage since 1999. Fifty cc. of air is drawn
In conventional phako nearly 80 to 85 cc/minute of fluid through a millipore 5 micron filter into a 50 cc.
is delivered into the anterior chamber through the syringe. This air is then injected through a 20G airway
irrigating silicon sleeve. In microincision phako, hardly needle into a one liter bottle of BSS or Ringer’s lactate
40 to 45 cc/minute of fluid can be delivered through solution, remembering to remove the airway needle
the irrigating choppers. One of the major hurdles is surge, after injection. Now one has a pressurized bottle which
and this is mainly due to insufficient fluid being delivered allows approximately 85 cc/minute of fluid to enter
into the anterior chamber. In conventional phako, the eye. This pressurized flow is necessary only during
irrigation is gravity fed and governed by the height of nucleus removal with the phako tip. During cortex
the bottle. This is not enough for micro-incision phako, removal with I/A tip less flow is required. Hence the
so other methods must be adopted to provide more 20 G airway needle should be re-inserted into the
fluid in the anterior chamber. bottle at this stage to allow the bottle to be gravity
fed rather than pressurized. Once the needle is
Methods to Increase Irrigation inserted, fluid will come out through it until it reaches
Through the Irrigating Chopper equilibrium. The bottle will now start working as a
1. Adding a fish pond pump: Dr. Amar Agarwal, who regular gravity fed bottle. The surgeon can
pioneered and popularized the technique, used a individualise the amount of filtered air to be injected
simple fish pond pump to infuse air into the BSS depending on his technique and the procedure.
bottle. This caused the fluid to gush out and Depending on the surge one can vary the amount
prevented surges. The main concern with this system of air injected from 25 to 75 cc.
Phakodynamics of Microincision Phako 163
5. Mechanized pressurized infusion: Provided by and aids chopping. For efficient chopping, occlusion and
combination anterior-posterior machines such as the thus high vacuum, are mandatory for fixation of the
Accurus (Alcon) and Millennium (Bausch & Lomb) nuclear piece so that it can eventually be divided further.
are very effective. The basic principle in modern-day phako should be
6. Pressurized plastic bottle using BP cuff: Here a normal to eliminate or use minimal ultrasound. This can be done
sphygmomanometer cuff is wrapped around a plastic with a mastery over fluidics so that the stability of the
BSS bottle and is inflated in order to achieve desired anterior chamber is maintained with high flow and
pressure. vacuum. However, in micro-phako, the same principle
cannot be applied; otherwise surge is guaranteed. Here
the flow rate and vacuum have to be toned down and
Flow rate and vacuum are the two main parameters the whole surgical procedure should be carried out at
that govern the outflow (aspiration). These are governed a slower pace. This allows enough fluid to enter the
by pumps in the machine. There are basically two types anterior chamber.
of pumps:
Desai’s Leak Phenomenon: An interesting phenomenon
Flow pumps: These can be either peristaltic or Concentrix has been observed and studied by the author. Each time
systems. Here the flow rate, as well as the vacuum, can the phako tip is buzzed, fluid leaks out through the incision
be individually regulated. The flow rate is adjusted in and practically a fine spray can be observed. We carried

Section 1
cc/minute and the vacuum does not build up until there
out a study on eye bank human eyes using the Sovereign
is an occlusion in the tip. Thus in flow pumps the flow
phako machine. It was found that there was a leak of
rate is commanded, whereas the vacuum varies with
5.75 ml. through the incision when the machine was
the degree of tip occlusion up to the preset vacuum limit.
set at flow rate of 20cc/minute, vacuum of 180 mmHg.
Vacuum pumps: Examples of these are the venturi, and 40 percent continuous power was used for 1 minute.
diaphragmatic and rotary vane pumps. Here the flow The collection in the drainage bag was 18 ml. Hence
rate cannot be commanded and is dependent on the each time the phako tip is buzzed, about 24 percent
set vacuum. Hence, these pumps do not have flow rate of the total outflow from the eye is through the primary
depicted on their display panel. The amount of vacuum incision. This has never before been taken into
governs a factory-set flow rate. These pumps have a consideration as being one of the causes of instability
rigid drainage cassette between the aspiration line and of the anterior chamber. When the phako tip is vibrating
the machine (unlike a drainage pouch employed with it is emulsifying and aspirating the nuclear pieces with
flow pumps). BSS fluid. Simultaneously fluid is leaking out through
Flow Rate is defined as the volume of fluid per unit the incision. This compounded effect causes unwanted
time, i.e. cubic centimeters or milliliters per minute, that instability of the anterior chamber and surges.
exits the anterior chamber through the phako/aspiration
tip. Flow rate governs the speed of the procedure. The
flow rate is what draws the nuclear pieces towards the
tip so that they can be removed – and so it should be Phako power modulations have brought about a change
set first in the machine. Vacuum is measured in millimeters in phakoemulsification techniques and show great
of mercury (mmHg). Vacuum is what grips the nuclear promise for the future of the surgery. The earlier
material which is occluding the phako tip. This grip allows machines had only continuous power, then came linear
ultrasound energy to emulsify the lens more efficiently continuous power, pulse mode, burst mode and finally
164 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

WhiteStar (hyperpulse / micropulse technology). We are phako power is always on, while in conventional pulse
aware that using the least amount of ultrasonic energy it is always 50 percent. The use of pulse mode is
leads to least endothelial damage and minimizes corneal particularly helpful in decreasing chatter as the interval
burns. The issue of wound burns was the first concern of rest period allows the fluidics to build up and the heat
of the surgeon while performing sleeveless phako. to dissipate. This allows more followability and swifter
Studies by Donnenfeld and Olsen have found that with emulsification. Less rather than more pulses per second
WhiteStar, the maximum temperature of the wound should be used. In micro-phako the author recommends
ranged between 27.4 and 34 degrees centigrade. To using three pulses per second.
cause corneal burns, the minimum temperature required Burst mode: It can be set as single or multiple bursts.
is 42 degrees centigrade. Thus, it is difficult to cause Here the duty cycle can be modulated. The surgeon
corneal burns with WhiteStar technology. Hence, it is can independently set the on and off times. The on times
considered to be “cold phako” technology. However, are all equal in power and length of time. The burst
with machines not using hyperpulse technology, the mode can be set from 30 to 500 milliseconds depending
temperature of the wound can rise above 42 degrees on different machines. The off time in single burst is
centigrade and cause corneal burns. To prevent this, the controlled by the surgeon (by pressing foot switch position
author has devised the Desai’s Insulated Phako Tip. This three again). In multi-burst they will be repeated at set
is described in detail in another chapter in this book. intervals by keeping foot switch position three pressed.
Section 1

There are two opposing forces in phako. Flow rate Burst mode is particularly helpful for hard, brunescent
and vacuum are the attracting forces, whereas ultrasound cataracts, making the initial vertical chop and while
energy is the repelling force. This repelling force is known impaling nuclear fragments. It uses much less ultrasound
as chatter. In micro-phako, chatter is advanced and this energy (USP & UST), in any grade of cataract, than the
is mainly due to the low flow rate and vacuum that is pulse mode.
inherent to the technique.
WhiteStar technology (Sonolase/hyperpulse/micropulse):
Different Power Modulations Here energy is delivered in extremely brief microsecond
bursts, interrupted by rest periods. The burst and rest
Continuous mode: Here power is continuously applied
period lengths are independently variable. This allows
with no “off” periods. The delicate ocular tissues are
one to shorten the pulse duration and increase the rest
saturated with low-level energy and resonant waves.
period, i.e. to precisely vary the duty cycle. On a
Pulse mode: Here ultrasound is delivered for a short 50 percent duty cycle (on time = off time), being able
period (“on” time), followed by a rest period when it to shorten the on pulse to 6 milliseconds permits a higher
is automatically shut off (“off” period). The on and off rate of 80 pulses per second. WhiteStar allows one to
periods are of equal duration. Each “on/off’ period vary the duty cycle by lengthening or shortening the
comprises a pulse. For instance, with a setting of 100 rest periods. For example, following a 6 millisecond
milliseconds long on pulse, each cycle of on/off pulse phako pulse with a 12 millisecond rest period creates
is thus 200 milliseconds, and this relates to 5 pulses per a 33 percent duty cycle giving 55 pulses per second.
second. (200 msec × 5 = 1 sec.). The frequency of The combination of these features provides three distinct
the pulses can be changed by shortening the duration clinical benefits: First, brief microsecond pulses allow for
of each on pulse, resulting in more pulses per second. lower ultrasound energy delivery. Secondly, the increased
Duty cycle = On time / on+off time. Thus in off times decrease heat build-up on the vibrating phako
continuous mode duty cycle is 100 percent because the tip, thus preventing corneal burns. Finally both the above
Phakodynamics of Microincision Phako 165
factors reduce the repelling forces thereby enhancing 2. Surgeon slows down the surgery i.e. uses shorter
the followability and reducing turbulence of nuclear bursts of ultrasound energy in foot switch position
particles at the tip. Thus if one can understand the three and allows fluid build-up. The surgeon should
advantages of pulse over continuous mode, these not attempt to purchase the nuclear fragment at one
advantages are multiplied many times over with time but should vary from foot switch position three
WhiteStar technology. Despite using less energy, full to one so that fluid builds up and surge is prevented.
ultrasound cutting ability is retained. It is particularly useful 3. Low compliance tubing: A tube with more elasticity
for brunescent cataracts, because of its cutting ability, (high compliance) will collapse when vacuum is built
better followability and less chatter. up. Thus the set machine parameters of vacuum and
Thus in micro-phako it is not advisable to use flow rate will not be delivered in the eye. To avoid
continuous power as it is used for sculpting in this a tube with low compliance should be used.
conventional phako. Shorter and multiple throws of 4. Smaller diameter tubings and phako tips: Flared
continuous power should be used to prevent heat build- phako tips and micro-flow 20 G. phako tips have
up and surge. The pulse mode should be set at three an internal bore of 0.7 mm. as compared to 0.9 mm.
to four pulses per second. The burst mode uses less in the normal tips. This restricts the flow and thus
energy than the pulse mode and should be used more prevents surges. The flared tip has a 19 G. opening
often. WhiteStar technology (Cold phako) has added for better grip with a 20 G. shaft for controlling surge.
a new impetus and life to the survival and success of

Section 1
This tip is not particularly helpful for micro-incision
micro-incision phako. The finely modulated pulses of phako. Here the 20 G. micro-flow tips score over
energy interrupted by extremely brief, variable cooling all others.
periods enables this technology to increase cutting 5. ABS tip (Alcon): This has a small bore in the side
efficiency and followability while directing less energy of the phako tip shaft, which allows the irrigation fluid
and chatter to the eye. to be sucked into the shaft, thus preventing a surge.
The ultimate goal in micro-phako is to remove the This cannot be used in micro-phako.
nucleus without creating a hot phako tip, i.e. Cold phako. 6. Modern-day pumps: have micro-processor based
Besides WhiteStar, the other methods of Cold phako fluidics control technology. For example, the Intellesis
are Laser phako, Phakotemesis, Vortex emulsification pump of the Sovereign machine has six inputs of
(Avantix, Bausch & Lomb), Fluid pulse systems different parameters. These are fed 50 times a second
(Aqualase) and NeoSoniX (Alcon). to the heart of the pump in order to make
adjustments in the fluidics. The fluid coupled pressure
SURGE PREVENTION sensor has a magnetic rod which is sensitive enough
Surge or anterior chamber instability is one of the biggest to measure 250 mm. of mercury on excursion of
impediments to the success and further development one mm. This helps recognize occlusions and flow,
of micro-phako. Surge occurs because there is not and directs the pump to prevent surges.
enough fluid going into the eye through the irrigating 7. Cruise control: It is a disposable flow restrictor that
chopper and various strategies have been devised to can be attached between the phako handpiece and
circumvent this problem. the aspiration tubing. It can be used for conventional
and microincision phako. It has a flow restrictor of
Surge Reduction Strategies internal diameter 0.3 mm. which is placed behind
1. Infusion can be increased and flow rate and vacuum
166 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

a mesh filter that traps all the nuclear emulsified Suggested machine parameters for Microphako
material. This prevents the narrow 0.3 mm. lumen
Irrigation Flow Rate Vacuum Energy
from getting clogged. This reduces surge, allowing Height (cc/mt) (mmHg) (Power set
the use of a regular phako tip (maintaining the (inches) according to
type and
holding power). It also allows the use of higher flow grade of
rates (26 cc/minute) and vacuums (400 mmHg) as cataract
Sculpting 30 + 12 14 30 Continuous /
one would use with coaxial phako. At 400 mmHg Micropulse
of vacuum on occlusion breaks, momentary surges Direct Chop 42 30 400 Burst/
can reach between 200 and 300 cc/minute. This Impaling Nucleus 42 20 150-200 Pulse/Burst/
device has practically no effect of surge on regular Epinucleus/last 24 20 50 Pulse/Burst/
aspiration flow rates below 50 cc/minute, making it quadrant Micropulse
Irrigation/Aspiration 24 36 450 linear
an extremely useful tool in microincision phako.
Section 1

Fig. 16.1: Insulated bent phako tip Fig. 16.3: 20G irrigating chopper with front opening and
two side holes – used in Three Port Phakectomy

Fig. 16.2: 20G disposable needle bent at tip to act as a Fig. 16.4: 20G irrigating chopper with front opening and
sharp irrigating chopper—as used by author four side holes; as developed by author
Phakodynamics of Microincision Phako 167

Fig. 16.5: 19G front opening MST (Duet)

irrigating chopper
Fig. 16.7: Vacuum surge suppressor

In summary, factors such as machine parameters,

surgical techniques, instruments and surge are greatly
intertwined and interdependent. Hence, it cannot be
emphasized enough that a proper understanding of the

Section 1
machine and the logical setting of its parameters in
accordance with the steps of surgery and type of cataract
is essential for optimizing efficiency and safety. The
backbone of present and future of phakoemulsification
is power modulation and fluidics.

