CME SERIES

phaco fundamentals
For The Beginning Phaco Surgeon

Supported by an unrestricted
educational grant from Bausch & Lomb

phaco fundamentals • 
Lesson Plans
Phaco Fundamentals 1.0
08 •••••••••••••••• 1. The Basic Phaco Machine
10 •••••••••••••••• 2. Concepts of Fluidics
12 •••••••••••••••• 3. Flow Balance & Tubing Compliance
14 •••••••••••••••• 4. Optimizing Phaco Fluidic Settings
An exploration of the basics of safe,
16 •••••••••••••••• 5. Fundamentals of Ultrasonic Phaco Power technically advanced cataract extraction
18 •••••••••••••••• 6. Continuous, Pulse, And Burst Phaco Modes
20 •••••••••••••••• 7. Hyper Settings
22 •••••••••••••••• 8. Variable Duty Cycle
24 •••••••••••••••• 9. Variable Rise Time And Custom Settings

T
26 •••••••••••••••• 10. Creating A Clear-Corneal Cataract Incision he causes of cataract are complex and that World War II aviators could tolerate shards of
28 •••••••••••••••• 11. Hand Position & Pivoting obscure, ranging from the unrelenting aircraft canopy glass in their eyes prompted him to
30 •••••••••••••••• 12. Bevel Position; Incision Spacing
forces of genetics and aging to the fate- use that material—actually polymethylmethacrylate,
ful impacts of environment, climate, or PMMA—to fashion the first intraocular lenses.
32 •••••••••••••••• 13. Foot Pedal Control During Steps Of Surgery diet, disease and trauma. Yet its effect Ridley’s innovation inspired surgeons to remove the
34 •••••••••••••••• 14. Viscoelastics: Dispersive & Cohesive is simple: the progressive cloud- opaque lens while leaving intact the
ing of the eye’s crystalline lens to capsular bag as a receptacle to hold
36 •••••••••••••••• 15. Capsulorhexis Creation the point of opaqueness, robbing The machine age saw his IOLs, and extracapsular cata-
•••••••••••••••• attempts to extricate
38 16. Hydrodissection and Hydrodelineation the patient of sight. Medicine’s ef- ract extraction was born. ECCE’s
forts to slow or halt this progression the lens via incision, breakthrough was the capsulotomy,
40 •••••••••••••••• 17. Concepts Of Nucleus Removal have failed. Yet—as was obvious but it wasn’t until removal of the anterior capsule to
42 •••••••••••••••• 18. Divide-and-Conquer Technique of Nucleus Removal even to the ancient Indian surgeon the second half of allow wholesale delivery of the
Sushruta—the answer to cataract nucleus, to be replaced by a PMMA
44 •••••••••••••••• 19. Stop-and-Chop Technique of Nucleus Removal lies in removing the obstruction to
the 20th century that
lens with known refractive quali-
46 •••••••••••••••• 20. Quick Chop Techniques of Nucleus Removal restore the passage of light onto the surgeons, empowered ties. It’s a nifty trick that remains
by microscopy and
48 •••••••••••••••• 21. Cortex Removal
macula. The history of cataract sur-
gery has been an unremitting quest
in many eye surgeons’ repertoires,
precision implements, and a staple of most residency train-
50 •••••••••••••••• 22. IOL Insertion to remove the obstacle—the no- finally succeeded at ing programs. Refinement of ECCE
52 •••••••••••••••• 23. Incision Closure & Dressings
longer-crystalline lens. Sushruta’s
genius was simply to nudge the ob-
cataract extraction. technique led to extraction via
smaller incisions that afforded sta-
54 •••••••••••••••• 24. Post-op Medications & Follow-up struction aside, a procedure called ble intraocular pressure during sur-
couching that persisted well into modern times. The gery and sealed without sutures, a variation called
machine age saw attempts to extricate the lens via manual small-incision cataract surgery. With SICS
incision, but it wasn’t until the second half of the and low-cost IOLs, cataract surgery now penetrates
20th century that surgeons, empowered by micros- even the world’s poorest communities and surgical
copy and precision implements, finally succeeded at volumes have risen into the millions.
Uday Devgan, MD, FACS cataract extraction.
Uday Devgan, MD, FACS is a cataract and refractive surgeon at the Maloney Vision Institute, the Yet the sheer mass of the cataractous lens posed a
premier private ophthalmic practice in Los Angeles, California. He performs the full spectrum Intracapsular cataract extraction involved removal physical barrier to smaller, less-traumatic incisions.
of corneal and lenticular refractive and restorative surgery and has instructed thousands of of the lens and capsular bag as one, with the refrac- Charles Kelman toppled this barrier with his idea of
surgeons in 30 countries. Dr Devgan is Chief of Ophthalmology at Olive View UCLA Medical tive power of the now-absent lens provided exter- emulsifying the nucleus inside the eye for removal
Center and Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of nally by massive “Coke bottle” spectacles. It’s hard via aspiration, a task accomplished with targeted
Medicine in Los Angeles, where he is the only faculty member to have earned the prestigious teaching award to believe today that ICCE was the state of the art ultrasound and dubbed phacoemulsification. Inci-
twice. Dr Devgan writes monthly columns in multiple ophthalmic journals worldwide and is a consultant for as recently as 1980. Sir Harold Ridley’s observation sions have been shrinking ever since, with advances
many major ophthalmic companies. He can be reached at www.UdayDevgan.com for further information.

 • WORLD REPORT CME SERIES phaco fundamentals • 

 Figure 1 Figure 2 Figure 3
in computer control and engineering and successive
generations of foldable IOLs allowing surgeons
to all but replicate the human lens with minimal
trauma to the eye. The incision-size benchmark for
WHAT IS YOUR PREFERRED EVALUATE HOW OLD IS
commercially available systems now has dropped CATARACT TECHNIQUE? YOUR PHACO SKILLS YOUR PHACO MACHINE?
below 2mm, as with Bausch & Lomb’s 1.8mm Stel-
Sample size: 1107 Sample size: 1060 Sample size: 779
laris™ platform and its Akreos™ MI60 foldable
intraocular lens.

While phacoemulsification has become the prevail-

3% 5%
ing standard in the industrialized world, where cata-
12% 13% 9%
ract usually is treated in its early stages before the
patient’s vision is dramatically impaired, this is not
the case in much of the world. In India and China, 35%
one can still encounter almost the entire history of 45%
cataract surgery—a relatively even mix of ECCE, 31% 55%
SICS and phaco punctuated by isolated pockets of
42%
ICCE and, by some experts’ telling, even linger- 50%
ing instances of couching. See figure 1. The good
news is that advanced surgical skills are spreading in
both countries. Surgeons are moving rapidly toward
phacoemulsification as more and more patients, in-
creasingly aware of the benefits of early interven-
tion, are expecting their ophthalmologists to use the PHACO SICS ECCE Other Basic Intermediate Advadced 1-3 Yrs 4-6 Yrs 7-9 Yrs 10 Yrs
& above
latest technologies.

But what exactly is phacoemulsification? While it’s

easy to conceptualize, it’s actually one of the most
complex forms of microsurgery—involving simul-
taneous machine-controlled irrigation and aspiration
to maintain anterior chamber stability, even while
the ultrasound tip manipulates and blasts away at
the nucleus. There’s a lot that can go wrong, and top
surgeons say the best defense against complications
is to know the technology as well as the procedure.
The purpose of this book, a compilation of the 24-
part Phaco Fundamentals series that was first syndi-
cated in Ophthalmology World Report, is to establish
a foundation of knowledge about all aspects of the
phacoemulsification system, its processes and its op-
erations. The author, Dr. Uday Devgan, is a renowned
U.S. surgeon in private practice at the Maloney Vi-
sion Institute in Los Angeles and associate clinical
professor of ophthalmology at the Jules Stein Eye
Institute in the School of Medicine of the University
of California, Los Angeles. Dr. Devgan has dedicat-
ed a large part of his teaching to understanding and
explaining the fundamentals of phaco in ways that
demystify the technology, and empower surgeons to
use it safely and to maximum advantage.
The Phaco Fundamentals series has given our World
Report editorial team a unique glimpse into the state
of cataract surgery in both India, where our circu-
lation exceeds 10,000 ophthalmologists, and China
where we have 17,000 registered readers. This com-
piled edition was requested by more than 3,000 doc-
tors in China and 1,100 in India, and each provided
a snapshot of their current practice. The compiled
data, comprising one of the largest surveys of cata-
ract ever undertaken in either country, revealed a
wide range of surgical skills and experience—and
a strong hunger for knowledge and surgical oppor-
tunity. In India, only about 14% of respondents de-
scribed their phaco skills as advanced, while 80%
placed themselves in the basic or intermediate cat-
egory. See figure 2. In both countries, doctors over-
whelmingly cited the cost of equipment as the main
barrier to their own adoption of phaco. Nonetheless,
the survey showed that Indian and Chinese ophthal-
mologists hold phaco in high regard, saying it was
attractive for clinical reasons—anterior chamber
stability, low rates of induced astigmatism, lower
rates of infection and other complications—as well
as practical ones such as patient comfort, reliability
and competitive market advantage. The study cap-
tured data about more than 2,000 phaco machines,
showing that large numbers are 4-5 years old and
likely to be replaced soon. See figure 3. Respon-
dents said their No.1 requirement in a replacement
system was affordability, followed by user friendli-
ness and ability to maintain a stable anterior cham-
ber during surgery.
About 70% of the 4,100-plus respondents said Phaco
Fundamentals was pitched to a comfortable level of
difficulty, but they also presented a long list of ideas
for further study—suggestions that editors are using
to design the next cycle, which we are calling Pha-
co Fundamentals 2.0. We’re preparing chapters on
many aspects of phaco practice, including the learn-
ing curve when transitioning to phaco from ECCE or
SICS, the different types of phaco systems, various
IOL types and applications, typical complications
and their management and pearls of best practice.
The editors of Ophthalmology World Report wish to
thank Dr. Uday Devgan for his brilliant insights and
clear explanations. And we thank Bausch & Lomb
for the unrestricted educational grant that made
Phaco Fundamentals possible. Finally, we wish to
thank the thousands of World Report readers who
requested the compilation and provided their views
and suggestions.
Jeffrey Parker
Editorial Director
Ophthalmology World Report