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phacoemulsification through a 0.9 mm corneal incision.
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J Cataract Refract Surg. 2002;28:1085–86.
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emulsification using the burst mode. J Cataract Refract Surg
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Refract Surg 2004;30.
6. Chang DF. Can cold phaco work for brunescent nuclei?
Cataract and Refractive Surgery Today 2001;1:20–23.
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20000 1.1 mm Turbosonics and 0.9 mm MicroTip.
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8. Davison JA. Performance comparison of the Alcon Legacy
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168 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)
9. Donnenfeld ED, Olson RJ, Solomon R, et al. Efficacy 15. Krey HF. Ultrasonic turbulences at the phacoemulsification
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technologies. J Cataract Refract Surg 2002;28:1054–60. 17. Olson RJ, Kumar R White Star technology. Curr Opin
11. Fine IH, Packer M, Hoffman RS. Use of power modulations Ophthalmol 2003;14:20–23.
in phacoemulsification. Choo-choo chop and flip 18. Soscia W, Howard JG, Olson RJ. Bimanual phacoemulsi-
phacoemulsification. J Cataract Refract Surg 2001;27:188– fication through 2 stab incisions. A wound-temperature
97. study. J Cataract Refract Surg 2002;28:1039–43.
12. Hayashi K, Hayashi H, Nakao F, Hayashi F. Risk factors 19. Soscia W, Howard JG,Olson RJ. Microphacoemulsification
for corneal endothelial injury during phacoemulsification. with WhiteStar. A wound-temperature study. J Cataract
J Cataract Refract Surg 1996;22:1079-84. Refract Surg 2002;28:1044–46.
13. Hoffman RS. Fine IH, Packer M, Brown LK. Comparison 20. Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic
of sonic and ultrasonic phacoemulsification using the phacoemulsification using a 1.4 mm incision: clinical
STAAR Sonic Wave system. J Cataract Refract Surg results. J Cataract Refract Surg 2002;28:81–86.
2002;28:1581–84. 21. Wilbrandt HR.Comparative analysis of the fluidics of the
14. Huetz WW, Eckhardt HB. Photolysis using the Dodick-ARC AMO Prestige, Alcon Legacy, and Storz Premiere
laser system for cataract surgery. J Cataract Refract Surg phacoemulsification systems. J Cataract Refract Surg
2001;27:208–212. 1997;23:766–80.
Section 1
Fluidics in Phakonit 169

Fluidics in Phakonit
L Felipe Vejarano
Alberto Vejarano
Alejandro Tello (Colombia)

INTRODUCTION • The amount of leakage through the incisions,

Section 1
determined by the relation between the outer
When performing bimanual microincision phaco-
diameter of the instruments (phaco needle and
emulsification—phakonit-surgery, knowledge and
irrigating chopper) and the incisions architecture
management of fluidics are crucial. The issue of
(shape, size and presence of an inner valve).
destabilization of the anterior chamber during the
• The amount of fluid aspirated through the phaco
procedure, mentioned by several authors, like
needle, determined by the resistance of the aspirating
Tsuneoka,1 is due basically to the fact that more fluid
line (determined by the inner diameter of tubing,
is going out of the eye than the amount that is entering
needle and tubing compliance) and the level of
onto the anterior chamber in a given moment. Although
vacuum in venturi pumps and the level of flow and
smaller-incision surgery promotes a more tightly closed
vacuum in peristaltic pumps.
and stable anterior chamber, the equilibrium between
It is necessary to maintain equilibrium between these
inflow and outflow rates is critical. This has been a
factors, in order to achieve a stable anterior chamber,
problem for surgeons initiating phakonit, since the
without jeopardizing the intraocular tissues (iris,
irrigation rate in this technique is usually less than in
endothelium, posterior capsule).
standard phacoemulsification. The factors that influence
the fluid balance in bimanual microincision
phacoemulsification are several:
• The infusion rate of the irrigating instruments. This
is determined by the fluidic resistance of the irrigating Increasing Inflow
line and instruments (determined by the inner Of the three parameters mentioned at the beginning of
diameter of tubing and instruments – chopper - and the chapter, the infusion rate and the amount of fluid
the irrigating port size) and the pressure of the fluid aspirated through the phaco needle (determined by
(bottle height, or amount of positive pressure applied bottle height, or amount of positive pressure applied to
to the bottle by any active system). the bottle by any active system, and vacuum/flow levels,
170 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

respectively, and both influenced by the resistance of Maintainer) will increase the inflow, but will not increase
the lines and instruments) may be changed easily during the IOP in a significant amount.
the procedure, and should be increased and decreased, Other option to warrant enough inflow is to use active
respectively, when a surgeon first notices modest chamber pressurized systems. Agarwal published an ingenious
shallowing immediately following occlusion breaks. system (the “antichamber collapser”) using an aquarium
Although for phacoemulsification, conventional gravity pump to generate a power fluid infusion, placing a
feed has been the standard, it is not always the best micropore air filter between the air pump and the infusion
option in microincision surgery unless you can increase bottle. Moreover, he uses two BSS bottles connected
it significantly, which is restricted by the ceiling height via a Y-shaped transurethral resection tubing set (TUR).
of the surgical room; 1” of bottle height above patient The TUR tubing has an internal diameter of 4.5 mm,
head is equivalent to 1.3 mm Hg of positive pressure it allows more fluid flow from the bottles than the
applied into the bottle by an active system, or 1.8 cm standard intravenous irrigation sets (inner diameter 2.5
of bottle height above the patient head is equivalent to mm).3,4 This system could be a good an easy option when
1 mm Hg of positive pressure. there is not available an active infusion system in the
Although we think that it is not indispensable, during phacoemulsification machine. A drawback of the system
the transition to Phakonit a surgeon may resort to an is that it is difficult to adjust it to different levels of inflow;
additional source of BSS, in order to guarantee a steady Apasamy Inc. (India) is working in an external pump
Section 1

anterior chamber. Blumenthal has shown that using an with measurements like internal pumps in the venturi
anterior chamber maintainer during standard machines.
phacoemulsification reduces both the amplitude and This kind of forced infusion is available in several
frequency of the anterior chamber depth fluctuation.2 phacoemulsification machines. Storz Premiere unit does
This may be not so critical in standard phaco, but may have a pressurized inflow system (IOP control), that
be helpful for the surgeon beginning Phakonit. However, injects air to the infusion bottle, and setting it at a level
the disadvantage of using an Anterior Chamber of 80 mm Hg we were able to achieve the infusion rate
Maintainer is the necessity of a third incision, and the of 47 cc/min and at 100 mm Hg we get 55 cc/min
increased turbulence, but it may make the procedure through the Vejarano’s Irrigating Chopper (AC7340,
very safe for the beginning phakonit surgeon, not only Accutome, Malvern, USA), using it along with standard
because it prevents surge, but also because it can maintain IV sets. An advantage of this kind of devices is that it
the anterior chamber depth in the case that the surgeon can be adjusted, increasing or decreasing the air pressure,
mistakenly retracts too much the irrigating chopper, losing and thus increasing or decreasing the inflow rate. In some
inflow. instances this pressurized inflow may be raised up to its
Care must be taken with the direction of the tip of maximum (100 mm Hg). The Accurus® machine (Alcon,
the Anterior Chamber Maintainer, because if it is directed Fort Worth., USA) has also a digitally controlled infusion
too posterior it could touch the iris or the capsule (causing system for instant access to elevated pressures via the
a variable degree of trauma), and could be cumbersome foot switch, utilizing the Anterior Vented Gas Forced
for the surgeon. Maybe the best way to place the Anterior Infusion Tubing (AVGFI®), it can reach the level of 120
Chamber Maintainer is like Blumenthal describes, using mm Hg.
a 1.5 mm corneal tunnel, parallel to the limbus. The The Vejarano’s Irrigating Chopper ® (Fig. 17.1)
usage of two BSS bottles (one connected to the irrigating (AC7340, Accutome, Malvern, USA), designed by one
chopper, and the other to the Anterior Chamber of us (LFV), has a 20 gauge (0.9 mm) outer diameter,
Fluidics in Phakonit 171

Fig. 17.2: Tsuneoka Chopper

Fig. 17.1: Vejarano’s Irrigating Chopper

with 0.5 mm dual sideports. As stated before, we can

obtain an irrigation rate of 47 to 55 cc/min, using
pressurized inflow and 47 cc/min using gravity with the

Section 1
bottle height set at 150 cm. Since in our cases of
phakonit, with this instrument, average time spent in
the real phacoemulsification of the nucleus (without taking
in account the previous and posterior surgical steps) is
5 min 21 sec, we consume an average volume of fluid
of 202 cc (range 167–258 cc). Fig. 17.3: Turbo Chopper
Similarly, Tsuneoka have reported that with his special
irrigation chopper (Fig. 17.2) (also 20 gauge outer anterior chamber during the procedure is less, it is
diameter, but 0.75 mm inner diameter), and elevating necessary to keep in mind that the more fluid entering
the bottle to 110 cm, he achieves a flow volume of 50 the anterior chamber, the more turbulence, and hence
cc/min.1, 5 Prakash initially reported a higher infusion rate trauma. For this reason it is desirable to minimize as much
of 90 cc/min,6 but recently he informed us that new as possible the amount of fluid going into the eye, and
measurements of his instrument yielded a flow rate of in order to maintain equilibrium it is also necessary to
48 cc/min (Fig. 17.3) (DP Prakash, personal communica- diminish to a minimum the leakage through incisions
tion). Agarwal mentions an irrigation rate of 160 cc/min (but taking into account that through the main incision
using the antichamber collapser along with the it is necessary certain amount of leakage for cooling)
transurethral resection tubing set.4 We have found that and the amount aspirated through the phaco needle.
in our technique, an irrigation rate of 47 to 55 cc/min,
Decreasing Outflow
using the Vejarano´s Irrigating Chopper® (AC7340,
Accutome, Malvern, USA), assures a very steady anterior Controlling BSS Leaking Through Incisions
chamber throughout the procedure. We think that using Ideally the side port incision, used to enter the irrigation
these not too high infusion rates is another advantage chopper, must be as watertight as possible when the
of this instrument, since although there is no doubt that instrument is in position, without compromising its
increasing the irrigation flow, the possibility of a shallow maneuverability, that’s why we highly recommend a
172 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

trapezoidal shape side port incision, because in Phakonit blade (Natural Clear Cornea Vejarano’s Microincision
this is the instrument that makes most of the movement Knife. AK6018 Accutome, Malvern, USA) (Figure: Main
necessary to emulsify the nucleus. incision 1,5 mm knife) (Fig. 17.5), but if we are planning
We have found that performing a 0.9/1.2 mm (inner/ to use the Microtip from any manufacturer that has 0.9
outer size) side port incision let us to use the Vejarano’s mm of outer diameter and 0.66 mm of inner diameter
Irrigating Chopper® (AC7340, Accutome, Malvern,USA), (approximately 20 gauge), we utilize 1.2 mm lancet or
which has 0.9 mm outer diameter, with almost no the same trapezoidal diamond knife (0.9/1.2 mm)
leakage and very good maneuverability. To achieve a (Accutome, Malvern,USA) than in the side port incision,
good architecture we use a 0.9/1.2 mm diamond knife to avoid additional expenses.
(Accutome, Malvern,USA) (Fig. 17.4) to perform the According to the gauges of the Irrigating instrument
side port incision, but an alternative is to use 20 gauge and the Phaco needle that you use, you can determine
vitreoretinal blades or 1.2/1.4 mm steel blades the proper size of your incisions, in order to avoid excess
(MicroSurgical Technology -MST, Redmond, USA). of outflow and instability of anterior chamber, calculating
We think that it is not indispensable that the main the circumference length of the instrument, using the
incision has a trapezoidal shape because in Phakonit, formula 2 πr, where r means radius of the instrument
the phaco needle does not move considerably, just back in mm; but since each lip of the incision covers a half,
and forth. Moreover in the wider (1.5 mm) incision a not the whole length of the instrument’s circumference
Section 1

trapezoidal shape could lead to excessive leakage. is necessary, you have to divide the result by two.
The incision length is contingent on the needle Moreover, the cornea is an elastic tissue and so you have
diameter. For instance, inserting standard Phaco needle to take in account the tissue compliance that we have
with 1.12 mm of outer diameter and 0.91 mm of inner calculated in approximately 13 percent. Thus the final
diameter or the Microflow ® (Bausch and Lomb, formula to decide upon the right length of the incision
Reference DP8230), 1.07 mm outer diameter needle is:
and also 0.9 mm of inner diameter (both approximately
[2 πr/2] – 13 percent, that is to say: πr × 0.87.
19 gauge), through this incision, allows a small amount
of leakage, in latest case influenced also by the presence As an example, if you are going to use a 20 gauge
of the grooves along the tip, and this warrants that the (0.9 mm diameter) irrigating chopper, your side port
cornea won’t be burned. When performing the main incision length must be:
incision for those needles we use a 1.5 mm diamond [π × 0.45 mm] = 1.413 mm × 0.87 = 1.22 mm

Fig. 17.4: Trapezoidal side port Incision Fig. 17.5: Main incision 1.5 mm knife
Fluidics in Phakonit 173
If you perform a bigger side port incision you will Table 17.1: List of Equivalences (diameter)
get excessive leakage, and if you perform it smaller you Gauges Inches Milimeters
will have problems with maneuverability and risk of 12 0.1046 2.6568
14 0.0747 1.8974
tearing the incision, affecting its water tightness.
16 0.0598 1.5189
If you are going to use a 1.07 mm outer diameter 18 0.0478 1.2141
needle, the calculation for the main incision will be as 19 0.0418 1.0617
20 0.0359 0.9119
follows: 21 0.0280 0.7110
22 0.0299 0.7595
[π × 0.535 mm] = 1.68 mm × 0.87 = 1.46 mm
24 0.0239 0.6071
If you perform a bigger main incision you will get 26 0.0179 0.4547
28 0.0149 0.3785
excessive leakage, and if you perform a smaller one you
will have problems with maneuverability and risk of
corneal burning. necessary to use standard flow levels (25 to 30 cc/min)
and vacuum levels (250 to 300 mm Hg), and in venturi
Controlling the Amount of Fluid Aspirated through machines a level of vacuum of 120 to 160 mm Hg. In
the Phaco Needle this setting, when occluding the phaco tip, the nuclear
In Phakonit you have to try to forget the high vacuum fragment will cause the aspiration line’s vacuum to build
levels that you’re use to, because the inflow that you up. In the moment that the occlusion is broken, and

Section 1
can get through any irrigating chopper never will be like the fragments are rapidly aspirated, the fluid in the
the one that you can get through the coaxial irrigation anterior chamber (which has reached a high pressure
in standard Phacoemulsification, as you can see below while the occlusion lasted) tends to rush into the
at the end of the chapter, so you must to change and aspiration line through the phaco tip, and the
adapt your parameters depending of the irrigating phenomena of surge may occur. This situation is even
chopper that you are going to use, for example, if it more critical in phakonit cases, since the irrigation rate
has frontal irrigation you have to reduce your parameters is always lower than in standard phacoemulsification.
to 63 percent, if it has inferior irrigation to 58 percent Surge control may be managed using several approaches
and if it has lateral irrigation to 45 percent. and strategies that will be discussed below.
Also you have to modulate your aspiration flow
avoiding surpassing levels above 25 to 30 cc/min, and Machines
use the software of your Phaco machine with bimodal Some machines have additional features designed to
aspiration or linear aspiration, this reduces the rise time diminish the possibility of surge. The Amo Prestige
and makes more controllable the events inside of the (Allergan, Irvine, Calif., USA) decreases its pump speed
anterior chamber. as the actual vacuum approaches the maximum vacuum
preset.7 The microprocessor controls a process making
Surge Control to programmed rise time. Through a feed-back system,
Since the goal of the surgery is not solely to maintain pump speed regulation is related to the prevailing
the anterior chamber space, but to permit the vacuum. Deflection of a flow-sensitive diaphragm on the
emulsification of the nucleus, it is necessary to use levels aspiration side is translated into voltage, which decreases
of vacuum that allow to achieve a good enough purchase the pump speed when 50 percent of the targeted vacuum
of the nucleus and its fragments, and perform an effective has been reached.8 When the pressure transducer senses
chopping procedure.. In peristaltic machines it is an occlusion break, the pump speed is increased again
174 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

over a short time rather than abruptly in order to occurs in the presence of a lower vacuum or flow so
minimize the amount of vacuum which needs that surge is minimized. Separating simultaneous linear
equilibration by venting.7 The Sovereign (Allergan, Irvine, control of vacuum and ultrasound into two planes of
Calif., USA) merges the advanced high vacuum fluidics pedal movement (pitch and yaw), with linear control
of the AMO Prestige unit (Allergan, Irvine, Calif., USA) of vacuum in phaco mode, the surgeon can approach
with the burst and occlusion mode programmability of material with safer lower vacuum levels and increase it
the AMO Diplomax (Allergan, Irvine, Calif., USA). The only after desired material is positively engaged. Most
Sovereign has an on-board fluidic computer that allows vacuum pumps do not allow attenuation of rapid rise
the pump to rotate forward and backward, which helps times, although the Storz Millennium and Premiere
surgeons to control the release of vacuum. machines are exceptions. 7 These pumps allow the
Microprocessors sample vacuum and flow parameters surgeon to set a time delay for full commanded vacuum
50 times a second, create a “virtual” anterior chamber buildup which starts when the surgeon enters foot pedal
model. At the moment of surge, the machine’s computer position.2 However, once this delay has elapsed, any
senses the increase in flow and instantaneously slows or subsequent engagement of material will be exposed to
reverses the pump to stop surge production. The a typically rapid vacuum pump rise time.
machine has several settings for pre- and post-occlusion,
four phaco modes and four memory modes. Phaco Needles
Section 1

For its part the Series 20000 Legacy with the new Changes in phaco needle designs, to make them safer
software Advantec and Everest (Alcon, Fort Worth., and more effective, have been developed as other
USA) has a pump system called TurboStaltic™ pump alternatives to avoid or minimize surge. The standard
that is a very smooth system, having a floating head so 19-gauge phaco needle has an outer diameter of 1.12
there are no pulsations as the pump speed and vacuum mm and an inner diameter of 0.91 mm. It has a good
build-up takes place. It has non-compliant fluidic channels holding power due to its large surface area, especially
to allow for higher vacuum with fewer pulsations. The if beveled. However when the occlusion is broken, there
tubing in the cassette (MaxVac™) has been replaced with is possibility of surge, since the inner diameter is larger,
rigid plastic fluidic channels that are totally non-compliant. to diminish this problem the Microtip 20-gauge was
It has the option of smaller aspiration tubing lumen, which designed, with 0.9 mm of outer diameter and 0.66 mm
providing increased fluidic resistance reduces total flow of inner diameter. The MicroFlow® tip (Bausch and
from the eye; that tubing has a thicker wall to reduce Lomb, Claremont, Calif., USA) designed by Barrett 9
the compliance, and these features help to obtunds surge, has an outer diameter of 1.07 mm (similar to a standard
even using high vacuum. We have found that this phaco needle), and although it has also an inner diameter
machine has a very good control of the surge of 0.9 mm at the end of the tip (again, similar to a
phenomenon. standard phaco needle), it has a smaller shaft inner
The Storz Millennium® and Premiere® (Bausch and diameter (0.5 mm). This tip has a good holding force,
Lomb, Claremont, Calif., USA) also achieve low system but unlike a standard 1.12 phaco needle, it provides
compliance via the use of lower compliance tubing.7 a fluidic resistance due to its smaller shaft inner diameter,
Moreover using the Millennium® the dual linear foot avoiding sudden increment in flow levels, after breaking
pedal can be programmed to separate both the flow the occlusion, when emulsifying fragments.7 It reduces
and vacuum from power. In this way, flow or vacuum this flow by about 40 percent. Other advantage of this
can be lowered before beginning the emulsification of design is that, due to its large diameter just at the tip,
an occluding fragment. The emulsification, therefore, more volume of nuclear material can be engaged and
Fluidics in Phakonit 175
aspirated per unit of time, requiring less ultrasound power in the tip diameter and vacuum level. This will cause
application relative to microtip needles, which are dampening of the surge on occlusion break. The ABS®
effective preventing surge, but are less effective port remains inactive as long as the main port is not
emulsifying the nuclear material. Moreover since the occluded. This system is used in the Legacy system in
MicroFlow® design has an internal ring surface within its Turbosonics™ ABS ® phaco tips (Alcon, For t
the tip, perpendicular to the long axis of the needle and Worth.USA).
therefore to the direction of the movement of the tip
while applying ultrasonic energy, produces additional Tubing
cavitation.7 It is possible, however, that after emulsifying In order to avoid surge, manufacturers have resort to
some lens material, and when returning to position 2 other approaches related with tubing. Since the amount
in the foot pedal, the emulsified material plugs the shaft, of fluid that surges into the aspiration port is a function
which is only 0.5 mm in diameter, and aspiration may of the device’s compliance, any fluid circuit component
become compromised. When the surgeon notes that which was changed in volume by the high vacuum needs
situation, it is necessary to apply a small amount of equilibration, for instance decreased tubing volume.7 If
ultrasound energy to the aqueous, even though the the tubing becomes constricted during the occlusion, it
material to emulsify is not evident at the end of the tip, then expands on occlusion break, and this expansion
just to make the tip vibrate, and solve the obstruction. is an additional source of vacuum production. This fluid

Section 1
Our experience using the MicroFlow® have been very may not be replaced rapidly enough by infusion to
good in regard to surge control. prevent shallowing of the anterior chamber. Thus having
Other tip designs using a similar principle are the flared tubes reinforced to prevent collapse, with minimal
tips, like the MicroSeal®. There are two kinds of those, compliance, will help to avert surge.
the Standard tip and Microtip, the outer diameter at the Of course they should still allow an ergonomic
tip are 1.32 and 1.02 mm and inner diameter are 1.07 manipulation of the tubing/handpiece, as well as (in
and 0.82 mm respectively; the difference is that this needle peristaltic pumps) allow the adequate functioning of the
has a smaller outer shaft diameter (0.76 mm) and a pump mechanism.7
larger inner shaft diameter (0.57 mm) than the Some manufacturers have designed other especial
MicroFlow ®. They work in a similar way, but for tubing system to diminish the flow, coiled tubing join
microincision the disparity between the outer diameter to the aspiration cassette that can help to slow the flow
at the end of the tip (1.32 or 1.02 mm) and the outer in the aspiration line, thus keeping the anterior chamber
shaft diameter (0.76 mm) may cause an excessive deep and stable. The outflow exiting from the eye is
leakage through the incision, because to introduce the slowed by the resistance of the curvature of each
tip you need a bigger incision than if you would introduce concentric spiral in the tubing. Staar (Monrovia, CA.,
only the shaft (disparity of 1.8/1.0 mm in standard and USA) uses this system (UltraVac V1®), other similar system
1.4/1.0 mm in microtip). of coiled tubing have been developed by Surgin (Tustin,
Other approaches to the issue of surge has been to CA, USA).
design a bypass port on the side of the phaco tip
(Aspiration Bypass System – ABS®).The ABS® tips have Devices at the Aspiration Line
0.175 to 0.230 mm (depending if it is the microtip or Other options to obtund surge include devices designed
standard tip) holes drilled in the shaft of the needle. to be placed in the way of the aspiration line. One of
During occlusion, the hole provides for a continuous these is the Vacuum Surge Suppresser - VSS (Surgin
alternate fluid flow, yielding a 4 to 15 cc/min, depending Inc., Tustin, Cal., USA) (Fig. 17.6). It is incorporated
176 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

We have experience using the Vacuum Surge

Suppresser - VSS ((Surgin Inc., Tustin, Cal., USA) and
the Cruise Control® (Staar, Monrovia, CA., USA) and
have found both of them to be useful to maintain an
anterior chamber even more stable.
Of course it is possible to combine any anti-surge
system with any tip, as an additional tool to the
capabilities of the machine and the surgeon’s skills.

Fig. 17.6: Vacuum surge suppresser

in the aspiration line and adjacent to the handpiece, and There are many kinds of irrigating choppers but the key
regulates fluid outflow of the eye. As vacuum increases, feature is whence they irrigate, so there are really only
VSS constricts its soft chamber, thereby limiting sudden four types of irrigating choppers:
outflow of a large amount of fluid and maintaining a - Frontal
deep and stable anterior chamber. - Inferior
Cruise Control ® is a device developed by Staar - Lateral
(Monrovia, CA., USA) (Fig. 17.7) as a filter between - Mixed (Frontal-Lateral)
Section 1

the phaco handpiece and aspiration tubing that captures We will analyze specific examples of each category:
nuclear material. The principle is the same: to reduce
FRONTAL (20 gauge)
flow through its 0.3 mm lumen. It easily attaches to
aspiration port on the phaco handpiece, and is • Advantages Good Inflow
compatible with peristaltic or venturi phaco machines. Good Gauge
It has a cylindrical filter mesh that retains all cataract Good Size of the Side Port Incision
material coming from the phaco handpiece. Only clear Disadvantages High Turbulence
fluid flows into the aspiration line. Occlusions and Flow pushes fragments away from the phaco needle
stagnation in the tubing are eliminated. Cruise Control More Tissue Trauma
limits the flow in a non-linear manner such that only Introduction technically difficult
excessive flows are limited. Regular flow rates, below 50
INFERIOR (18 gauge)
cc/min are not affected. Cruise Control works regardless
• Advantages The best Liquid Circulation in the A.C.
of the size and configuration of phaco tips or tubing,
• Disadvantages Lowest Inflow in relation with its
and may be more forgiving with bottle height.
Big Gauge to Improve Inflow
Big Side port Incision
Excessive Turbulence
Introduction technically difficult

LATERAL (20 gauge)

• Advantages Enough Inflow, provides 60-67
percent of Frontal and 65-73 percent
Fig. 17.7: Cruise control of Inferior
Fluidics in Phakonit 177
Good Gauge Table 17.2: Standard phaco with sleeve inflow
Good Size of the Side Port Incision Gravity Pressurized
Minimal Turbulence 1 m 1.3 m 80 mmHg 100 mmHg

Good Liquid Circulation in the AC. 80 cc/min 103 cc/min 114 cc/min 142 cc/min

Allows currents to direct nuclear

fragments to the phaco tip.
• Disadvantages In Very High Vacuum levels insufficient
Table 17.3: Choppers inflow. Frontal irrigation (cc/min)
Inflow (you don’t have to use them). 20 (Figures: Tsuneoka, Olson, Olson II and Nagahara
MIXED (FRONTAL-LATERAL) (20 gauge) Gravity Pressurised
1 m 1.3 m 80 mmHg 100 mmHg
• Advantages Good Inflow Tsuneoka 48 60% 62 60.2% 81 71% 88 62%
Good Gauge Olson 48 60% 60 58.2% 78 68.4% 80 56.3%
Olson II 55 68.7% 62 60.2% 76 66.6% 81 57%
Good Size of the Side Port Incision Naghara 53 66.2% 60 58.2% 78 68.4% 84 59.1%
If you have anterior Occlusion, the Note: percentage is related to standard Phaco inflow.
Lateral Ports avoid Collapse
• Disadvantages To Much Turbulence
Flow pushes fragments away from the

Section 1
phaco needle
More Tissue Trauma
We measured the flow rate of the 20 g, Vejarano´s
Irrigating Chopper ® (AC7340, Accutome, Malvern,
USA), using gravity (at different heights) and using the
IOP-pressurized inflow- in the Storz Premiere (at different
levels of pressure). It is evident the wide difference
between the two systems. It is crucial to keep this in mind
when using this kind of instruments, since the inflow rate
Tsuneoka Chopper
is lower than using the irrigation sleeve around the phaco
tip. Using BSS bottle height of 1 m the irrigating chopper
achieves a flow rate of 31 cc/min, while the phaco needle
with the irrigating sleeve on, achieves 80 cc/min. To
achieve an inflow rate of 47 cc/min with the irrigating
chopper (reached using the IOP pressurized system at
80 mm Hg) bottle height must be set at 150 cm above
of the patient head, which in some surgical rooms may
not be possible. In this situation it is necessary to use
pressurized inflow. We also took measurements of the
best known irrigating choppers of the market, and
compared one to another and with the standard Phaco
tip with standard sleeve. Olson Chopper
178 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

Table 17.5: Lateral irrigation (cc/min) 20 G

(Figures: Braga-male and Vejarano’s choppers)
Gravity Pressurised

1 m 1.3 m 80 mmHg 100 mmHg

Braga-Mele 38 47.5% 52 50.5% 62 54.3% 68 47.9%
Vejarano 31 38.7% 41 39.8% 47 41.2% 55 38.7%
Note: percentage is related to standard Phaco inflow.

Olson II Chopper
Section 1

Braga-male Chopper

Nagahara Chopper

Table 17.4: Inferior irrigation (cc/min) 18 G

(Figure: Alio chopper)
Gravity Pressurised
1 m 1.3 m 80 mmHg 100 mmHg
ALIO 40 50% 64 62.1% 72 63.1% 84 59.1%

Note: percentage is related to standard Phaco inflow.