 • WORLD REPORT CME SERIES phaco fundamentals • 


Readers’
letters
More than 4,100 World Report readers
requested this Phaco Fundamentals
compilation, and many told us why.
Here is a sampling of reader views
about the 24-part series.
M O
y hospital focuses on cat-
aract, so I’m particularly excited
about receiving the consolidat-
ed edition of “Phaco Fundamentals”. I really
appreciate the cataract-related content of your
magazine. Your strong editorial focus on practi-
cality is really helpful for me in my work. I hope
to see more articles about the management of
post-cataract complications and difficult cases
as well as the perspectives and experiences of
experts from other hospitals, which can inform
my own practice. I also appreciate your report-
ing about various hospital management mod-
els and approaches, and hope to see more…
Wang Peng,
Xian Central Hospital, Xian First
Railway Bureau, Shaanxi province
 • WORLD REPORT CME SERIES
I I
am a regular reader of World
Report and find it very informative
in all aspects. The series by Dr.Uday
Devgan has been a wonderful guide for a bud-
ding surgeon like me. I would like to have the
booklet of the complete series of the “Phaco
Fundamentals” so that I can preseve it for a
lifetime…
Maithili Kulkarni,
Gandhinagar, Nagpur, Maharashtra
W
ith a population of 1.3 bil-
lion, China has millions of peo-
ple with cataract. Phacoemulsi-
fication is reaching just the tip of the iceberg,
and the scope for development is vast. Phaco
needs to be widely promoted and organized...
Zhang Xinkang,
Dawn Hospital, Yancheng, Jiangsu Province
O
phthalmology World Report
has earned the admiration of many
readers for its excellent reports,
speedy dissemination of knowledge and qual-
ity printing. It’s essential ready for me, and I re-
ally appreciate it. Compared to (its predecessor)
Ophthalmology Times, Ophthalmology World
Report is even more useful and authoritative. It
publishes the latest information about surgical
technique as well as the latest medical equip-
ment. Surgery requires both technical skills and
advanced equipment, and the “Phaco Funda-
mentals” series integrates both, giving valuable
insight into actual phaco operations….
He Haining,
Yan’an City Hospital, Shaanxi province
I I
’m an ophthalmologist and a
loyal reader. I’ve spent 20 years at the
grassroots, pioneering phaco surgery
for cataract, and find the magazine to be very
helpful. I save every issue of World Report as a
reference, but my set is incomplete so I really
hope to receive the collected issue of “Phaco
Fundamentals”....
Lü Jinyu,
Miyun County Central Hospital, Beijing
t’s indeed a fantastic effort on your
part to come out with a very simplified
yet comprehensive series on phaco
fundamentals, which is very useful for residents
like me…
Geetha Madhavan,
Sri Ramachandra University, Chennai
O
phthalmology World Report
carries a lot of cataract coverage
and the “Phaco Fundamentals”
series is really good. I’d like to see such se-
rial coverage of other topics too. I especially
like reading your Cover Story profiles, which
introduce practitioners’ work and career de-
velopment. Your reporting on both surgery and
therapies is so useful that I can put it directly
into practice, which is excellent…
Zhang Ximei,
Shanxi Provincial Eye Hospital
I
am very much impressed by Dr.
Uday Devgan’s “Phaco Fundamen-
tals” series. I wish to have the full se-
ries in the collected form. I wish to thank you
and Bausch & Lomb for offering the booklet
covering all 24 lessons at no charge…
S. Muthuramalingam,
Madurai, Tamil Nadu
phthalmology World Report
has become an important win-
dow through which I learn about
new clinical techniques, advances and ideas.
It is extremely helpful. My department is only
now embracing phacoemulsification. For a rel-
atively inexperienced doctor like me, I’m keen
to obtain an elementary knowledge of phaco
through your magazine and hope you can pro-
vide audio/visual discs and other training ma-
terials. Ten thousand thanks!
Zhou Jian,
Yicheng Hospital, Anqing City, Anhui Province
I
’m ardently awaiting my copy of
“Phaco Fundamentals” I hope your
magazine can organize more of this
type of training, which is extremely useful for
us on the front lines of clinical practice…
Xie Lianyong,
Mentougou District Hospital, Beijing
M
any thanks for the Phaco
Fundamentals series, from
which I have profited deeply.
My hospital doesn’t yet have phacoemulsifica-
tion, but I can learn all about phaco through
your magazine. This way, if conditions permit
we’ll definitely purchase a system. I hope you
can extend the the series to make it even more
splendid…
Chen Yanli,
Weian Sight Restoration Hospital,
Hebei Province
P
hacoemulsification has yet
to penetrate most county level
hopsitals, so grassroots practitio-
ners like me really need resources like Phaco
Fundamentals to shore up our learning. Please
continue to publish this kind of series….
Niu Lihe,
She County First People’s Hospital,
Handan, Hebei Province
P
lease acknowledge my re-
quest for the complete series of
“Phaco Fundamentals”. It is a fan-
tastic series for phacoemulsification beginners
like me…
Junaid S Wani,
SMHS and Associated Hospitals of
Government Medical College, Srinagar
have gone through the “Phaco
Fundamentals” lesson series and
found it very useful…
Jalpa Vashi,
BW Lions Eye Hospital, Bangalore
phaco fundamentals • 
LESSON 01 Figures 2,3,4

The Basic
Foot Position 2:

<eejF[ZWbFei_j_ed ?hh_]Wj_ed0<eejFei_j_ed' Vacuum / Aspiration of fluid

Phaco foot position 2 is the control of the relative aspira-

Phaco Machine
;AJ>9 tion and vacuum level of the fluid from the eye. There
7DIIA:
is a linear control of vacuum and flow, so that the top
of foot position 2 provides less vacuum or flow than the
Fei_j_ed' E=68DB68=>C:
middle or bottom range of the same foot position 2. This
^gg^\Vi^dc >GG><6I>DC
is similar to the gas pedal in a car, where the car’s throttle
All phaco platforms share the same basic structure and concepts. The A>C:
;DDIE:96A
is opened more as the gas pedal is further depressed. To
phaco machine aims to balance fluidics within the eye, while delivering create the vacuum and the aspiration flow of fluid, the
ultrasonic energy and vacuum in order to emulsify and Fei_j_ed(
aspirate the phaco machine must have a fluid pump. The most com-
Vhe^gVi^dc
E=68D
cataract through a small incision. EGD7: mon types of fluid pumps are peristaltic and venturi,
and these will be explained fully in future columns.
>gg^\Vi^dcd[[aj^Y^cidi]ZZnZ^h
Fei_j_ed) i]Z[jcXi^dcd[e]VXd[ddiedh^i^dc& The vacuum and aspiration levels that are created draw