Vejarano’s Chopper

Table 17.6: Mixed (Frontal-lateral)

irrigation (cc/min) 20 G
(Figure: Turbo chopper)
Gravity Pressurised
1m 1.3m 80 mmHg 100 mmHg
Turbo 36 45% 48 46.6% 60 52.6% 65 45.8%

Note: percentage is related to standard Phaco inflow.

Alio chopper
Fluidics in Phakonit 179

Turbo Chopper

CONCLUSION Safe chop 1

In conclusion, the standardize chop technique (Safe
Chop) (Figs Safe chop 17.1 to17. 7) and fluidics balance

Section 1
when performing phakonit is critical. The goal is to create
a steady state within the anterior chamber. To reach that
goal the surgeon must take in account several issues:
infusion rate of the irrigating instruments, amount of
leakage through the incisions, and amount of fluid
aspirated through the phaco needle. We have found
very good stability of the anterior chamber using a 0.9
mm outer diameter irrigating chopper (Vejarano’s
Irrigating Chopper®, AC7340,Accutome, Malvern,USA)
Safe chop 2
through trapezoidal 0.9/1.2 mm side port, with a snug
and almost watertight fitting. When using the Storz
Premiere machine and the MicroFlow® phaco needle,
1.07 mm diameter through 1.5 mm incision we use the
pressurized inflow (IOP control in the Storz Premiere
system) at a level de 80 to 100 mm Hg.; when using
the Legacy Advantec with Everest software machine with
the Microtip phaco needle 0.9 mm diameter through
1.2 mm incision, we use bottle height set at 160 cm.
We think that these combinations yield a very good
balance of fluids, maintaining a very stable anterior
chamber, without causing that an excessive amount of
Safe chop 3
fluid enters the eye, which could cause more turbulence
and trauma. We advise that the surgeon change his amount approximately equivalent to the percentage of
parameters from standard phaco (vacuum) to an the inflow, according with the irrigating chopper used
180 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

Safe chop 4 Safe chop 7

of microincision, we think that every cataract surgeon

who wants to keep himself updated should be ready
for the transition.
Section 1

1. Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic
phacoemulsification using a 1.4 mm incision: clinical
results. J Cataract Refract Surg 2002; 28:81-86.
2. Blumenthal M, Assia E. Using an anterior chamber
maintainer to control intraocular pressure during
phacoemulsification. J Cataract Refract Surg 1994; 20: 93-
Safe chop 5 96.
3. Agarwal A, Agarwal S, Agarwal A. Antichamber collapser
(letter). J Cataract Refract Surg 2002;28:1085.
4. Agarwal S, Chaudhry R, Chaudhry S. Bomba Anticolapso
de Cámara. In: Fako, Fakonity Fako con láser. Highlights
of Ophthalmology International, Panamá, 2002.
5. Tsuneoka H, Takuya S, Takahashi Y. Feasibility of
ultrasound cataract surgery with a 1.4 mm incision. J
Cataract Refract Surg 2001;27:934-40.
6. D.P. Prakash, MD. “Cutting phaco sleeve permits ultrasmall-
incision surgery: Using a cut sleeve without irrigation
eliminates water splashing and improves visibility during
surgery”. Ocular Surgery News Europe/Asia-Pacific
edition 6/1/03.
7. Seibel B.S. Phacodynamics: Mastering the tools and
techniques of Phacoemulsification Surgery. Third Edition.
Slack Inc. Thorofare, USA. 1999.
8. Wilbrandt H. Comparative analysis of the fluidics of the
Safe chop 6 AMO Prestige, Alcon, Fort Worth.USA, Fort Worth.USA
Legacy, and Storz Premiere phacoemulsification system. J
(as explained above). This will allow a safe and smooth Cataract Refract Surg 1997;23:766-80.
procedure. 9. Barrett, G.D. Improved fluid dynamics during
phacoemulsification with a new (MicroFlow) needle
Since the trend of cataract surgery all over the world design, ASCRS Symposium on Cataract, IOL and
in the future undoubtedly will be toward the direction Refractive Surgery, Washington, USA, 1996
Anterior Capsule Staining During Microphaco 183

Anterior Capsule
18 Staining During
Suresh K Pandey (Australia)
Liliana Werner
David J Apple (USA)

Section 2
INTRODUCTION dye with a viscoelastic solution may also be used for
better anterior capsule staining, and for limiting contact
During the past few years there has been enormous
with adjacent ocular tissues.
interest in the use of vital dyes to enhance visualization
Cataract surgeons agree that an anterior capsulorhexis
during various steps of anterior and posterior segment
should be the goal of every opening of the anterior
ophthalmic surgical procedures. Use of nontoxic
ophthalmic dyes for anterior capsule staining in advanced, capsule. Circular continuous capsulorhexis (CCC) has
white cataracts allows performance of a safe and gained widespread popularity because it offers
successful anterior capsulorhexis. Both indocyanine green unquestionable advantages over other capsulotomy
(0.5%) and trypan blue (0.1%) provide excellent techniques.1 Because of complications such as intraocular
visualization and currently preferred over fluorescein- lens (IOL) asymmetrical fixation, decentration, or pea
sodium (2%) dye. Trypan blue has the advantage of podding of the IOL haptics associated with the envelope
being less costly when compared to indocyanine green. or the can-opener capsulotomy techniques, CCC is
Staining of the anterior capsule can be done under an preferred in phacoemulsification (PE) or planned
air bubble or by spreading the dye under the viscoelastic extracapsular cataract extraction.2
solution or by mixing the dye with viscoelastic to limit
the contact with adjacent ocular tissues. Viscoelastic
solutions can be used to visco-seal the incision site in
order to avoid escape of the air bubble, and to minimize
any anterior chamber fluctuations. Anterior capsule In today’s clinical practice, white, mature and
staining under high molecular weight viscoelastic solution hypermature cataracts are still commonly seen, especially
may be helpful for intumescent and hypermature cataract in the developing world (Figs 18.1A to D). It is difficult
patients presenting with high intralenticular pressure and to perform a CCC in the presence of mature cataracts
a fragile anterior lens capsule. Alternatively, mixing the because the red reflex, which aids the visualization of
184 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

Section 2

Figs 18.1A to D: Photographs showing different examples of white cataracts. A to C. Anterior (surgeon’s) view
(Courtesy: Abhay R. Vasavada, MD, Ahmedabad, India). D. Miyake-Apple posterior view.

the actual tearing process, is absent. With poor visibility, Dye-assisted Anterior Capsulorhexis
errant capsular tearing is very common and difficult to Dyes, such as fluorescein sodium and indocyanine green
control, thus jeopardizing in-the-bag IOL implantation. (ICG), have a long history of safety in humans. There
It may also lead to serious complication. The accepted have been an increasing number of reports of enhanced
recommendations to aid CCC in such cases are: dimming visualization by staining intraocular tissues during cataract
the operating room lights, increasing the operating surgery and vitreoretinal surgery with the use of nontoxic
microscope magnification and coaxial illumination, and capsular dyes, such as fluorescein sodium, ICG, and
using high-density viscoelastics. The use of air, diathermy, trypan blue.5-18 Staining of ocular tissues by using these
endoilluminator, vitrectome, scissors, and the two-stage aforementioned ophthalmic dyes makes visual
CCC approach have also been suggested.3,4 differentiation and manipulation of tissues easier.
Anterior Capsule Staining During Microphaco 185
Enhanced viewing of the ocular tissues can promote a disadvantages of each dye (Table 18.1). Staining of or
surgeon’s ability to evaluate clinical structural relationships damage to the corneal endothelium and anterior
and may help attain surgical objectives with fewer chamber structures is a major concern. ICG and trypan
complications. blue selectively stain dead corneal endothelial cells.
We have extensively studied the use of nontoxic Because the endothelial cells are alive in human cataract
ophthalmic dyes (fluorescein sodium, ICG and trypan surgery, ICG and trypan blue neither stain these cells
blue) to enhance visualization of various intraocular tissues nor obstruct the surgeon’s view. Fluorescein sodium can
while performing various critical steps of the modern stain the cornea and also migrate to the vitreous cavity
phacoemulsification procedure (Pandey SK, Werner L, because of its smaller molecular weight (376 d). We were
Escobar-Gomez M, Apple DJ. Anterior capsule staining able to demonstrate the leakage of fluorescein sodium
in advanced cataracts: A laboratory study using post- into the vitreous cavity using the Miyake-Apple posterior
mortem human eyes; presented at the joint meeting of video/photographic technique (Figs 18.2A to C).5,6 In
American Academy of Ophthalmology, Orlando, Florida, the study of Horiguchi et al,17 fluorescein sodium could
October 1999; Pandey SK, Werner L, Apple DJ, et al. not be removed from the vitreous cavity by an irrigation-
Dye-enhanced cataract surgery in human eyes obtained aspiration system.
postmortem: A laboratory study to learn critical steps Cost is another major factor when considering use
of phacoemulsification: XVIIth Congress of the European of an ophthalmic dye. Reconstituted ICG dye is only

Section 2
Society of Cataract and Refractive Surgery, second prize: good for 10 hours and is expensive (approximately US
“Scientific Category,” Vienna, Austria, September 1999, $ 90.00 for 25 mg ICG). It is preferable to schedule
Pandey SK, Werner L, Apple DJ, Chang DF, Osher RH, several patients with absent or poor red reflexes on the
et al. Dye-enhanced ophthalmic surgery: experimental same surgery day and use only a single bottle of ICG
studies and clinical applications; presented at the joint (which contradicts operation theater guidelines in many
meeting of American Academy of Ophthalmology, countries). Commercially marketed intraocular solutions
Anaheim, Florida, November 2003).5-13 In this text, we of trypan blue is currently in the process for FDA
will address the use of nontoxic ophthalmic dyes for approval and therefore are not currently available in
anterior capsule staining in white/advanced mature the United States.18,19 However, there are well known
cataracts. pharmacies that will prepare trypan blue for use in the
Staining of the anterior capsule with ophthalmic dyes United States. Prices of trypan blue available from
is a useful adjunct for performing continuous circular pharmacies in the United States will vary significantly,
capsulorhexis (CCC) in cases of advanced/white cataract. but averages US $20.00 for a single use vial.
Fluorescein sodium was the first dye advocated for this Internationally, trypan blue 0.1% solution (ready to be
use.14-16 ICG and trypan blue were further recommended used) for capsular staining is manufactured by DORC
for this purpose. 17,18 There are advantages and International b.v. (Vn Zuidland, Holland) under the trade

Table 18.1: Characteristics of the three dyes used for anterior capsule staining
Dye Concentration Advantages Disadvantages
Fluorescein sodium 2% Blue light enhancement Low molecular weight
can be used Vitreous leakage
Staining of the cornea
Indocyanine green 0.50% High molecular weight Cost may be prohibitive
No vitreous leakage
Trypan blue 0.10% High molecular weight Not indicated in pregnant/fertile
No vitreous leakage females and children
186 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

name of VisionBlue®, as proposed by Melles.18 Trypan

blue is less expensive than ICG,19 and to the best of our
knowledge, the cost of a 1 mL ampule of trypan blue
(VisionBlue®, is approximately US $ 15, compared to
the US $ 90.00 cost of 1 ampule of 25 mg ICG powder.
We would like to emphasize care when performing
anterior capsule staining in vitrectomized patients during
cataract surgery. Inadvertent staining of the posterior lens
capsule may occur secondary to diffusion of dye into
the vitreous cavity, thereby obscuring the red reflex.20
A However, the trypan blue molecule is large and under
normal circumstances does not appear to cross the intact
zonula ciliaris (cilary zonules). It is likely that an intact
anterior hyaloid face would prevent bulk flow of dye
into the vitreous cavity. The surgeon should avoid using
any ophthalmic dyes in cataract surgery combined with
implantation of hydrophilic acrylic lenses having a high
Section 2

water content (>70%), as this can lead to permanent

staining (discoloration) of the IOL by some ophthalmic
dyes.21 This discoloration may become associated with
a decrease or alteration in the best-corrected visual acuity,
B and eventually require IOL explantation/exchange. We
have recently analyzed 2 Acqua™ hydrophilic acrylic
lenses (Mediphacos, Belo Horizonte, MG, Brazil)
explanted secondary to bluish discoloration after use of
trypan blue dye. This was confirmed in a postmortem
human eye implanted with Acqua™ lens after the
capsular bag was stained using 0.1% trypanblue dye
(Fig. 18.3).21

Figs 18.2A to C: Miyake-Apple posterior view of a human
eye obtained post-mortem showing the progressive leakage
of fluorescein sodium into the vitreous cavity after intracameral
subcapsular injection. Note that the intensity of the leakage
increases as time progresses.
A. Five minutes after intracameral subcapsular injection.
B. Same globe, 15 minutes after intracameral subcapsular
injection. Fig. 18.3: Gross photograph taken from the explanted Acqua™
C. Same globe, 2 hours after intracameral subcapsular lens in a dry state. Note that blue staining is denser in the
injection optic area
Anterior Capsule Staining During Microphaco 187
Surgical Techniques seal the incision site. The dye is then injected over the
Preparation of the dyes for injection can be accomplished capsule. Only a few drops are needed and it can be
at the beginning of the surgical day. Trypan blue is spread over the capsule by manipulation of the cannula
available and ready for injection requiring no dilution. over the capsular surface. There is a tendency for the
ICG can be prepared as described by Horiguchi and dye is to accumulate at the periphery of the lens near
associates.17 A total of 0.5 mL of the provided diluent the iris. This can be overcome by “dragging” or “pulling”
are mixed with the dry ICG powder. A total of 4.5 mL a drop of the dye over the lens capsule using the natural
of balanced salt solution are then added to this and the attractive forces between the drop of dye and the
solution mixed. This can be used for multiple cases cannula. In all capsular staining techniques, the excess
throughout the surgical day (regulations permitting). A
dye should be removed from the anterior chamber prior
2 percent fluorescein sodium solution was prepared by
to commencing the CCC.
mixing 1 mL of 10 percent fluorescein for intravenous
Akahoshi proposed the “soft shell stain technique”
use (Alcon Ophthalmic, Fort Worth, TX, USA) with 4
for performing a CCC in white cataract cases (Akahoshi
mL of balanced salt solution (BSS®).
The techniques originally reported for staining the T, Soft shell stain technique fort white cataract, presented
anterior capsule using fluorescein sodium include staining at the ASCRS symposium on Cataract, IOL, and
from above under an air bubble, as proposed by Nahra Refractive Surgery, Boston, MA, May 2000). A small
and Castilla (Nahra D, Castilla M, Capsulorhexis in no amount of viscoelastic (Viscoat®) was injected into the

Section 2
view cataract: Staining of the anterior capsule with anterior chamber followed by high molecular weight
2 percent fluorescein, presented at the annual meeting viscoelastic material (Provisc®) to fill the chamber
of the American Academy of Ophthalmology, October completely. The author then injected ICG solution on
1996, Chicago, Illinois, USA), and intracameral the lens surface with a bent 27 gauge visco canula. The
subcapsular injection of fluorescein sodium (staining from anterior capsule was uniformly stained green and easily
below) with blue-light enhancement.15,16 Either of these visualized while the cornea remained unstained.
techniques can be used with ICG and trypan blue as According to the author, the soft shell stain technique
well. is extremely useful for CCC of white cataracts.
The first technique (staining under an air bubble) is Robert H. Osher, MD modified the staining technique
currently used by most surgeons with ICG or trypan of using capsular dye by filling the anterior chamber with
blue and will be described in detail (Figs 18.4A to F and a high molecular weight sodium hyaluronate- Healon
18.5A to C). The beginning of the procedure starts with 5®. Balanced salt solution is then injected beneath the
a small paracentesis. Air is injected into the anterior Healon 5® with low infusion pressure so Healon 5® will
chamber and care is taken to avoid over inflating the not be displaced. With balanced salt solution on the
eye by allowing aqueous to escape. Pressure on the anterior capsule it is very easy to paint the capsular dye
posterior lip of the paracentesis facilitates the aqueous on it in a very thin layer. This technique allows excellent
air exchange. Air in the anterior chamber makes it visualization of anterior capsule and safety of using the
unsteady and any instrument entering the eye will cause dye inside the eye (Osher RH. Viscoelastics: In the thick
some air to escape, with a rise of the lens-iris plane. A of complicated cataract cases. EyeWorld, March 2003;
small amount of high-density viscoelastic placed near Pandey SK, Werner L, Apple DJ, Chang DF, Osher RH,
the incision can prevent the air bubble from escaping et al. Dye-enhanced ophthalmic surgery: experimental
the anterior chamber, thus minimizing the risk of sudden studies and clinical applications; Instruction Course;
collapse. Most of the drawback of this technique can Presented at the Joint Meeting of American Academy
be avoided by careful use of a viscoelastic solution to of Ophthalmology, Anaheim, Florida, November 2003).
188 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

Section 2


Figs 18.4A to F: Photographs illustrating the surgical steps of the staining of the anterior capsule under an air bubble using
0.5 percent ICG solution in a case of advanced cataract associated with uveitis (Courtesy of David T. Vroman, MD, Storm
Eye Institute, Charleston, SC, USA).
A. Injection of the 0.5% ICG solution within the anterior chamber.
B. Replacement of the ICG stained viscoelastic solution from anterior chamber with unstained viscoelastic solution.
C. Initiation of the anterior capsulorhexis. Note the better contrast provided by the ICG stained anterior lens capsule against
unstained lens cortex.
D. ICG-enhanced rhexis is in progress.
E. and F. Completion of anterior CCC. Note the green staining of the flap of anterior lens capsule.

During microphacoemulsification procedure, it is Kayikicioglu and coworkers22 proposed a technique

important not to overfill the anterior chamber with for limiting the contact of trypan blue by mixing the dye
Healon. 5 Overfilling the eye makes instrument with a viscoelastic solution. These researchers mixed
introduction, capsulorhexis, hydrodissection, and IOL 0.4 percent trypan blue with 1 percent sodium
insertion more difficult. With Healon 5 in place, the one- hyaluronate in a 2 mL syringe. The dye, mixed in a
step capsulorhexis forceps (Rhein Medical, Tampa, Fla) viscoelastic solution, is injected onto the anterior lens
can be helpful to open the capsule and conduct the tear capsule, which covers the anterior capsule without
with a single instrument. coming in contact with the corneal endothelium. Trypan
Anterior Capsule Staining During Microphaco 189

Figs 18.5A to C: Anterior (surgeon’s) view of a human eye obtained post-mortem with advances cataract showing the
staining of the anterior capsule using trypan blue dye. Cornea and iris were excised to allow better visualization of the
anterior capsule. Note the visualization of the anterior capsule is enhanced by the trypan blue

blue mixed with sodium hyaluronate greatly increased Although the viscoelastic may be tinged with dye, this
the visibility of the anterior lens capsule without does not impede performing capsulorhexis. According
significantly touching the adjacent tissues. There is a to authors, this method does not add to operating time,
potential risk of corneal decompensation after intraocular requires no additional instrumentation or materials and
use of a self-mixed solution; however, these authors used is safe.

Section 2
this technique without significant surgical and Intracameral subcapsular injection is another, but less
postoperative adverse effects.22 commonly used, technique of anterior capsule
Laureano and Coroneo23 described a “one-step” staining.5,15,16 It has the advantage of trapping the dye
method for staining the anterior lens capsule with trypan in the subcapsular space, mostly in the center and in
blue. The trypan blue dye is instilled via a paracentesis the midperipheral part. It gives sufficient time for the
port at the start of a cataract extraction – as aqueous surgeon to perform any maneuver until the CCC releases
humor is allowed to exit the anterior chamber which it. Meanwhile, the dye remains in contact with the
consequently shallows, the resulting pupil block confines posterior surface of the anterior capsule. This may be
the dye to the anterior chamber. Viscoelastic is the used a possible explanation for the better staining observed
to flush dye-stained aqueous from the anterior chamber, in our laboratory study on postmortem human eyes (Figs
circumventing the need for anterior chamber washout. 18.6A to C).5 The capsule and cortex are both stained

Figs 18.6A to C: Photographs illustrating the surgical steps of the staining of the anterior capsule under an air bubble
using 0.1% trypan blue solution in a case of advanced cataract Note the staining of the anterior lens capsule with trypan
blue facilitates the visualization of the capsulorhexis, by creating a contrast between the blue stained capsule and the non-
stained underlying lens mass. (Courtesy of GRJ Melles, MD, PhD, Rotterdam Eye Hospital, The Netherlands)
190 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)

by the dye used, but they can be clearly distinguished are commonly used for anterior capsule staining, and
from the feathery appearance of the cortex and the considered nontoxic for corneal endothelial cells.
smooth staining of the capsule. The CCC is fairly easy Horiguchi et al,17 reported the technique of staining the
to perform by grasping the injection hole. This technique anterior capsule using a 2 percent solution of ICG in
was originally proposed for fluorescein with blue-light patients with mature cataracts. They compared the results
enhancement,15,16 but we also used it with ICG and trypan of phacoemulsification and IOL implantation in 2 groups
blue.5 When the capsular flap is inverted, the stained of 10 eyes. In the first group, the anterior capsule was
posterior surface of the anterior capsule enhances stained with ICG before CCC, and in the second, no
visualization and thus facilitates tearing during CCC. dye was used. There was no statistically significant
Furthermore, this can be performed without the need difference reported in their study between both groups
for any special type of illumination, such as a cobalt blue- concerning specular-microscopy endothelial cell
filter. We would like to emphasize that there is the risk counting, and laser flare-cell photometry, thus the
of anterior capsule tear formation after subcapsular staining procedure was considered to be safe.
injection of dye. However, we did not observe this Norn, in 1980,24 published a follow-up of 24 patients,
complication (anterior capsule tear) in any postmortem eight years after an injection of 0.1% aqueous trypan
human eyes used in our laboratory study.5 blue solution in to the anterior chamber during cataract
The intracameral subcapsular injection technique extraction. After eight years follow up, no adverse effect
Section 2

should not be attempted for performing CCC in on endothelium damage was noted. Recently, Van
intumescent and hypermature cataracts owing to the high Dooren et al25 compared the endothelial cell densities
intralenticular pressure and fragile anterior lens capsule between both eyes of 25 patients who underwent bilateral
that may easily result in radial tear formation. However, phacoemulsification with or without trypan blue capsule
intracameral injection of dye to stain the capsule can staining. These authors noted no mid-term endothelial
help the surgeon to “re-locate” the leading edge of a cell damage was induced by the intraoperative use of
“lost” capsulorhexis edge due to focal loss of red reflex. trypan blue for anterior capsule staining after 1 year
This is important because there are times when the follow-up.
ophthalmic surgeon cannot anticipate that the anterior In an ongoing study, Tehrani and associates found
lens capsule will be difficult to visualize or the capsulotomy that the stained anterior lens capsule using trypan blue
is initiated, and the leading edge is lost. In such cases, was actually weaker, and less force was required to begin
it is possible to relocate the “lost” rhexis edge after the tear at the capsule edge (Mana Tehrani, MD, Personal
anterior capsule staining with intracameral injection of communication, November 2003). These authors
dye. (Chang DF. Surgeons are dyeing for visualization performed special elasticity tests using fresh lens capsules,
in mature white cataract cases. EyeWorld, January 2003; which were removed, during routine cataract surgery
Pandey SK, Werner L, Apple DJ, Chang DF, Osher RH, in human eyes. One half of the excised capsule was dyed
et al. Dye-enhanced ophthalmic surgery: experimental with VisionBlue® the other half (non-stained) was used
studies and clinical applications; presented at the joint as a control. Analysis of 15 capsules suggested that the
meeting of American Academy of Ophthalmology, capsules that stayed in contact with the trypan blue was
Anaheim, Florida, November 2003). actually weaker, in terms that only a half of strength was
necessary to tear up the capsule. The precise mechanism
Safety and Efficacy is not clear at present, and requires further investigations.
Several studies have evaluated the safety and efficacy However, this phenomenon seems to be due to the
of capsular dyes. Currently, ICG and trypan blue dyes presence of preservative in the trypan blue solution.
Anterior Capsule Staining During Microphaco 191
Clinical experience with ICG and trypan blue for When injecting under an airbubble, the dye should
anterior capsule staining in mature white or brunescent be injected after the paracentesis but prior to creating
cataracts was first reported by David Chang26 in two the main incision to help with anterior chamber stability.
consecutive, non-randomized series of mature or Viscoelastic solutions can be used to visco-seal the incision
brunescents cataracts. The technique of dye injection site in order to avoid escape of the air bubble, and to
under an air bubble was utilized. ICG dye was used in minimize any anterior chamber fluctuations.
the first series, and trypan blue in the subsequent series. Use of nontoxic ophthalmic dyes for anterior capsule
According to the author, ICG dye provided excellent staining in advanced, white cataracts allows performance
visualization with white or cortically mature cataracts but of a safe and successful CCC.5,17-19,26,27 Capsular dyes may
poorly with black or nuclear mature cataracts, while also be helpful for performing the CCC in traumatic
trypan blue dye created a more intense and persistent cataract cases presenting with torn anterior lens capsule.28
staining with both types of cataract according to this first Anterior capsule staining in such cases may be helpful
clinical study (Chang DF, MD. Compare two dyes. Eye to distinguish the densely stained anterior capsule from
Net 2000;4:22). the (irregular or unstained stained) lenticular tissues.
Trypan blue dye can also be helpful when training
Guidelines and Recommendation for Surgeons
residents in the techniques of CCC, and when
We would like to provide some recommendations and performing CCC and other steps of phacoemulsification
guidelines for ophthalmic surgeons regarding suitable

Section 2
in cases presenting with nebular and/or macular corneal
ophthalmic dyes and the anterior capsule staining opacity.29 Anterior capsule staining can also be useful
technique. These are based on our experience in when converting from a can-opener technique to CCC.
postmortem human eyes, use on patients from our Surgeons operating only rarely on children may also
institution, as well as published clinical reports from find anterior and posterior capsule staining useful as an
several other surgeons.5-19 Both ICG and trypan blue aid to dealing with the elastic nature of the capsule, and
are currently preferred over fluorescein sodium dye, due the increased tendency for the run-away rhexis. Even
to better staining of the anterior capsule and the absence
when the cataract is not completely white, the learning
of vitreous leakage (due to high molecular weight).5 Both
curve when beginning CCC in unfamiliar territory (such
of these dyes provide excellent visualization of the anterior
as pediatric cases) can be shortened by enhanced
capsule flap during CCC, without causing any toxic
visualization of the capsular edge. These dyes may be
effects to the corneal endothelium. Trypan blue has the
useful for operating on adult and pediatric cataract cases
advantage of being less costly when compared to the
with poor or no red reflex, or when the surgeon is
cost of ICG. Trypan blue should be avoided in fertile/
learning, or in developing-world settings with inexpensive
pregnant females and in children due to the possible
surgical microscopes and imperfect co-axial light.
teratogenic and/or mutagenic effects observed in animal
studies when using this dye. Currently, 0.1% trypan blue
is the concentration used by most surgeons.12,18 Further REFERENCES
studies may be helpful to determine the least 1. Gimbel HV, Neuhann T. Development, advantage, and
methods of the continuous circular capsulorhexis
concentration of the trypan-blue dye (e.g., 0.05%,
technique. J Cataract Refract Surg 1990;16:31-37.
0.025%, 0.01%, etc.) that can be used to stain the 2. Assia EI, Apple DJ, Barden A, et al. An experimental study
anterior lens capsule in order to perform CCC. ICG comparing various anterior capsulotomy techniques. Arch
Ophthalmol 1991;109:642-47.
remains a valuable alternative for these special patients 3. Brusini P. Capsulorhexis in mature cataracts: Why not? Doc
(children and pregnant females). Ophthalmol 1992;81:281-84.
192 Mastering the Art of Bimanual Microincision Phako (Phakonit/MICS)
4. Gimbel HV. Two stage capsulorhexis for endocapsular 16. Fritz WL. Fluorescein blue light assisted capsulorhexis for
phacoemulsification. J Cataract Refract Surg 1990;16: mature or hypermature cataract. J Cataract Refract Surg
246-49. 1998;24:19-20.
5. Pandey SK, Werner L, Escobar-Gomez M, et al. Dye- 17. Horiguchi M, Miyake K, Ohta I, Ito Y. Staining of the lens
enhanced cataract surgery. Part 1: anterior capsule staining capsule for circular continuous capsulorhexis in eyes with
for capsulorhexis in advanced/white cataract. J Cataract white cataract. Arch Ophthalmol 1998;116:535-37.
Refract Surg 2000;26:1052-59. 18. Melles GRJ, Waard PWT, Pameyer JH, Beekhuis WH.
6. Werner L, Pandey SK, Escobar-Gomez M, et al. Dye- Trypan blue capsule staining in cataract surgery. J Cataract
enhanced cataract surgery. Part 2: learning critical steps of Refract Surg 1999;24:7-9.
phacoemulsification. J Cataract Refract Surg 2000;26: 19. Jacob S, Agarwal A, Agarwal A, et al: Trypan blue as an
adjunct for safe phacoemulsification in eyes with white
cataract. J Cataract Refract Surg 2002;28:1819-25.
7. Pandey SK, Werner L, Escobar-Gomez M, et al. Dye-
20. Birchall W, Raynor MK, Turner GS. Inadvertent staining of
enhanced cataract surgery. Part 3: Posterior capsule staining the posterior lens capsule with trypan blue dye during
to learn posterior continuous curvilinear capsulorhexis. J phacoemulsification. Arch Ophthalmol 2001;119:1082-
Cataract Refract Surg 2000;26:1066-71. 83.
8. Pandey SK, Werner L, Apple DJ. Capsular dye-enhanced 21. Werner L, Apple DJ, Crema AS, et al. Permanent blue
cataract surgery. In: Nema HV, Nema N (Eds): Recent discoloration of a hydrogel intraocular lens caused by
Advances in Ophthalmology, Volume 6, New Delhi, India, intraoperative use of trypan blue. J Cataract Refract Surg
Jaypee Brothers, 2002;11-29. 2002;28:1279-86.
9. Pandey SK, Werner L, Apple DJ. Ophthalmic dyes for adult 22. Kayikicioglu O, Erakgun T, Guler C. Trypan blue mixed with
and pediatric cataract surgery. In: Garg A, Pandey SK (Eds): sodium hyaluronate for capsulorhexis. J Cataract Refract
Textbook of Ocular Therapeutics. New Delhi, India, Jaypee Surg 2001;27:970.
Brothers, 2002;357-75. 23. Laureano JS, Coroneo MT. A Minimalist Method For
10. Pandey SK, Werner L, Apple DJ, Wilson ME. Dye-enhanced Crystalline Lens Capsular Staining With Trypan Blue. J
Section 2