T
he three main functions of the phaco machine ally works by depressing it towards the floor with the the fluid out of the eye and into a waste fluid collec-
e]VXd
are: (1) to provide irrigation into the eye, (2) to dominant foot (the right foot for most surgeons). Each tion via the outflow tubing. The regulation of vacuum
create vacuum/aspiration to remove the cataract, foot pedal position is additive to the previous positions,
and (3) to deliver ultrasound energy in order to emulsi- so that while the pedal is in position 2 (vacuum/aspira-
7if_hWj_ed0<eejFei_j_ed( and aspiration is controlled by the foot pedal, with more
depression of the pedal resulting in higher levels. There
fy the nucleus. These three functions correspond to the tion) it is also providing the full function of position 1 are two primary sources of fluid outflow during phaco-
three phaco foot-pedal positions. The phaco foot pedalE=68D;DDIE:96A
(irrigation). Similarly, once the pedal is in foot position emulsification: the outflow from the phaco probe cre-
is the primary instrument used to control the phaco ma-EDH>I>DC6C9;JC8I>DC
3 (ultrasound energy), it is also providing the function ated by the fluid pump, and the leakage of fluid from the
chine during cataract surgery. This foot pedal tradition- of position 2 (vacuum/aspiration), as well as position 1 incisions. [ Figure 3: Vacuum and aspiration of fluid from the eye is
(irrigation). [ Figure 1 illustrates additive pedal functions. ] ;AJ>9 the function of phaco foot position 1. ]
Figure 1 EJBE

Foot Position 1: Irrigation K68JJBA>C: L6HI:;AJ>9 Foot Position 3: Ultrasound Energy

<eejF[ZWbFei_j_ed ?hh_]Wj_ed 0<eejFei_j_ed'

It’s important to realize that during phacoemulsifica- The bottom-most position of the foot pedal is position
tion, we are working in the very small space of the 3, which controls the delivery of ultrasound energy into
anterior and posterior chambers,
;AJ>9 compromising well the cataract. There is linear control of the ultrasound
7DIIA:
under 1 cubic centimeter of space together. During KVXjjbVcYVhe^gVi^dcd[[aj^Y[gdbi]Z energy level so that further pedal depression results in
Fei_j_ed' the surgery we must always maintain the stability and
E=68DB68=>C: ZnZ^h[jcXi^dcd[e]VXd[ddiedh^i^dc more ultrasound energy, such as would be needed for a
structure within the eye, particularly to prevent col- denser cataract. Note that if the pedal is in position 3,
^gg^\Vi^dc lapse of the anterior and posterior chambers which can
>GG><6I>DC ;DDIE:96A
we are already engaging the full function of both posi-
lead to severe complications. A>C: tions 1 and 2. The irrigation is on, and the vacuum and
KbjhWiekdZ0<eejFei_j_ed) aspiration level is at its highest preset level. Ultrasound
Fei_j_ed( The irrigation function of the phaco machine is meant energy should only be applied once the tip of the phaco
Vhe^gVi^dc
E=68D
to provide a source of fluid EGD7:
infusion into the eye during probe is in contact with part of the cataract.
the surgery. By depressing the foot pedal to position 1,
>gg^\Vi^dcd[[aj^Y^cidi]ZZnZ^h
the infusion is turned on. There is no linear control of the When we look at the phaco probe closely, we see that
Fei_j_ed) infusion—the infusion isi]Z[jcXi^dcd[e]VXd[ddiedh^i^dc&
either turned on or turned off. there are three lines attached: (1) the infusion tubing
e]VXd The height of the infusion bottle determines the rela-
JAIG6HDJC9
EDL:GL>G:
carrying fluid into the eye, (2) the outflow tubing that
removes the fluid via flow that is created by the phaco
7if_hWj_ed
tive infusion pressure and flow rate during0<eejFei_j_ed(
the sur- machine’s fluid pump, and (3) the line that carries the
gery. To keep the eye inflated during surgery, we need electrical signals to control the ultrasound energy at the
E=68D;DDIE:96A to ensure that the fluid inflow rate is greater than the
fluid outflow rate.
tip of the phaco probe. These three lines correspond to
the three phaco foot pedal positions.
EDH>I>DC6C9;JC8I>DC Edh^i^dc(Xdcigdahi]ZYZa^kZgnd[i]Z
[ Figure 2: Irrigation of fluid into the eye is the function of phaco foot [ Figure 4: Foot pedal position 3 controls the delivery of the ultrasound
position 1. ]
jaigVhdjcYZcZg\n^cidi]ZZnZ energy into the eye. ]
;AJ>9
EJBE

K68JJBA>C: L6HI:;AJ>9
 • WORLD REPORT CME SERIES phaco fundamentals • 
 Zkh_d]
ikh][ho$
A[[f_d\bem
]h[Wj[h
j^Wdekj\bem
LESSON 02 je[dikh[
Figure 2

Concepts of Fluidics
ijWX_b_jo modulated by changing the bottle height and therefore the pressure
<bem?iH[bWj[ZJeJkX_d]I_p[
e\j^[[o[ gradient, as well as changing the radius of the inflow tubing. ]

Zkh_d]
6#HB6AA7DG:
ADL;ADL
7#A6G<:7DG:
=><=;ADL
K688JB
<:C:G6IDG
Modulating Fluid Outflow
ikh][ho$ For fluid outflow, there are two sources of fluid leav-
Due to the small volume of the anterior and posterior chambers, the ing the eye: (1) the fluid that is removed via the phaco
control of fluidics during phacoemulsification surgery is important to probe as a result of the vacuum level generated by the
ensure efficient removal of the cataract while preventing complica- fluid pump, and (2) fluid leakage from the incisions.
tions due to tissue collapse.
The rate of the fluid outflow via the phaco needle is
<bem?iH[bWj[ZJeJkX_d]I_p[ determined by the radius of the needle and tubing, as
Ed^hZj^aaZÉhZfjVi^dch]dlhi]VihbVaaZgWdgZijW^c\6 well as the change in pressure generated by the phaco
6#HB6AA7DG: 7#A6G<:7DG: K688JB
gZfj^gZh]^\]ZgkVXjjbVcYgZhjaih^cVadlZg[adl! machine’s fluid pump. The rate of the fluid outflow loss

T
he basic concept of fluidics is that the inflow of
fluid must be greater than the outflow of fluid.
By keep a constant infusion pressure and limit-
ing the outflow, we can ensure that the eye stays in-
flated and stable during surgery. If we allow the outflow
to exceed the fluid inflow, even for just a fraction of
a second, we experience surge within the eye and this
can cause chamber instability, collapse of the eye, and
aspiration of the posterior capsule. The primary rule for
phaco fluidics is to keep the inflow greater than the out-
flow. [ Figure 1: Keep inflow greater than outflow to ensure stability
of the eye during surgery. ]
Modulating Phaco Fluid Flow:
Poiseuille’s Equation
The basic equation that governs all fluid flow during
phacoemulsification surgery is Poiseuille’s Equation:
F = ΔP π r 4 / 8 η L
ADL;ADL =><=;ADL <:C:G6IDG
VhXdbeVgZYidaVg\ZgWdgZijW^c\7l]^X]XVcVX]^ZkZ
V]^\][adll^i]aZhhkVXjjbgZfjgZY#I]ZX]Vc\Z^c[adl^h
via the incisions depends on their size and the relative
ZmedcZci^VaangZaViZYidi]ZgVY^jhd[i]Zi^W^c\# fit of the instruments within these incisions.
Some degree of fluid leakage from the incisions is help-
The change in pressure, can be modulated by raising ful to allow cooling of the phaco needle and to prevent
or lowering the height of the bottle relative to the pa- thermal injury during surgery, particularly in early in
tient’s eye: the higher the bottle, the higher the infusion the learning stages of phacoemulsification. With the
pressure. The inflow tubing has a large radius in order use of advanced phaco power modulations, more ex-
Ed^hZj^aaZÉhZfjVi^dch]dlhi]VihbVaaZgWdgZijW^c\6
to maximize the flow and make sure that we keep our perienced phaco surgeons tend to move towards tighter
<bem?iH[bWj[ZJeJkX_d]I_p[
gZfj^gZh]^\]ZgkVXjjbVcYgZhjaih^cVadlZg[adl!
inflow greater than the outflow. Similarly, the size of
VhXdbeVgZYidaVg\ZgWdgZijW^c\7l]^X]XVcVX]^ZkZ incisions which can give more stable fluidics.

Figure 1
A[[f?D<BEM>EKJ<BEM
™DcZhdjgXZd[[aj^Y>C;ADL
"7diiaZd[WVaVcXZYhVaihdaji^dc
™IldhdjgXZhd[[aj^YDJI;ADL
"6he^gViZY[aj^Yk^Vi]Ze]VXdegdWZ
;sºEg
In this equation, F = flow, ΔP = pressure gradient, r = theV]^\][adll^i]aZhhkVXjjbgZfjgZY#I]ZX]Vc\Z^c[adl^h
infusion channel within the phaco probe (or other
radius of the tube, η = viscosity of fluid, and L = length
ZmedcZci^VaangZaViZYidi]ZgVY^jhd[i]Zi^W^c\#
infusion )
instrument) is kept as large as possible so as to
Ed^hZj^aaZ The composition, nature, and size of the inflow and
of the tube. We are concerned with the relative relation- not cause a bottleneck effect. [ Figure 3: Fluid inflow can be
:fjVi^dc outflow tubing are different.
ºE"egZhhjgZ\gVY^Zcig2gVY^jhd[i]ZijWZ
ship and not the exact values, therefore, for simplicity
we can simplify this formula. The viscosity of the fluid
is relatively constant, as is the length of the tubing. And
the values of pi and 8 are constant. This leaves us with ?D<BEM
Figure 3 EKJ<BEM
a simpler equation: F ~ ΔP r 4 ºE2YZiZgb^cZYWnWdiiaZ]Z^\]i ºE2YZiZgb^cZYWn[aj^Yejbe
<bem?iH[bWj[ZJeJkX_d]I_p[
g"YZiZgb^cZYWn[adlijW^c\ g"YZiZgb^cZYWndji[adlijW^c\h^oZ
Flow is proportional to the change in pressure times the

;sºEg)
"Adhhd[[aj^Y[gdb^cX^h^dcaZV`V\Z radius of the tubing to the fourth power. Because the h^oZ^c[adl^gg^\Vi^dc\^chigjbZci VcYdji[adle]VXdcZZYaZh^oZ
value for tubing size is exponential, a small change to Ed^hZj^aaZ
the radius results in a large change in the relative flow. :fjVi^dc
;aj^Y^c[adlXVcWZbdYjaViZYWnX]Vc\^c\i]ZWdiiaZ]Z^\]iVcYi]ZgZ[dgZi]Z
ºE"egZhhjgZ\gVY^Zcig2gVY^jhd[i]ZijWZ
This is clearly illustrated in a common sense situation egZhhjgZ\gVY^Zci!VhlZaaVhX]Vc\^c\i]ZgVY^jhd[i]Z^c[adlijW^c\#
A[[f_d\bem of drinking with straws. [ Figure 2: Poiseuille’s Equation shows
]h[Wj[h that smaller bore tubing (A) requires higher vacuum and results in a
?D<BEM EKJ<BEM
j^Wdekj\bem lower flow, as compared to larger bore tubing (B) which can achieve a
high flow with less vacuum required. The change in flow is exponen- ºE2YZiZgb^cZYWnWdiiaZ]Z^\]i ºE2YZiZgb^cZYWn[aj^Yejbe
je[dikh[ g"YZiZgb^cZYWn[adlijW^c\ g"YZiZgb^cZYWndji[adlijW^c\h^oZ
tially related to the radius of the tubing. ]
ijWX_b_jo h^oZ^c[adl^gg^\Vi^dc\^chigjbZci VcYdji[adle]VXdcZZYaZh^oZ
e\j^[[o[ Modulating Fluid Inflow
Zkh_d] The source of fluid inflow is the bottle of balanced salt
;aj^Y^c[adlXVcWZbdYjaViZYWnX]Vc\^c\i]ZWdiiaZ]Z^\]iVcYi]ZgZ[dgZi]Z
ikh][ho$ solution that is hanging on the phaco machine. The
egZhhjgZ\gVY^Zci!VhlZaaVhX]Vc\^c\i]ZgVY^jhd[i]Z^c[adlijW^c\#
two factors that determine the rate of inflow are: the
change in pressure and the radius of the inflow tubing.

10 • WORLD REPORT CME SERIES phaco fundamentals • 11

LESSON 03 Figures 2, 3, 4

Flow Balance &

of tubing due to high vacuum levels occurs most com-
9ebbWfi[ZJkX_d]Ijeh[i;d[h]o monly during occlusion of the phaco probe, and then
once the occlusion breaks, the tubing rebounds and the

Tubing Compliance
dXXajh^dcd[ijW^c\ surge occurs. This is called post-occlusion surge and
$i^el^i]XVigVXi
is one of the main causes of posterior capsule rupture
during cataract surgery.
Xdbea^VciijW^c\
XdaaVehZhVcY
hidgZhZcZg\n
Phaco Needle Sizing
Surge is the situation when the outflow of fluid from the eye exceeds edhi"dXXajh^dc The size of the phaco needle is important for phaco
the inflow, even for just a fraction of a second. When this occurs, hjg\Zl]Zc
fluidics because it affects the outflow rate. The impor-
ijW^c\gZWdjcYh
the chamber tends to collapse and the posterior capsule can be sucked tant thing to remember from Poiseuille’s Equation is
into the phaco probe in an instant, resulting in a ruptured posterior 8dbea^VciijW^c\XVcXdaaVehZ that the flow is proportional to the radius of the tube
capsule and vitreous loss. VcYXVjhZhjg\ZYjg^c\XViVgVXihjg\Zgn# to the fourth power. This means that a small change in
the size of the phaco needle can result in a very large
change in the flow. Comparing two common size pha-
co needles, 0.9mm versus 1.1mm, with all other fac-
<bem_iH[bWj[ZjeJkX_d]I_p[ tors equal it is surprising to see that the flow through
the larger 1.1mm needle is more than twice that of the
0.9mm needle. As the needle size decreases, the flow
&%%
drops exponentially.
-% G:A6I>K:;ADL
KH If we switch from a 1.1mm phaco needle to a 0.9mm

I
n order to maintain this flow balance, where the
inflow is always greater than the outflow, we can
use different sized tubing. If we look at the inflow
tubing we notice that it is significantly different than
the outflow tubing.
Figure 1
9ecfWh_iede\
Ekj\bemWdZ?d\bemJkX_d]
Ide/hbVaa!g^\^Ydji[adlijW^c\#
7diidb/aVg\Z![aZm^WaZ^c[adlijW^c\
Inflow vs. Outflow Tubing
The inflow tubing is large bore with walls that are thin,
and the tubing is very flexible. The purpose of this tub-
ing is to provide a high flow of fluid under low pressure
situations. The maximum pressure achieved within this
inflow tubing is determined by the height of the infu-
sion bottle, and this level is not very high.
The outflow tubing is smaller bore with thick walls, and
the tubing is very rigid and relatively non-compliant.
Because the flow varies exponentially with the radius
<bem_iH[bWj[ZjeJkX_d]I_p[
of the tubing, the smaller bore outflow tubing can help
ensure that the outflow is less than the inflow. The out-
flow tubing has rigid, thick walls in order for it to have
a low compliance which helps to prevent surge. The
maximum pressure achieved within the outflow tubing
is determined by the fluid pump of the phaco machine
and can easily exceed 500 millimeters of mercury.
This high vacuum level can cause collapse of the out-
flow tubing if its walls are too thin and of high com-
pliance. When the outflow tubing collapses, and then
rebounds back to its normal state after the vacuum lev-
el drops, this energy release causes an immediate and
dangerous surge of fluid out of the eye. This collapse
+%
E=68D9>6B:I:G needle, with all other phaco parameters unchanged, the
)%
relative flow will decrease by more than half—to 45%
'%
of the relative flow through the 1.1mm needle. In order
%
%#% %#& %#' %#( %#) %#* %#+ %#, %#- %#. &#% &#& &#' to achieve the same flow while decreasing the needle
size, a very substantial increase in the pressure gradient
;adlgViZkVg^ZhZmedcZci^Vaanl^i] is required.
i]Ze]VXdcZZYaZY^VbZiZg#
Once we determine the proper tubing size and phaco
needle size for our needs, we can then select the other
parameters of the phaco machine. Remember that the
tubing size and phaco needle size are explicit variables
that play an important role in the fluidics.
6hbVaaX]Vc\Z^ci]ZcZZYaZh^oZXVcgZhjai^cV
aVg\ZYZXgZVhZ^ci]Z[adlgViZ#
In our next lesson we will explain the variables that are
%#.bbi^e adjustable on the phaco machine: bottle height, vacuum
9>6B:I:G2%#.BB level, and aspiration flow rate. We’ll also examine the
G69>JH2%#)*BB
G69>JH)2%#%)&%BB)
two primary types of fluid pumps that are used in phaco
machines: peristaltic and venturi.
G:A6I>K:;ADL2)*
&#&bbi^e
9>6B:I:G2&#&BB Figure 1: Comparison of Inflow and Outflow Phaco Tubing.
G69>JH2%#**BB Figure 2: Compliant tubing can collapse and cause surge during
cataract surgery.
G69>JH)2%#%.&*BB)
Figure 3: Flow rate varies exponentially with the size of the phaco
G:A6I>K:;ADL2&%% needle radius/diameter.
Figure 4: A small change in the needle size can result in a large
decrease in the flow rate.