adult and pediatric cataract surgery. In: Buratto L, Werner Cataract Refract Surg 2004 (In press).
L, Zanini M, Apple DJ (Eds): Phacoemulsification: 24. Norn MS: Per operative trypan blue vital staining of corneal
Principles and Techniques. Thorofare, NJ, Slack Inc., 2002, endothelium; eight years follow up. Acta Ophthalmol
chapter 41, pp 565-85. 1980;58:550-55.
11. Pandey SK, Werner L, Apple DJ. Staining the anterior 25. van Dooren BT, de Waard PW, Poort-van Nouhuys H,
capsule. J Cataract Refract Surg (Letter) 2001;27:647-48. Beekhuis WH, Melles GR. Corneal endothelial cell density
12. Pandey SK, Werner L, Wilson ME, et al. Anterior capsule after trypan blue capsule staining in cataract surgery. J
Cataract Refract Surg 2002;28:574-75.
staining: Current techniques, guidelines and recom-
26. Chang DF. Capsule staining and mature cataracts: A
mendations. (letter). Indian J Ophthalmol 2002;50:157-
comparison of indocyanine green and trypan blue dyes.
59. Br J Ophthalmol. (video report) July 2000.
13. Feron EJ, Veckeneer M, Parys-Van Ginderdeuren R, et al. 27. Nodarian M, Feys J, Sultan G, Salvanet-Bouccara A.
Trypan blue staining of epiretinal membranes in Utilisation du bleu trypan pour la réalisation du
proliferative vitreoretinopathy. Arch Ophthalmol capsulorhexis dans la chirurgie de la cataracte blanche. J
2002;120:141-44. Fr Ophtalmol 2001;24:274-76.
14. Mansour AM. Anterior capsulorhexis in hypermature 28. Newsom TH, Oetting TN. Indocyanine green staining in
cataracts (letter). J Cataract Refract Surg 1993;19:116-7. traumatic cataract. J Cataract Refract Surg 2000;26:
15. Hoffer KJ, McFarland JE. Intracameral subcapsular 1691-93.
fluorescein staining for improved visualization during 29. Bhartiya P, Sharma N, Ray M, et al. Trypan blue assisted
capsulorhexis in mature cataracts (letter). J Cataract Refract phacoemulsification in corneal opacities. Br J Ophthalmol
Surg 1993;19:566. 2002;86:857-59.
Dynamics of Temperature Control in Microphaco 193

Dynamics of Temperature
19 Control in Microphaco
with New Insulated
Phako Tip
Dipan Desai (India)

Section 2
INTRODUCTION is markedly increased at temperatures beyond 60 degrees
Microincision phako has been well accepted because of centigrade. In conventional phako, the irrigating fluid
several advantages over conventional phako. Some of surrounds the phako tip and cools it. However, in
the obvious advantages are decreased incision size, microincision phako, in order to decrease the incision
improved surgical control, more physiological size and improve the phako dynamics the irrigation is
phakodynamics, good anterior chamber maintenance, separated from the aspiration phako needle. Hence the
less astigmatism, reduced risk of endophthalmitis and phako tip is not cooled and there are greater chances
faster visual rehabilitation. Because irrigation is separated of wound burns. Studies have shown that if aspiration
from aspiration the added advantage is that all the fluid was blocked, then wound burn would occur at 80 percent
comes in through one incision and exits through the continuous power after 45 seconds with the regular
other. The irrigation fluid in conventional phako has a phako tip.
tendency to push the fragments away from the aspiration In order to prevent thermal damage to the cornea,
tip, whereas the incoming stream of fluid in micro-phako the author devised the Desai’s Insulated Phako Tip in
assists in mobilising lens fragments to the phako tip 1998 (Figs 19.1 and 19.2). Teflon is used as the insulating
without inducing competing currents around it. This is material. This is coated over the needle, sparing the last
a definite advantage over conventional phako. 2 mm. of the tip opening. The front end of the tip is
However, with microincision phako (sleeveless bent like a Kelman tip. This has the advantage of effecting
phako), the first concern to come to the surgeon’s mind the best emulsification at any given phako power. When
is that of corneal burns. The tip, moving 40,000 times a regular phako tip with an internal diameter of 0.9 mm.
per second, definitely generates friction and heat. The is bent, it’s internal diameter is decreased and it works
delicate cornea is made up of collagen fibrils and can like a microflow tip (0.7 mm). This confers the additional
be easily damaged when the temperature rises beyond advantages of improved fluidics and stable anterior
42 degrees centigrade. However, the thermal damage chamber.
194 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

• Bent tip: The bend on the tip makes it behave like

a Kelman tip. Studies have shown that the Kelman
tip is the most efficient one for its cutting and ultrasonic
ability. It allows use of lower phako energy and thus
decreases chatter. The bend also puts less stress on
the corneal incision leading to less striae, increased
visibility and clearer corneas on the first post-operative
day. The bend also helps to maneuver the nucleus
in the bag and this facilitates chopping and other
• Decreased internal diameter: allows use of greater
Fig. 19.1: Desai’s insulated microflow tip flow rate and vacuum, thus improving speed and
followability while using least ultrasonic energy. This
allows efficient fluid management.
• Flexibility of use: This tip can be used in any phako
machine without micro-pulse technology (WhiteStar,
hyperpulse). It would also be an added advantage
Section 2

in machines with micro-pulse technology, during

difficult situations.
• Increased surgeon’s comfort and leverage in difficult
situations: The coating provides a dull finish which
reduces glare and increases visibility of the tip. In
difficult situations, such as hard cataracts where more
phako energy and time are required, the coating
allows less wound burn and clearer corneas on the
Fig. 19.2: Desai’s insulated bent phakotip first post operative day.
Other methods to prevent corneal burns:
The advantages of the new insulated tip are: 1. Continuous wound irrigation by assistant.
• Decreased wound burns: The insulated coating 2. The irrigating silicon sleeve of the phako hand piece
prevents heat transfer even with tight-fit incisions. is cut short leaving 2-3 mm. of the sleeve from the
• Allows tighter incisions: This is very important to hub (Fig. 19.3).
prevent surges. In micro-phako there is less fluid 3. Avoiding tight-fit incisions when tip is not insulated
entering the eye through the irrigating chopper – as studies have shown that wound temperature goes
approximately 40-45 ml/minute – compared to 80- up to 58.2 degrees centigrade using conventional
85 ml/minute in conventional phako. Thus any phako machines.
wound leak would prove to be detrimental to the 4. Use of WhiteStar/Micropulse technology. Studies
procedure and would increase surge related have shown that when aspiration is clamped, then
complications. The insulated tip allows “tight-fit” even with 3 minutes of micro/ultra pulse the
incisions and reduces wound leak and fluid turnover temperature does not rise beyond 32.4 degrees
while improving the chamber depth, followability and centigrade. Eric Donnenfeld and Randall J. Olson
fluidics. showed that using micro / ultrapulse technology
Dynamics of Temperature Control in Microphaco 195
For more information and help regarding coating of
the tip, one is welcome to contact the author.

1. Olson RJ, Crandall AS. Prospective randomized
comparison of phacoemulsification cataract surgery with
a 3.2-mm vs a 5.5-mm sutureless incision. Am J Opthalmol
1998; 125:612-20.
2. Shearing SP, Relyea Rl , Loaiza A, Shearing RL. Routine
phacoemulsification through a 1 millimeter non-sutured
incision. Cataract 1985; 2(2):6-11.
3. Tsuneoka H, Shiba T, Takahashi Y. Feasibility of ultrasound
cataract surgery with a 1.4 mm incision . J Cataract Refract
Fig. 19.3: Thermal imagery shows reduction of heat Surg 2001; 27:934-40.
afforded by WhiteStar technology 4. Soscia W, Howard JG, Olson RJ. Microphacoemulsification
with WhiteStar; a wound-temperature study. J Cataract
Refract Surg 2002; 28:1044-46.
(WhiteStar), wound temperature as measured
5. Soscia W, Howard JG, Olson RJ. Bimanual phaco-
contiuously during human nucleus removal by emulsification through 2 stab incisions; a wound-
microphako never went beyond 36 degrees temperature study. J Cataract Refract Surg 2002 ;28:1039-

Section 2
centigrade. 43.
6. Tsunoeka H, Shiba T, Takahashi Y. Ultrasonic phaco-
In summary, the insulated phako tip offers an
emulsification using a 1.4 mm incision; clinical results; J
invaluable answer to the problem of corneal burns during Cataract Refract Surg 2002;28:81-86.
microincision phako performed with machines not using 7. Sporl E, Genth U, Schmalfuss K, Seiler T. Thermo-
micropulse technology. It offers comprehensive mechanical behavior of the cornea. Ger J Opthalmol 1997;
advantages as enumerated above allowing even the 8. Goldblatt WS, Finger PT, Perry HD, et al. Hyperthermic
novice to venture into the exciting realm of microincision treatment of rabbit corneas. Invest Opthalmol Vis Sci 1989;
phako surgery. 30:1778-83.
196 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Ultrasmall Incision
20 Intraocular Lenses
Suresh K Pandey (Australia)
Randall J Olson
Liliana Werner
Nick Mamalis (USA)
Section 2

INTRODUCTION hydrophilic and hydrophobic biomaterials (Acri.Smart™,

UltraChoice™, and SmartIOL™). We also present brief
The evolution of cataract surgery and the intraocular
details on clinical and laboratory studies concerning these
lens (IOL) since Sir Harold Ridley’s invention of the
implant in 1949 has been one of the stellar achievements
in current ophthalmology.1 The advent of small-incision
cataract surgery made possible by phacoemulsification MICROINCISION INTRAOCULAR LENSES
and foldable IOLs represents a major milestone in this Acri.Smart™ lens
evolutionary process. Phacoemulsification has become The first microincision IOL available for implantation
the preferred method of cataract surgery owing to through sub-2 mm incisions was the Acri.Smart™ lens
numerous advantages such as a small self-sealing incision, (model H44-IC-1, manufactured by Acri.Tec GmbH,
less surgically induced astigmatism, and a closed-chamber Berlin, Germany) (Fig. 20.1).9 The Acri.Smart™ lens is
with controlled capsular surgery.2 Our experience and a hydrophilic acrylic lens with 25 percent water content
that of several other surgeons suggests that with evolving and a hydrophobic coating. The first Acri.Smart™ lens
phaco technology, it is possible to perform bimanual was pre-folded as follows: after dehydration up to
microphacoemulsification through microincisions (less 27 percent, the optic of the lens was rolled onto itself
than 1.2 mm) without significant complications.3-12 As to create a pre-folded lens that was shorter in diameter.
IOL technology becomes available that enables insertion The overall design is that of a plate haptic lens with square
through very small surgical wounds, it is clear that edges. The lens has an optical diameter of 6 mm and
microincision cataract surgery will become more a total length of 12.3 mm. A folded +19-diopter lens
common place. has a width of about 1.2 to 1.3 mm, therefore, it can
In this chapter, we provide an overview of currently be inserted through a microincision. Acri.Smart™ lenses
investigational microincision lenses manufactured from (model 48 S with a 5.5 mm optic, and model 46S with
Ultrasmall Incision Intraocular Lenses 197
a 6.0 mm optic) have been developed for implantation For implantation (if the recently developed injector
with a specially designed injector through a sub-2.0 mm is not available), the UltraChoice™ IOL is taken from
incision. Their overall design is also that of plate haptic the container and gently held with a McPherson forceps
lenses with square edges, which are loaded into the (Fig. 20.2). The lens is then placed in a bowl of balanced
injector already in a hydrated state, thus the unfolding salt solution that is approximately at body temperature.
is faster than with the dehydrated version. A published Once it becomes foldable, it is taken with the gloved
report indicates that Acri.Smart™ can be inserted through hand holding it between the index finger and the thumb.
sub a 2 mm incision and unfolds in a relatively slow, Then, it is rolled in a rubbing motion. It is preferable
controlled fashion in the capsular bag, being completely to do this in the bowl of balanced salt solution so that
unfolded within a half-hour (Figs 20.1A to E).9 Model the lens remains well rolled. The lens is then carefully
36A, with a special aspherical design has also been implanted into the capsular bag after using a viscoelastic
developed to compensate for the positive spherical solution. To assure proper placement of the lens, the
aberration of the cornea, in a mechanism probably similar teardrop shaped holes on the haptic should point in a
to that of the Pfizer Tecnis® lens.11 clockwise direction. The smooth optic lenticular surface
Experimental studie s using closed-system and should be facing posteriorly. After implantation, the
Miyake-Apple posterior video techniques suggest that natural temperature of the eye causes the lens to open
it is possible to insert the Acri.Smart lens through a sub gradually within the capsular bag in approximately 20