12 • WORLD REPORT CME SERIES phaco fundamentals • 13

LESSON 04

Optimizing Phaco
the cataract while we mechanically chop it. The effect
of the vacuum level varies with the bore of the phaco EYYkbki_edH[gk_h[Z
needle due to the effect of surface area. The larger the
je7Y^_[l[CWn_ckcLWYkkc

Fluidic Settings
cross-sectional surface area of the phaco needle, the
greater the holding power given the same amount of
vacuum. The vacuum level determines the “holding
DXXajh^dcCDI6X]^ZkZY
power” or “grip” of the phaco tip onto nuclear pieces. ADLkVXjjbaZkZa
EDDG\g^e[dgX]dee^c\

The challenge of cataract surgery arises in large part from the small Optimizing your settings
In order to optimize the phaco fluidic settings, it is im-
confines of the working space. The anterior and posterior chamber
portant to match the parameters to the technique and
combined typically comprise less than 1 cubic centimeter of space and
the surgeon’s preference.
provide very little room for error. The function of the phaco fluidics
is to balance the inflow and outflow of fluid in order to maintain the
The first decision is the selection of phaco needle size,
working space, bring cataract material to the phaco tip, and prevent with the most common sizes being the smaller-bore
collapse of the eye. Optimizing the phaco fluidic settings is instrumental 0.9mm needle and the larger bore 1.1mm needle size.
to the efficiency and safety of phacoemulsification surgery. If your preference is a quicker procedure with rapid
nucleus removal, the larger 1.1mm needle size is pre-
ferred since it will give a significantly greater flow rate.
If your preference is a slower but more controlled pro-
cedure, then the smaller-bore 0.9mm needle is more
suited to your technique.
The bottle height determines the inflow of fluid into the
eye. In order to help prevent surge, it is important to
keep the inflow of fluid greater than the outflow of fluid
at all times. The inflow of fluid comes from only one
DXXajh^dc>H6X]^ZkZY
B6M>BJBkVXjjbaZkZa
<DD9\g^e[dgX]dee^c\
D88AJH>DCD;I=:E=68DI>E>H
G:FJ>G:9ID68=>:K:
I=:EG:H:IB6M>BJBK68JJBA:K:A
L>I=E:G>HI6AI>8HNHI:BH
> Occlusion of the phaco tip is required to achieve the preset
maximum vacuum level with peristaltic systems.
ed to the phaco tip is determined by the peristaltic flow
rate, with 20cc/min being very slow and 50cc/min be-
ing very fast. The same vacuum and flow rate settings
can be used for the entire nucleus removal procedure
during phaco chop.
For divide-and-conquer, there are two distinct parts

W
ith a typical peristaltic phaco machine plat-
form, the most common type in the US mar-
ket, there are only a few parameters that are
adjustable: the bottle height, the flow rate, the maxi-
mum vacuum level, and the phaco needle size.
Perhaps the most important parameter is the selection
of phaco needle size. From our previous lesson, we re-
call that the difference in flow between a larger bore
needle and a small bore needle varies exponentially
due to Poiseuille’s Equation. In summary, the smaller
bore phaco needles are suited for high-vacuum, low-
flow fluidics, while the larger bore needles are better
suited for high-flow, low-vacuum fluidics. The analogy
of drinking a milkshake via a small bore cocktail straw
versus a larger bore drinking straw works well to il-
lustrate this point.
The flow rate for a peristaltic machine is typically giv-
en in cc of fluid per minute. This is determined by the
rate at which the peristaltic rollers milk the fluid along
the outflow tubing. With the phaco needle unobstructed
the maximum flow rate is achieved and in large part,
determines the speed at which things happen in the eye.
Upon occlusion of the phaco needle with cataract ma-
terial the flow rate declines and approaches zero. The
flow rate determines the speed at which things happen
in the eye during phacoemulsification.
The bottle height determines the inflow rate of fluid into
the eye. Very much like a water-tower in a small town,
the height of the fluid above the eye creates a force-
ful infusion of fluid via gravity: the higher the infusion
bottle, the greater the inflow pressure and inflow rate.
With an unobstructed phaco needle, the flow rate is at
the maximum, but the vacuum level is very low—very
far from the maximum vacuum level that the surgeon
has selected. The vacuum level in a peristaltic-based
system is only achieved upon occlusion of the phaco
tip. (Figure 1) The higher the vacuum, the greater the
holding power—and the holding power is used to fixate
source, the bottle of balanced salt solution, while the
outflow of fluid comes from two sources, the suction
via the phaco needle and the leakage from the incisions.
If, at any time, the outflow out-strips in the inflow, the
eye will collapse and there is a high likelihood of pos-
terior capsule rupture. It is often advantageous to start
with a high bottle height to ensure a sufficient inflow
of fluid, and then to taper it downwards to minimize
the posterior displacement of the lens-iris diaphragm
due to the infusion pressure. If you sometimes notice
corneal striae and anterior chamber instability during
your surgery, you may benefit from increasing the bot-
tle height.
For phaco chop, holding power of the nucleus is impor-
tant in order to securely fixate it while using the chopper
to mechanically disassemble the nucleus. This requires
a relatively high vacuum, such as 200-250 mmHg with
the 1.1mm needle, or 300-400mmHg with the 0.9mm
needle. Once the nucleus has been broken into smaller
fragments, the speed at which the fragments are attract-
of nucleus removal: sculpting of the nucleus and then
quadrant removal, and different fluidic settings are
required for each. For grooving and sculpting of the
nucleus, the work is being done by the ultrasonic en-
ergy and thus the flow and vacuum settings are quite
low – just enough to aspirate the nuclear material re-
moved from each forward stroke of the phaco probe.
A vacuum level of less than 100mmHg and a flow rate
of less than 30cc/min is sufficient for this purpose. For
quadrant removal, a moderate amount of holding pow-
er is required to bring each quadrant into the phaco tip.
Using a higher vacuum level of 200-300mmHg and a
flow rate of 30-50cc/min, depending on the needle size,
is typically sufficient for this purpose.
With knowledge of the concepts behind the variables,
it is easy to tailor the fluidic settings to the surgeon
and technique. Understanding the concepts behind the
phaco fluidic settings is instrumental in optimizing the
parameters for increasing the efficiency and safety of
your phaco technique.

14 • WORLD REPORT CME SERIES phaco fundamentals • 15

LESSON 05 Figure 1 Figure 2

Fundamentals of KbjhWiekdZ;d[h]o
KbjhWiekdZ;d[h]o
Ijhea[Yh[Wj[i
7FJ07Xiebkj[F^WYeJ_c[
7FJ0 7Xiebkj[F^WYeJ_c[

Ultrasonic
"bZX]Vc^XVa^beVXi
Ijhea[Yh[Wj[i 
6EI2E]VXdI^bZ6kZgV\ZE]VXdEdlZg
"XVk^iVi^dc$^beadh^dc
"bZX]Vc^XVa^beVXi
"[aj^YVcYeVgi^XaZlVkZ 6EI2
&*hZXdcYh&%%edlZg2&*hZXXdcYh6EI
E]VXdI^bZ6kZgV\ZE]VXdEdlZg
"XVk^iVi^dc$^beadh^dc
"]ZVih^YZh[[ZXi (%hZXdcYh&*%edlZg2&*hZXXdcYh6EI
"[aj^YVcYeVgi^XaZlVkZ &*hZXdcYh&%%edlZg2&*hZXXdcYh6EI
+%hZXdcYh&'*edlZg2&*hZXXdcYh6EI
"]ZVih^YZh[[ZXi (%hZXdcYh&*%edlZg2&*hZXXdcYh6EI

Phaco Power
+%hZXdcYh&'*edlZg2&*hZXXdcYh6EI
Id9ZXgZVhZ6EI
KVg^VWaZHigd`ZAZc\i]
d[bVm Id9ZXgZVhZ6EI
9ZXgZVhZE]VXdI^bZ
KVg^VWaZHigd`ZAZc\i] 9ZXgZVhZ6kZgV\ZE]VXdEdlZg
L^i]8dchiVci;gZfjZcXn
d[bVm
9ZXgZVhZE]VXdI^bZ
9ZXgZVhZ6kZgV\ZE]VXdEdlZg
L^i]8dchiVci;gZfjZcXn
The phaco ultrasound probe delivers energy into the eye that can
be used to break up the cataract to facilitate emulsification and Figure 3 Figure 4
aspiration. It accomplishes this by vibrating at a fixed frequency when Efjc_p[ZF^WYeI[jj_d]i KbjhW#bem7FJ06WhdajiZE]VXdI^bZ
the foot-pedal is depressed to position three. When we titrate the Efjc_p[ZF^WYeI[jj_d]i KbjhW#bem7FJ06WhdajiZE]VXdI^bZ
amount of ultrasound energy we place into the eye, we are keeping
the frequency constant but we are increasing the stroke length and
therefore, the total amount of energy.

ÆOZgdHZXdcYE]VXdÇÐ&hZXdcY
6EI2&,hZXdcYh)2%#+-hZXdcYh
ÆOZgdHZXdcYE]VXdÇÐ&hZXdcY
6EI2&,hZXdcYh)2%#+-hZXdcYh

for us automatically, and it displays as the “APT”. both the average phaco power and the phaco time. The
average phaco power can be decreased by limiting the
It makes sense that if you deliver 15 seconds of energy foot pedal depression in position three or by decreasing
at 100% power, it is about the same as 30 seconds at the maximum phaco power level on the machine.