Section 2
2-mm incision in postmortem human eyes. Figs 20.1F seconds (Fig. 20.2). A specially designed roller/injector
and G illustrate well-controlled unfolding of the system with an autoclavable, reusable cartridge made
Acri.Smart IOL. The capsulorhexis opening and the of Teflon is now available for this lens and allows insertion
capsular bag geometry were well maintained without through a 1.5 mm incision.
any evidence of ovaling or distortion. Experimental studies using closed-system and
Miyake-Apple posterior video techniques suggest that
ThinOptX (UltraChoice™) IOL it is possible to insert the rolled/folded lens through a
Another lens available for insertion through a sub sub 2-mm incision in postmortem eyes. The Miyake-
2.0 mm incision is the UltraChoice™ (ThinOptX, Apple posterior video technique demonstrated well-
Abingdon, VA, USA) lens.8 The UltraChoice™ IOL is controlled unrolling/unfolding of the ThinOptX ®
manufactured from hydrophilic acrylic material with 18 UltraChoice™ lens in the capsular bag after injection
percent water content. The refractive index of the of body temperature BSS® (Figs 20.2A to H). The
material is 1.47. The dioptric power of this lens ranges capsulorhexis opening and the capsular bag geometry
from +15 to +25 diopters, as of April 2003. The optical were well-maintained. The lens was well-centered in the
thickness is 300-400 microns, with a biconvex optical bag and removal of residual viscoelastic was not difficult.
configuration having a meniscus shape. The overall Clinical experience with the ThinOptX® IOL was
diameter of the lens is 11.2 mm, and the optical diameter recently reported by Dogru and associates.13 These
is 5.5 mm. The ultrathin properties of the lens are authors prospectively assessed the clinical and visual
attributable to its Fresnel optic design. Other unique outcomes after phacoemulsification and implantation of
properties of the UltraChoice™ IOL include its flexibility the rollable ThinOptX® IOL and compared the results
and ability to retain original memory. The manufacturer with those after implantation of a foldable hydrophobic
has received CE Mark approval for the UltraChoice™ acrylic IOL (AcrySof® MA60BM, Alcon Inc, Fort Worth,
monofocal cataract lens in September 2002 in Europe TX, USA) in 16 consecutive eyes of 8 patients with
and FDA trials are in progress in the USA. corticonuclear cataract. The patients’ refractive status,
198 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Section 2

Ultrasmall Incision Intraocular Lenses 199


Figs 20.1A to G: Photographs illustrating designs and perfor-

mance of the Acri.Tec Acri.Smart™ lens in a clinical and
laboratory setting.
A. Schematic drawing showing the Acri.Smart™ lens model

Section 2
B and C. Gross photographs showing the Acri.Smart™ lens
model 48S.
D and E. Clinical photograph showing insertion of the
Acri.Smart™ lens (model H44-IC-1) through a sub-2 mm
incision. (Courtesy: Amar Agarwal, MD, Chennai, India).
F and G. Miyake-Apple views showing a well-centered
Acri.Smart™ lens (model H44-IC-1) in the capsular bag of
a human eye obtained postmortem.

uncorrected and best-corrected distance visual acuities,

and contrast sensitivity were assessed preoperatively and
1 week and 1, 3, and 6 months after surgery. Results C

200 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Section 2

Figs 20.2A to H: Photographs demonstrating performance of the
ThinOptX® UltraChoice™ IOL in a clinical and laboratory setting.
A. Photograph showing the design characteristics of the ThinOptX® UltraChoice™ IOL.
B. Special injector designed for use with the UltraChoice™. (Courtesy: ThinOptX, Abingdon, VA, USA).
C to F. Clinical pictures obtained under an operating microscope, showing injection of the UltraChoice™ lens through a
1.45 mm incision, using the new roller/injector system. The lens unrolls in 20 seconds once injected into the capsular
bag. (Courtesy: ThinOptX, Abingdon, VA, USA).
G. Miyake-Apple posterior view of a human eye implanted with the ThinOptX® UltraChoice™ IOL. Note the IOL slowly unfolding
inside the capsular bag, upon reaching normal body temperature.
H. Miyake-Apple posterior view of a human eye implanted with the ThinOptX® UltraChoice™ IOL. Note the well-centered
lens within the capsular bag.

of this study suggested that the ThinOptX® IOL provided Medennium SmartIOL™
best corrected near and distance visual acuities
The third microincision IOL in the experimental,
comparable to those provided by the AcrySof® IOLs.
preclinical phase is the SmartIOLTM (Medennium, Inc.
The significantly higher contrast acuities attained after
implantation of the ThinOptX® lens may be attributable Invine, CA, USA). This is an IOL made of thermoplastic
to its ultrathin properties. hydrophobic acrylic gel polymer that can be formed to
Ultrasmall Incision Intraocular Lenses 201

Section 2

202 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Section 2


Ultrasmall Incision Intraocular Lenses 203
through a small incision. Upon reaching body
temperature the IOL reconfigurates into its original size,
and fills the entire capsular bag. This process takes about
30 seconds and results in a lens about 9.5 mm wide
and 2 to 4 mm thick (averaging about 3.5 mm at the
center), depending on dioptric power.
According to the Helmholtz theory, presbyopia is
caused by loss of flexibility in the ageing crystalline lens.
Because it entirely fills the capsular bag, the SmartIOL™
may theoretically restore accommodation. Due to its high
refractive index, small changes in the shape will result
in significant changes in the lens power. The hydrophobic
M acrylic biomaterial is expected to adhere to the lens
Figs 20.3A to M: Photographs illustrating design characte- capsule, which may possibly reduce capsular bag
ristics and experimental performance of the one-piece and opacification. Furthermore, a lens that has the dimensions
three-piece SmartIOL™ (Medennium Inc., Irvine, CA.)
A to D. At room temperature, or colder, the SmartIOL®
of a natural lens would not cause problems with
biomaterial is formed into a solid rod of approxi- decentration or edge glare and could reduce spherical

Section 2
mately 30 mm length and 2 mm width. Note the aberration, as induced by standard IOLs. A new design
transformation of the rod into a biconvex lens, after
immersion in balanced salt solution at body (three-piece SmartIOL™) with poly (vinylidene fluoride)
temperature. (Courtesy: Medennium Inc., Irvine, CA, (PVDF) haptics is under investigation, which will probably
eliminate potential problems related to the different
E. Side-view of a human eye obtained postmortem
showing insertion of the solid rod into the eye after diameters of the capsular bags in different eyes.
a clear corneal incision. Experimental studies using closed-system and
F to I. Photographs obtained from the Miyake-Apple
posterior video technique showing the unfolding of Miyake-Apple posterior video techniques demonstrated
the one-piece SmartIOL™ within the capsular bag that experimental designs of one-piece and three-piece
of a postmortem human eye after injection of body
SmartIOLs centered well within the capsular bag without
temperature BSS®. Note the reconfiguration of the
solid rod to a biconvex lens that fills the entire any evidence of capsular bag distortion (Figs 20.3A to
capsular bag. This process takes about 30 seconds M).
and results in a lens about 9.5 mm wide and about
3.5 mm thick at the center, depending on the dioptric
J to M. Photographs obtained from the Miyake-Apple
posterior video technique showing the unfolding of Globally, contemporary cataract surgeons have witnessed
the three-piece SmartIOL™ (with PVDF haptics)
great advancements in cataract surgery, foldable IOLs
within the capsular bag of a postmortem human eye
after injecting body temperature BSS®. and phaco technology. Microincision lenses (Acri.Smart®,
ThinOptX® UltraChoice®, and SmartIOL®) are being
any size and shape with any dioptric power imprinted developed by the manufacturers that will take advantage
on it. The refractive index of the hydrophobic acrylic of micro-incision cataract surgery. Many other companies
biomaterial is 1.47, and the glass transition temperature are working on innovative micro-incision IOL designs.
is 20-30 degrees celsius. At room temperature, or colder, Experimental studies using the Miyake-Apple posterior
the material is formed into a rod of approximately video technique confirm the well-maintained
30 mm in length and 2 mm in width for implantation configuration of the capsular bag after implantation of
204 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

these lens designs. It was possible to insert UltraChoice™ 5. Tsuneoka H, Hayama A, Takahama M. Ultrasmall-incision
bimanual phacoemulsification and AcrySof SA30AL
IOLs through sub-2 mm incisions as indicated by recent implantation through a 2.2 mm incision. J Cataract Refract
clinical and laboratory studies. A short-term clinical study Surg 2003;29:1070-1076.
of the ThinOptX® UltraChoice™ IOL suggests that this 6. Soscia W, Howard JG, Olson RJ. Microphacoemulsification
with WhiteStar. A wound-temperature study. J Cataract
design provides good visual outcome, and better contrast Refract Surg 2002; 28:1044-46.
sensitivity than a common foldable IOL due to its ultrathin 7. Donnenfeld ED, Olson RJ, Solomon R, et al. Efficacy
properties. and wound-temperature gradient of whitestar
phacoemulsification through a 1.2 mm incision. J Cataract
Refract Surg 2003; 29:1097-1100.
Acknowledgment 8. Pandey SK, Werner L, Agarwal A, et al. Phakonit. cataract
Supported in part by a grant from Research to Prevent removal through a sub-1.0 mm incision and implantation
of the ThinOptX rollable intraocular lens. (Letter). J
Blindness, New York, New York, USA, to the Department
Cataract Refract Surg 2002; 28:1710-13.
of Ophthalmology and Visual Sciences, University of 9. Agarwal A, Agarwal S, Agarwal A. Phakonit with an AcriTec
Utah, Salt Lake City, Utah, USA. IOL. J Cataract Refract Surg. 2003;29:854-55.
10. Olson RJ. Clinical experience with 21-gauge manual
microphacoemulsification using Sovereign WhiteStar
REFERENCES Technology in eyes with dense cataract. J Cataract Refract
1. Trivedi RH, Apple DJ, Pandey SK, Werner L, Vasavada Surg 2004;30:168-172.
AR, Ram J. Sir Harold Ridley-He changed the world so 11. Werner L, Apple DJ, Schmidbauer JM. Ideal IOL (PMMA
we can see better. Indian J Ophthalmol 2003;51:211-16. And Foldable) For Year 2002. In: Buratto L, Werner L,
Section 2

2. Linebarger EJ, Hardten DR, Shah GK, Lindstrom RL. Zanini M, Apple DJ, Eds. Phacoemulsification:
Phacoemulsification and modern cataract surgery. Surv Principles and Techniques. Thorofare, NJ: Slack Inc.;
Ophthalmol 1999; 44:123-47. 2002:435-51.
3. Mamalis N. Is smaller better (editorial)? J Cataract Refract 12. Werner L, Mamalis N. Wavefront corrections of intraocular
Surg 2003; 29:1049-1450. lenses Ophthalmol Clin North Am 2004;17:233-45.
4. Agarwal A, Agarwal A, Agarwal S, et al. Phakonit: 13. Dogru M, Honda R, Omoto M, et al. Early visual results
Phacoemulsification through a 0.9 mm corneal incision. with the rollable ThinOptX intraocular lens. J Cataract
J Cataract Refract Surg 2001;27:1548-52. Refract Surg 2004;30:558-65.
Phakonit 215

Amar Agarwal
Athiya Agarwal
Sunita Agarwal
Ashok Garg (India)

Section 2
On August 15th 1998 the authors (Amar Agarwal) The problem in phacoemulsification is that we are not
performed the first 1 mm cataract surgery by a technique able to go below an incision of 3.0 mm. The reason
called PHAKONIT.1,2 In this the cataract was removed is because of the infusion sleeve. The infusion sleeve
through a bimanual phaco technique. It was performed takes up a lot of space. The titanium tip of the phaco
without any anesthesia. The first live surgery in the world handpiece has a diameter of 0.9 mm. This is surrounded
of Phakonit was performed on August 22nd 1998 at by the infusion sleeve which allows fluid to pass into the
Pune, India by the authors (Amar Agarwal) at the Phako eye. It also cools the handpiece tip so that a corneal
and Refractive surgery conference. This was done in front burn does not occur.3
of 350 ophthalmologists. The authors separated the phaco tip from the infusion
The problem with this technique was to find an IOL, sleeve. In other words, the infusion sleeve was taken
which would pass through such a small incision. Then out. The tip was passed inside the eye and as there was
on October 2nd 2001 the authors (Amar Agarwal) did no infusion sleeve present the size of the incision was
smaller. In the left hand an irrigating chopper was held
a case of Phakonit with the implantation of a Rollable
which had fluid passing inside the eye. The left hand
IOL. This was done in their Chennai (India) hospital.
was in the same position where the chopper is normally
The lens used was a special lens from ThinOptX. This
held; i.e. the side port incision. The assistant injects fluid
lens used a Fresnel principle and was designed by Wayne (BSS) continuously at the site of the incision to cool the
Callahan from USA. The first such ultrathin lens was phaco tip.
implanted by Jairo Hoyos from Spain. One of the authors Dr DP Prakash from India then showed with digital
(Am A) then modified this into a special 5 mm optic calipers a sub 1 mm cataract surgery using a 21 gauge
rollable IOL. irrigating chopper and a 0.8 mm phaco needle.
216 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

The name PHAKONIT has been given because it shows
phaco (PHAKO) being done with a needle (N) opening
via an incision (I) and with the phako tip (T). This is
also because it is Phako being done with a Needle Incision

1. Bimanual phaco
2. Microincision cataract surgery
3. Microphaco
4. Bimanual microphaco
5. Sleeveless phaco
Fig. 22.1: A 26 gauge needle with viscoelastic making an entry
in the area where the side portis. This is for entry of the irriga-