T
he stroke of the phaco needle creates a mechani-
cal impact as the metal phaco needle hits the cata-
ract material. It also creates cavitation and implo-
sion as a microvoid is created just in front of the phaco
needle. A fluid and particle wave is propagated into the
cataract material, and heat is created as a by-product. It
is important to avoid choosing phaco power settings that
cause excessive heat build-up as this can burn the cornea
and damage the delicate ocular structures.
The phaco pinch test is a simple way to determine if
your ultrasound power settings are likely to cause an
incision burn in the eye. During wet lab testing, pro-
gram your selected settings into the phaco machine,
remove the protective silicone sleeve from the phaco
needle, grasp the needle between your fingers, and
push the foot-pedal all the way down. If your settings
cause excessive heat build-up, the needle will get hot
and may even burn your fingers. But it’s better to singe
your fingertips than fry your patient’s cornea.
During surgery, the phaco machine keeps track of the
average phaco power, given as a percentage of maxi-
mum, as well as the total time during which phaco ul-
trasonic power was delivered. These are displayed as
“U/S AVE,” which stands for “ultrasound average” and
“EPT,” which is “elapsed phaco time”.
We can measure and compare the amount of phaco en-
ergy that we use in surgery by calculating the APT: Ab-
solute Phaco Time. This is done by multiplying the “U/
S AVE” by the “EPT”, which the phaco machine does
50% power, or 60 seconds at 25% power. This is be-
cause for each of these three examples, the APT (Abso-
lute Phaco Time) is 15 seconds.
It is important to give as little ultrasonic phaco energy
as possible during the cataract surgery. The ultrasonic
energy can easily damage the corneal endothelial cells,
and excessive phaco energy can cause pseudophakic
bullous keratopathy and corneal decompensation. The
most important way to decrease the APT is to use a me-
chanical method of nucleus disassembly such as phaco
chop. This is far more efficient than techniques like di-
vide-and-conquer, resulting in less energy delivery as
well as shorter operative time.
To maximally decrease the APT, we need to decrease
The phaco time can be decreased by applying the ul-
trasonic power when cataract pieces are at the phaco
tip and are not aspirated by the vacuum forces alone.
Additionally, phaco time can be reduced by deliver-
ing smaller pulses or bursts of phaco energy instead
of continuous ultrasound. This method of breaking up
the ultrasonic energy into smaller packets of pulses and
bursts is called phaco power modulation and it will be
the subject of the next lesson.
With optimized ultrasonic phaco power parameters, it
is possible to remove cataracts with less than 1 second
of absolute phaco time, yielding immediate clear cor-
neas and happy patients.

16 • WORLD REPORT CME SERIES phaco fundamentals • 17

LESSON 06
Continuous, Pulse,
And Burst Phaco
Modes
The basic power settings are continuous, pulse, and burst. In the
continuous power setting, continuous energy is delivered with variable
power depending on how long the foot pedal is depressed. The maximum
power setting can be preset and then one has control of the maximum
amount of phaco power delivered—the longer the foot pedal is
depressed, the greater the phaco power.
n the pulse mode, the pulses of energy delivered
have variable power depending on how long the
foot pedal is depressed. The more time it is de-
pressed, the greater the power of each sequential pulse
of energy. The defining feature of pulse mode is that
after each pulse of energy delivered, there is a period
of time in which no energy is delivered between in-
creasing periods of energy, the “off” period. Alternat-
ing between the “on” and “off” pulse, reduces heat and
delivers half the energy into the eye.
Finally, in burst mode, each burst of energy has the same
power but the interval between each burst increases as
the foot pedal is depressed: The further the foot pedal
is depressed, the shorter the “off” period between each
burst. As a result, at maximum foot pedal depression,
the bursts of energy will become continuous delivery of
energy. When referring to modulations of phaco pow-
er, the terms “burst” and “pulse” may seem similar, but
they refer to two entirely different concepts.
Surgeons are familiar with the concept of “continuous”
phaco energy which is delivered in a linear fashion:
as the phaco foot-pedal is depressed, the energy level
increases. “Pulse” mode simply gives the same linear
control of phaco energy, however the energy is always
18 • WORLD REPORT CME SERIES
Figures 2, 3, 4
phaco machine to aspirate the cataract and then give
8Wi_YJof[ie\Fem[hCeZkbWj_ed F^WYe9edj_dkeki small bursts of phaco energy only when necessary. Be-
cause we can program these bursts of phaco power to
E]VXd8dci^cjdjh be very short (as quick as a few milliseconds), we can
effectively give hundreds of tiny bursts and still total
less than 1 second of total phaco time.
E]VXdEdlZg3
E]VXdEajhZ
Because the phaco foot-pedal now controls the rest in-
:[[ZXid[Ejh]^c\ terval between identical bursts, we do not have linear
i]Z;ddiEZYVa9dlc ;ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 control of the phaco power level. For this reason, it is
E]VXd7jghi important to use a lower phaco power setting when
using burst mode as compared to pulse or continuous
8dci^cjdjh:cZg\n9Za^kZgn modes. When the foot-pedal is maximally depressed,
KVg^VWaZEdlZgYZeZcY^c\dc
the rest interval between bursts is zero and the phaco
[ddieZYVaYZegZhh^dc probe essentially delivers continuous energy.
For surgeons using a divide-and-conquer technique of
F^WYeFkbi[ surgery, the foot-pedal can be maximally depressed
during grooving, thereby delivering continuous phaco
energy to facilitate sculpting of the nucleus. Then to
remove the quadrants, the foot-pedal is only partially
Figure 1 depressed in position 3 so that only bursts of phaco
E]VXdEdlZg3
power are used for segment removal. Finally, for the
8Wi_YJof[ie\Fem[hCeZkbWj_ed F^WYe9edj_dkeki epi-nucleus removal, the foot position 3 is barely en-
tered, and just a few bursts of energy are delivered for
E]VXd8dci^cjdjh ;ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 removal of the softer cataract portions.
Most phaco machines have two settings for burst mode:
E]VXdEdlZg3
8dci^cjdjh:cZg\n9Za^kZgn single burst and multiple burst. Single burst delivers
E]VXdEajhZ KVg^VWaZEdlZgYZeZcY^c\dc just one single burst of energy, for burying the phaco
:[[ZXid[Ejh]^c\ [ddieZYVaYZegZhh^dc probe into a nucleus for chopping. I do not ever use this
i]Z;ddiEZYVa9dlc ;ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 mode, but instead prefer multiple burst mode because I
E]VXd7jghi can still deliver just one single burst by barely entering
foot-position 3, and I still have the ability to deliver
F^WYe8khij
8dci^cjdjh:cZg\n9Za^kZgn many more bursts and varying intervals with further
KVg^VWaZEdlZgYZeZcY^c\dc foot-pedal depression.
[ddieZYVaYZegZhh^dc
For my technique of quick-chop, I typically use just
E]VXdEdlZg3
one phaco setting: Multiple burst mode, with a burst
time of 20 milliseconds, a power of 10%, and an end-
delivered in pulses. “Burst” mode defines a specific and
F^WYeFkbi[ point duty cycle of 50%. This means that I can give
identical “burst” of phaco energy, then as the foot-pedal ;ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 50 of these identical bursts at 10% power to equal just
is depressed, these identical bursts of energy are deliv- one second of continuous phaco at 10% power. Or in
ered more rapidly, until the interval of time between 7jghi:cZg\n9Za^kZgn absolute terms, I can give 500 of these identical bursts
E]VXdEdlZg3
bursts is infinitely small. KVg^VWaZ7jghi>ciZgkVaYZeZcY^c\dc at 10% power to equal just one second of continuous
[ddieZYVaYZegZhh^dc phaco at 100% power. It comes as no surprise that most
Burst mode allows a true phaco-assisted aspiration of ZkZgnWjghil^aa]VkZi]ZhVbZedlZg cataracts can be removed with an energy equivalent
the lens nucleus. We use the vacuum and fluidics of the ;ddiEZYVa9ZegZhh^dc^cEdh^i^dc(3 that is less than 2 seconds of absolute power at 100%.
8dci^cjdjh:cZg\n9Za^kZgn phaco fundamentals • 19
KVg^VWaZEdlZgYZeZcY^c\dc
LESSON 07 Figures 2, 3, 4