Section 2

All the cases done by the authors have been done Without
Any Anesthesia. But the technique of Phakonit can be
done under any type of anesthesia also. In the cases
done by the authors no anesthetic drops were instilled
in the eye nor was any intracameral anesthetic injected
inside the eye. The authors have analyzed that there
is no difference between topical anesthesia cataract
surgery and no anesthesia cataract surgery. They have
stopped using anesthetic drops. But Phakonit can be
done with any type of anesthesia.
Fig. 22.2: Clear corneal incision made with the keratome. Note
Incision the left hand has a straight rod to stabilize the eye as the case
is done without any anesthesia. These instruments are made
In the first step a needle with viscoelastic is taken and by katena (usa)
pierced in the eye in the area where the side port has
to be made (Fig. 22.1). The viscoelastic is then injected
inside the eye. This will distend the eye so that the clear Rhexis
corneal incision can be made. Now a temporal clear The rhexis is then performed. This is done with a needle
corneal incision is made. A special knife can be used (Fig. 22.3). In the left hand a straight rod is held to
for this purpose. (Fig. 22.2). This keratome and other stabilize the eye. The advantage of this is that the
instruments for Phakonit are made by Huco (Switzerland) movements of the eye can get controlled as one is
and Gueder (Europe). working without any anesthesia.
Phakonit 217

Fig. 22.3: Rhexis started with a needle Fig. 22.4: Phakonit irrigating chopper and phako probe
without the sleeve inside the eye
the nucleus due to vacuum rise. To avoid undue pressure
Hydrodissection is performed and the fluid wave passing
on the posterior capsule the nucleus is lifted a bit and
under the nucleus checked. Check for rotation of the
with the irrigating chopper in the left hand the nucleus

Section 2
chopped. This is done with a straight downward motion
from the inner edge of the rhexis to the center of the
nucleus and then to the left in the form of an inverted
After enlarging the side port a 20 gauge irrigating chopper L shape. (Fig. 22.5). Once the crack is created, the
connected to the infusion line of the phaco machine is nucleus is split till the center. The nucleus is then rotated
introduced with foot pedal on position 1. The Agarwal 180º and cracked again so that the nucleus is completely
irrigating chopper with a special design of Larry Laks split into two halves.
from USA has been made by the MST (Microsurgical The nucleus is then rotated 90º and embedding done
Technology) company. This is incorporated in the Duet in one half of the nucleus with the probe directed
system. Other excellent irrigating choppers by the same horizontally (Fig. 22.6). With the previously described
company are David Changs, Randall Olsons, Robert technique, 3 pie-shaped quadrants are created in one
Oshers, Howard Fines and Hiroshi Tseunokas irrigating half of the nucleus. Similarly 3 pie-shaped fragments
chopper. Other choppers available in the market are are created in the other half of the nucleus. With a short
from F Vejarano. The phaco probe is connected to the burst of energy at pulse mode, each pie shaped fragment
is lifted and brought at the level of iris where it is further
aspiration line and the phaco tip without an infusion
emulsified and aspirated sequentially in pulse mode.
sleeve is introduced through the clear corneal incision
Thus the whole nucleus is removed (Fig. 22.7). Note
(Fig. 22.4). Using the phaco tip with moderate
in Figure 22.7 no corneal burns are present. Cortical
ultrasound power, the center of the nucleus is directly
wash-up is the done with the bimanual irrigation
embedded starting from the superior edge of rhexis with
aspiration technique (Figs 22.8 and 22.9).
the phaco probe directed obliquely downwards towards
the vitreous. The settings at this stage is 50 percent phaco
power, flow rate 24 ml/min and 110 mm Hg vacuum.
When nearly half of the center of nucleus is embedded, One of the real bugbears in Phakonit when we started
the foot pedal is moved to position 2 as it helps to hold it was about the problem of destabilization of the anterior
218 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 22.5: Phakonit started. Note the phako needle in the right Fig. 22.7: Phakonit completed. Note the nucleus has
hand and an irrigating chopper in the left hand. Phakonit be- been removed and there are no corneal burns
ing performed. Note the crack created by karate chopping.
The assistant continuously irrigates the phaco probe area
from outside to prevent corneal burns
Section 2

Fig. 22.8: Bimanual irrigation aspiration started

Fig. 22.6: Phakonit continued. The nuclear pieces are

chopped into smaller pie-shaped fragments

chamber during surgery. This was solved to a certain

extent by using an 18 gauge irrigating chopper. A
development made by us (SA) was to use an anti-
chamber collapser 4, 5 which injects air into the infusion
bottle (Fig. 22.10). This pushes in more fluid into the
eye through the irrigating chopper and also prevents
surge. Thus, we were not only able to use a 20 gauge
irrigating chopper but also solve the problem of
destabilization of the anterior chamber during surgery.
This increases the steady-state pressure of the eye making
the anterior chamber deep and well maintained during Fig. 22.9: Bimanual irrigation aspiration completed
Phakonit 219
An IV set is used to connect the BSS bottle to the
irrigation tubing of the handpiece (Fig. 22.10). The
bottles are kept at a height of about 65 centimeters above
the operating field. The automated air pump, which is
similar to the pump used in fish tanks to supply oxygen
to the fish, is utilized to forcefully pump air into the
irrigation bottle at a continuous rate. The air pump is
connected to the BSS bottle through an IV set. A
micropore air filter is used between the air pump and
the infusion bottle so that the air pumped into the bottle
is sterile. Sterile air is pumped into the infusion bottle,
pressurizing it to force fluid into the anterior chamber,
thereby neutralizing surge and maintaining a deep
Fig. 22.10: Anti-chamber collapser
anterior chamber through out the procedure.
the entire procedure. It even makes phacoemulsification With this increased fluid volume we were able to
a relatively safe procedure by reducing surge even at maintain a deep anterior chamber and no surge was

Section 2
high vacuum levels. Thus, this can be used not only in observed in our routine Phakonit or phacoemulsification
phakonit but also in phacoemulsification. cases.

Surge Discussion
When an occluded fragment is held by high vacuum
Surge is defined as the volume of the fluid forced out
and then abruptly aspirated, fluid rushes into the phaco
of the eye into the aspiration line at the instant of
tip to equilibrate the built up vacuum in the aspiration
occlusion break. When the phacoemulsification
line, causing surge. This leads to shallowing or collapse
of the anterior chamber. Different machines employ a handpiece tip is occluded, flow is interrupted and vacuum
variety of methods to combat surge. These include usage builds up to its preset values. Additionally the aspiration
of noncomplaint tubing,4 small bore aspiration line tubing may collapse in the presence of high vacuum
tubing,4 microflow tips,4 aspiration bypass systems4, dual levels. Emulsification of the occluding fragment clears
linear foot pedal control 4 and incorporation of the block and the fluid rushes into the aspiration line
sophisticated microprocessors4 to sense the anterior to neutralize the pressure difference created between
chamber pressure fluctuations. the positive pressure in the anterior chamber and the
The surgeon dependent variables to counteract surge negative pressure in the aspiration tubing. In addition,
include good wound construction with minimal leakage5
if the aspiration line tubing is not reinforced to prevent
and selection of appropriate machine parameters
collapse (tubing compliance), the tubing, constricted
depending on the stage of the surgery.5 An anterior
during occlusion, then expands on occlusion break.
chamber maintainer has also been described in literature
to prevent surge, but an extra side port makes it an These factors cause a rush of fluid from the anterior
inconvenient procedure. Another method to solve surge chamber into the phaco probe. The fluid in the anterior
is to use more of phacoaspiration and chop the nucleus chamber is not replaced rapidly enough to prevent
into smaller pieces. shallowing of the anterior chamber.
220 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

The maintenance of intra ocular pressure (steady– THINOPTX ROLLABLE IOL

state IOP) during the entire procedure depends on the ThinOptX the company that manufactures these lenses
equilibrium between the fluid inflow and outflow. In most has patented technology that allows the manufacture
phacoemulsification machines, fluid inflow is provided of lenses with plus or minus 30 diopters of correction
by gravitational flow of the fluid from the balanced salt on the thickness of 100 microns. The Thinoptx
solution (BSS) bottle through the tubing to the anterior technology developed by Wayne Callahan, Scott
chamber. This is determined by the bottle height relative Callahan and Joe Callahan is not limited to material
to the patient’s eye, the diameter of the tubing and most choice, but is achieved instead of an evolutionary optic
importantly by the outflow of fluid from the eye through and unprecedented nano-scale manufacturing process.
the aspiration tube and leakage from the wounds. The lens is made from off-the-shelf hydrophilic material,
The inflow volume can be increased by either which is similar to several IOL materials already on the
increasing the bottle height or by enlarging the diameter market. The key to the ThinOptX lens is the optic design
of the inflow tube. The intraocular pressure increases and nano-precision manufacturing. The basic advantage
by 10 mm Hg for every 15 centimeters increase in bottle of this lens is that they are Ultra-Thin lenses. One of
height above the eye.5 High steady-state IOPs increase the authors (Am A) modified this lens to make a special
phaco safety by raising the mean IOP level up and away 5 mm optic rollable IOL.
from zero, i.e. by delaying surge related anterior chamber
Section 2

collapse. Air pump increases the amount of fluid inflow Lens Insertion Technique
thus making the steady-state IOP high. This deepens the The lens is taken out from the bottle. The lens is then
anterior chamber, increasing the surgical space available held with a forceps (Fig. 22.11). The lens is then placed
for maneuvering and thus prevents complications like in a bowl of BSS solution that is approximately body
posterior capsular tears and corneal endothelial damage. temperature. This makes the lens pliable. Once the lens
The phenomenon of surge is neutralized by rapid inflow is pliable it is taken with the gloved hand holding it
of fluid at the time of occlusion break. The recovery to between the index finger and the thumb. The lens is
steady-state IOP is so prompt that no surge occurs and then rolled in a rubbing motion. It is preferable to do
this enables the surgeon to remain in foot position 3 this in the bowl of BSS so that the lens remains rolled
through the occlusion break. High vacuum phaco- well.
emulsification can be safely performed in hard brown The lens is then inserted through the sub 1.4 mm
cataracts using an air pump. Phacoemulsification under incision carefully (Fig. 22.12). One can then move the
topical or no anesthesia6 can be safely done neutralizing lens into the capsular bag (Fig. 22.13). The natural
the positive vitreous pressure occurring due to squeezing warmth of the eye causes the lens to open gradually.
of the eyelids. Viscoelastic is then removed with the Bimanual irrigation
The air pump is a new device, which helps to prevent aspiration probes (Fig. 22.14). The tips of the footplates
surge. This helps to prevent posterior capsular rupture, are extremely thin which allow the lens to be positioned
with the footplates rolled to fit the eye.
helps deepen the anterior chamber and one can work
comfortably even in hard cataracts. The air pump pumps
air into the infusion bottle thus tending to push more Topography
of fluid into the eye and with greater force. Now, we We also perfomed topography with the orbscan to
routinely use the air pump in all our cases. compare cases of phakonit and phaco and we found
Phakonit 221

Fig. 22.11: The phakonit ThinOptX rollable IOL when

removed from the bottle

Fig. 22.13: The rollable IOL in the capsular bag

Section 2
Fig. 22.12: The rollable IOL inserted through the incision

that the astigmatism in phakonit cases is much less Fig. 22.14: Viscoelastic removed using bimanual irrigation
compared to phaco (Figs 22.15 to 22.17). Stabilization aspiration probes
of refraction is also faster with Phakonit compared to
phaco surgery.
bonded UV-absorber. It is a single piece foldable IOL
like a plate-haptic IOL. The lens is sterilized by autoclaving.
ACRITEC IOL The lens comes in a sterile vial, filled with water and
The Acry.Lyc IOL is manufactured by the Acri.Tec wrapped in a sterile pouch.
company in Berlin, Germany. This lens is a sterile
foldable intraocular lens made of hydrophobic acrylate. Lens Loading Technique
The intraocular lens (Fig. 22.18) consists of highly purified To remove the IOL one should open the Medipeel pouch
biocompatible hydrophobic acrylate with chemically at the defined spot. The lens vial or bottle is then taken
222 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

Fig. 22.15: Phako foldable and phakonit thinOptX IOL. The

figure on the left shows a case of phako with a foldable Iol
and the figure on the right shows phakonit with a ThinOptX
rollable IOL
Section 2

Fig. 22.16: Phako foldable IOL orbscan results. The figure
on the left is the pre-operative orbscan. The figure on the Fig. 22.17A and B: Phakonit with a rollable IOL orbscan re-
right is the one day post-operative orbscan. Note the sults. Note the similarity between the two orbscan pictures.
difference between the two orbscan pictures. This is the site This shows the minimal astigmatism created
where the clear corneal temporal incision was made

out and placed on the sterile tray. The lens is like a plate the injector the injection of the lens is done by the spongy
haptic IOL. The next step is to prepare the injector. First tip (Fig. 22.19) till one can see the lens coming into the
of all the injector tip is fitted with a sponge tip which nozzle of the cartridge.
comes with the cartridge. This will prevent the injector
tip from damaging the lens while inserting it inside the Lens Insertion Technique
eye. The lens is then taken out from the bottle/vial. After the Phakonit procedure is completed, the incision
The lens is then held with a forceps. The lens is then is increased to 1.5 mm. Then the tip of the cartridge
placed in the cartridge. Viscoelastic is injected in the is kept at the site of the incision. Remember the cartridge
cartridge and once the flanges of the IOL are in the is not inserted inside the anterior chamber. Now, the
groove of the cartridge the cartridge is closed and then lens is gradually inserted through the incision
inserted in the injector. Once the cartridge is fixed onto (Fig. 22.20). One can watch the lens unfolding inside
Phakonit 223

Section 2
Fig. 22.18: The Acri.Lye foldable IOL

Fig. 22.20: The IOL inserted through a 1.5 mm incision


Another technique by which one can perform Phakonit
is to use an anterior chamber maintainer. The authors
started this technique. They call it Three-port Phakonit.
Just as a three port vitrectomy, here also we have three
ports, hence the name—Three-port Phakonit.
Fig. 22.19: The tip of the Acri.Tec injector with the spongy There are pros and cons in every technique. The
tip ready in place to push the IOL problem in three port phakectomy is that it is too
cumbersome. Surgeons prefer to have two ports only.
Some surgeons prefer three ports as an anterior chamber
the capsular bag. The inferior haptic goes into the bag maintainer is present in the eye and thus the anterior
and the superior haptic is gradually tucked inside the chamber is always formed. At present it is easier to
capsular bag. Viscoelastic is then removed with the perform Phakonit using a 20 gauge irrigating chopper
Bimanual irrigation aspiration probes (Fig. 22.21). with the anti-chamber collapser.
224 Mastering the Art of Bimanual Microincision Phaco (Phakonit/MICS)

One of the real bugbears in Phakonit when we started
it was about the problem of destabilization of the anterior
chamber during surgery.1-5 This was solved