Hyper Settings
can set a burst mode as small as 4 milliseconds, which

>of[hI[jj_d]i =heel_d]%IYkbfj_d] is 125 times finer and more precise than using manual
A^`ZV[^cZanhZggViZY`c^[Z!]^\]ejahZgViZh control by the surgeon.
\^kZi]ZXjii^c\[ZZad[Xdci^cjdjhZcZg\n#
<gZViZggVc\Zd[edhh^W^a^i^Zh
The range of programmability of the pulse and burst phaco settings Modern surgery is primarily phaco-assisted aspira-
tion of the nucleus. The majority of the forces that are
has expanded considerably. While ™EjahZBdYZ/
previous generations of phaco 8dci^cjdjh
used to remove the nucleus from the eye are fluidic
platforms had pulse rates of up toVh]^\]Vh&'%ejahZh$hZXdcY
20 pulses per second, the newer forces—the flow, aspiration, and vacuum forces. The
generation machines have the ability to deliver up to 120 pulses per ultrasonic power delivery is there to assist the fluidics
™7jghiBdYZ/
second. Similarly, the older machines had burst widths as narrow as 30 &+ejahZh$hZX once a denser piece of nucleus is encountered. My pre-
VhadlVh)b^aa^hZX$Wjghi
milliseconds, while the new platforms are able to deliver burst widths ferred setting for phaco surgery is burst mode, with a
as fine as just 4 milliseconds. very fine burst width. As the pedal is depressed further
&'%ejahZh$hZX in foot-position 3, the rest interval between bursts de-
creases until the burst width and rest interval are equal,
:bjaViZ8dci^cjdjhE]VXd resulting in a 50% duty cycle. The effective number
l^i]>7B<i]ZZcZg\n of bursts per second increases as the rest interval de-
creases and using a burst width of 5 milliseconds and
allowing 5 milliseconds of rest between each burst, the
;\\[Yje\Fkbi[i%I[YedZFFI maximum number of bursts per second is 100. (Math: 1
8dci^cjdjh 8]Vc\^c\i]ZEEHl^aadejbV\^XVaan second / 10 millisecond cycle = 100 bursts per second).
Figure 1
YZXgZVhZi]Z6EI/ This results in being able to effectively control the duty

T
he advantage of this upgraded range of program- cycle and the burst rate per second at the same time via
mability is the smoothness and precision of pow- >of[hI[jj_d]i =heel_d]%IYkbfj_d] the foot-pedal.
er delivery. With the standard settings in pulse EjahZY A^`ZV[^cZanhZggViZY`c^[Z!]^\]ejahZgViZh
'EEH
mode, where each pulse is as long as each rest period, \^kZi]ZXjii^c\[ZZad[Xdci^cjdjhZcZg\n# For surgeons who wish to continue to perform their
dhZX
the pulse mode can deliver good cutting power with half
<gZViZggVc\Zd[edhh^W^a^i^Zh
&hZX 'hZX
standard technique of phaco-emulsification, simply
the energy of continuous phaco energy. [ Figure 1 ] ™EjahZBdYZ/ 8dci^cjdjhchanging from continuous phaco power to a hyper
Vh]^\]Vh&'%ejahZh$hZXdcY pulse rate of 100 pulses per second will allow them
-EEH
The more pulses per second we can give, the smoother to cut the energy delivery in half. This halving of the
the power delivery will be—very similar to serrations ™7jghiBdYZ/ dhZX &hZX 'hZX
ultrasound energy will result in less endothelial cell
&+ejahZh$hZX
on a knife. If we want to harness the sculpting and cut- VhadlVh)b^aa^hZX$Wjghi damage, less heat production, and clearer corneas and
ting ability of the phaco hand-piece for grooving of sharper vision immediately post-op. For surgeons who
the cataract nucleus, it makes sense that a knife with a perform the divide-and-conquer method of nucleus dis-
smooth blade would cut well. A coarsely serrated knife &'%ejahZh$hZX
assembly, make the switch to a hyper pulse mode and
with large, widely spaced serrations would not cut as
:bjaViZ8dci^cjdjhE]VXd
;\\[Yje\Fkbi[i%I[YedZFFI you will immediately perform better surgery without a
smoothly. However if we use a very finely serrated 8]Vc\^c\i]ZEEHl^aacdibV\^XVaan change in your technique.
knife, it would likely cut the best of all. Using a very l^i]>7B<i]ZZcZg\n YZXgZVhZi]Z6EI/
high pulse rate of 100 or more pulses per second results Changing the number of pulses per second does NOT
in the cutting ability of a very finely serrated knife, yet ;\\[Yje\Fkbi[i%I[YedZFFI
change the amount of power delivered into the eye.
delivers half of the energy of continuous phaco power. 8]Vc\^c\i]ZEEHl^aadejbV\^XVaan Whether we give 2 pulses per second or 8 pulses per
[ Figure 2 ]
8dci^cjdjh 'EEH
second, note that the total energy, as represented by the
YZXgZVhZi]Z6EI/
green blocks, is the same. [ Figures 3 and 4 ] The same
Hyper settings in burst mode allow finer and more pre- applies when we compare 10 pulses per second to 100
-EEH
cise delivery of bursts of phaco power. If we use con- pulses per second. The reduction in the amount of en-
tinuous phaco energy mode and try to use our foot to EjahZY 'EEH
ergy delivered is due to the ratio of the on:off pulses,
dhZX &hZX 'hZX
deliver small bursts of phaco power, the best we can dhZX &hZX 'hZX which is known as the duty cycle. In our next lesson,
do is about a half-second of energy per pulse, which is I]ZIdiVa6bdjcid[E]VXd:cZg\nYZa^kZgZY^h:FJ6A# we will explain duty cycles and their effect on phaco
500 milliseconds. Using the newer hyper settings we power delivery.
-EEH

20 • WORLD REPORT CME SERIES dhZX &hZX 'hZX phaco fundamentals • 21

 GVi^dd[DCidD;;^h'%/-%!]ZcXZ(&ZkjoYoYb[

LESSON 08 '*%bhZXdc '*%bhZXd[[ '*%bhZXdc '*%bhZXd[[

Variable Duty Cycle

=:6I 8DDA =:6I 8DDA Figure 2
%hZX
LWh_WXb[:kjo9oYb[
:mVbeaZVi'EjahZh$HZXdcY &hZX

GVi^dd[DCidD;;^h*%/*%!]ZcXZ+&ZkjoYoYb[
the quadrants. For this quadrant removal, a lower duty
cycle of 20-40% can be used since the principal force for
=heel_d]%IYkbfj_d] nucleus removal is the fluidics and not the ultrasound.

Egd\gVbb^c\ Using the variable duty cycle programming allows the

When we choose a mode such as pulse mode, LWh_WXb[:kjo9oYb[
which alternates phaco k^VGViZh surgeon to deliver just the right amount of ultrasound
power pulses with periods of rest, the default ratio is 50:50.
LZXVcX]Vc\Zi]ZYjinXnXaZid'%
*%YjinXnXaZ &%EjahZ$HZXdcY energy during each phase of surgery. The concept to re-
This is called a 50% duty cycle, as each complete cycle is composed of )%YjinXnXaZ member is that a higher duty cycle results in better cut-
energy on for 50% of the time, then energy off for 50% of the time. ting power but increased heat generation and more ener-
This default ratio can be changed to alter the ratio of ultrasound gy-related damage to the corneal endothelium. Using the
energy to the rest interval. lower duty cycle allows more fluidic aspiration of nucle-
'%YjinXnXaZ ar fragments while minimizing heat and phaco power,
resulting in clear corneas immediately after surgery. And
we all know that clear corneas on post-op day one make
&%%bhZXdc
=:6I EDj_c[
)%%bhZXd[[
8DDA
&%%bhZXdc
=:6I
)%%bhZXd[[
8DDA
for good visual acuity and very satisfied patients.
%hZX :mVbeaZVi'EjahZh$HZXdcY &hZX
"JaigVhdjcY:cZg\n9Za^kZgZY
GVi^dd[DCidD;;^h'%/-%!]ZcXZ(&ZkjoYoYb[
"?VX`"]VbbZgGZejah^dc:[[ZXi
"=ZVi<ZcZiViZY
Figures 3, 4

E<<j_c[

U
ltrasound energy creates helpful cavitation and Figure 1 9^gZXiEgd\gVbb^c\ LWh_WXb[:kjo9oYb[
"6he^gVi^dcd[CjXaZVg;gV\bZcih
mechanical forces that are used to break up
"8dda^c\d[E]VXdI^e
)%bhZXDCi^bZ >cEjahZBdYZ!
the cataract nucleus; however, this energy also
LWh_WXb[:kjo9oYb[
"CdJaigVhdjcY:cZg\n +%bhZXD;;i^bZ i]ZYZ[VjaiYjinXnXaZ^h*%
can create significant heat. The jack-hammer effect of
ultrasound energy can cause repulsion of the nuclear =heel_d]%IYkbfj_d]
fragments from the phaco tip. It is helpful to alternate
periods of phaco energy with rest periods, as the rest Egd\gVbb^c\
periods are when we achieve cooling of the phaco In the pulse mode, the default duty cycle is 50%. [ Figure
k^VGViZh
needle and aspiration of the nuclear fragments. If we *%YjinXnXaZ 3 ] For instance, the pulse is “on” for 250 msec and “off”
&%EjahZ$HZXdcY
change the ratio of the on period, when ultrasound en- for 250 msec. The benefit of the new power modulation '*%bhZXdc '*%bhZXd[[ '*%bhZXdc '*%bhZXd[[
)%YjinXnXaZ =:6I 8DDA =:6I 8DDA
ergy is delivered, to a shorter duration, then we can fa- software is that the duty cycle can be changed. For ex- %hZX :mVbeaZVi'EjahZh$HZXdcY &hZX
vor the aspiration and cooling of the phaco needle over ample, we may select a duty cycle of 20%, which results GVi^dd[DCidD;;^h*%/*%!]ZcXZ+&ZkjoYoYb[
the heat generation and jack-hammer repulsion effects in 100 msec “on” and 400 msec “off”, giving a ratio of
of the ultrasound. [ Figure 1 ] 20:80. [ Figure 4 ] We can then harness the benefits of a
'%YjinXnXaZ
lower duty cycle which results in longer cooling time for
To program in a change in this ratio, there are two dis- the phaco needle, thus decreasing the amount of phaco LWh_WXb[:kjo9oYb[
tinct methods: entering a new duty cycle or direct pulse EDj_c[ energy delivered to the eye. In addition, during the ex-
LZXVcX]Vc\Zi]ZYjinXnXaZid'%
programming. For example, if I am using 10 pulses per "JaigVhdjcY:cZg\n9Za^kZgZY tended “off” time, no energy is delivered and nuclear
second and I’d like to slightly reduce the ultrasound "?VX`"]VbbZgGZejah^dc:[[ZXi fragments can be easily aspirated.
energy, I can decrease it from a 50% duty cycle to a "=ZVi<ZcZiViZY
40% duty cycle. This can be done by dropping the duty When do we want higher or lower duty cycles? The
cycle ratio as seen on the control panel of the phaco answer depends on the phase of surgery. For sculpting
platform. Alternatively, I can delineate the specific on E<<j_c[ 9^gZXiEgd\gVbb^c\
the nucleus, such as with the technique of divide-and-
and off periods for each cycle, with an on-time of 40 "6he^gVi^dcd[CjXaZVg;gV\bZcih conquer, we need to deliver sufficient energy to be able
milliseconds followed by an off-time of 60 millisec- "8dda^c\d[E]VXdI^e
)%bhZXDCi^bZ
to cut the grooves. This requires a duty cycle of about
&%%bhZXdc
=:6I
)%%bhZXd[[
8DDA
&%%bhZXdc
=:6I
)%%bhZXd[[
8DDA

onds, I will achieve the same result—a total cycle time "CdJaigVhdjcY:cZg\n +%bhZXD;;i^bZ
40-60%. Once we have the grooves placed in the nucle- %hZX :mVbeaZVi'EjahZh$HZXdcY &hZX

of 100 milliseconds, with 10 pulses per second and a us and we have cracked it into quadrants, we can use a GVi^dd[DCidD;;^h'%/-%!]ZcXZ(&ZkjoYoYb[
40% duty cycle. [ Figure 2 ] lower duty cycle during the phaco-assisted aspiration of

22 • WORLD REPORT CME SERIES phaco fundamentals • 23

LESSON 09 Figure 2 Figure 3

Variable Rise Time Fkbi[I^Wf_d]0

LWh_WXb[H_i[J_c[
Fkbi[I^Wf_d]0
LWh_WXb[H_i[J_c[
8[d[\_jie\LWh_WXb[H_i[J_c[
9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n

And Custom Settings

GVbe^c\"JeZVX]ejahZ GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n YZa^kZgZY^cidi]ZZnZ
&%%bhZXgVbe &%%bhZXgVbe 8dda^c\WZilZZcejahZh 8dda^c\WZilZZcejahZh

Keep in mind that the ultrasonic phaco power is a repulsive force: HfjVgZLVkZEahZh
like a jack-hammer, the phaco needle moves back and forth into the
cataract at a fixed frequency (between 28,500 times/second E]VXd:cZg\nHVkZY
and 40,000 times/second, depending on the platform).
'*%bhZXdc '*%bhZXd[[ '*%bhZXdc '*%bhZXd[[
We’ve all seen this during surgery and often call =:6I
it “chatter”—
8DDA =:6I 8DDA

%hZX :mVbeaZVi'EjahZh$HZXdcY &hZX

when the ultrasonic power mechanically pushes Fkbi[I^Wf_d]0 Fkbi[I^Wf_d]0
'*%bhZXdc
=:6I
'*%bhZXd[[
8DDA
'*%bhZXdc
=:6I
'*%bhZXd[[
8DDA 8[d[\_jie\LWh_WXb[H_i[J_c[
GVbeZY"JeEjahZh
the nucleus off the phaco tip. LWh_WXb[H_i[J_c[ LWh_WXb[H_i[J_c[
%hZX :mVbeaZVi'EjahZh$HZXdcY &hZX
9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n
GVbe^c\"JeZVX]ejahZ GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n YZa^kZgZY^cidi]ZZnZ
&%%bhZXgVbe &%%bhZXgVbe 8dda^c\WZilZZcejahZh 8dda^c\WZilZZcejahZh
Suggested settings for surgeons ting a maximum level of 10-30% is suggested. Keep
First, remember to keep your phaco needle and all the burst width short, between 20 and 80 milliseconds,
vacuum and flow levels the same as to what you are ac- and make sure that you use an “end-point duty cycle” of
HfjVgZLVkZEahZh
customed. Also, no change in your surgical technique is 50%. Depending on your machine, you may have to en-
needed. The only thing that we will be changing is the ter >of[h9eeb8_cWdkWbF^WYe
this as a “minimum burst interval” which should be

T
E]VXd:cZg\nHVkZY
o reduce the repulsive force of phaco we can or burst width is so short that there is insufficient time way that the phaco power will be delivered. set equal to your burst width in milliseconds to achieve
decrease the phaco power, but this isn’t always to fully ramp '*%bhZXdc
up each packet of phaco'*%bhZXdc
'*%bhZXd[[ energy. For'*%bhZXd[[
ex- the effective end-point duty cycle of 50%.
=:6I 8DDA =:6I 8DDA
the best answer, particularly when a nucleus is ample, if it %hZX
takes 40 milliseconds to ramp-up the
:mVbeaZVi'EjahZh$HZXdcY
power &hZX
If you are accustomed to continuous phaco mode, you
dense and requires more phaco power for emulsifica- from zero to the preset level, but the defined burst width will likely have an easy
'*%bhZXdc
=:6I 8DDAtime starting
'*%bhZXd[[
=:6I with a hyper-pulse
'*%bhZXdc '*%bhZXd[[
8DDA You can further tailor your settings GVbeZY"JeEjahZh
to better suit your
tion. Instead, if we initially attack the nucleus with is just 25 milliseconds, the desired phaco power level mode%hZX
of 60-120 pulses/second, initially
:mVbeaZVi'EjahZh$HZXdcY at a 50%&hZX duty technique and your patient population, without chang-
lower power, then hold on to it with the vacuum fluid- will not be achieved. cycle, and using the same maximum phaco power that ing your surgical technique. Transitioning to the new
ics of the phaco machine, we can ramp up the power to you’re used to. This one simple change will likely cut phaco power modulation software is an easy way to
a higher level. The new phaco power modulation soft- Figure 1 your total phaco time and energy in half with virtually improve your surgical outcomes and efficiency while
ware on most platforms allows this automatically, with no effect on your technique. decreasing the heat and energy placed into the eye.
millisecond precision. Fkbi[I^Wf_d]0 Fkbi[I^Wf_d]0 8[d[\_jie\LWh_WXb[H_i[J_c[
6YkVcXZhEdlZgBdYjaVi^dc^hVGZfj^gZbZci
LWh_WXb[H_i[J_c[ LWh_WXb[H_i[J_c[
If you are accustomed to a pulsed phaco mode, you will
Figure 4
Burst and pulse modes deliver square-wave energy by have an easy time staying with about the same number9ZXgZVhZhi]ZVbdjcid[e]VXdZcZg\n
GVbe^c\"JeZVX]ejahZ GVbe^c\"JeVeVX`Zid[e]VXdZcZg\n
default, which means the power goes from zero to the of pulses per second and keeping your maximum phacoYZa^kZgZY^cidi]ZZnZ
>of[h9eeb8_cWdkWbF^WYe
preset level immediately, and the resulting waveform &%%bhZXgVbe &%%bhZXgVbe
power the same, while
8dda^c\WZilZZcejahZh
decreasing your duty cycle to
8dda^c\WZilZZcejahZh
on the oscilloscope looks like a square. With a variable 25-45%. You can then implement a variable rise time in
rise time, we can have the phaco energy ramp-up over order to further decrease the total phaco time and ener-
the course of each individual pulse or burst, resulting in gy and enhance purchasing power and follow-ability. HfjVgZLVkZEahZh
a ramped wave. [ Figures 1, 2, 3 ]
Phaco chop surgeons will have an easier time adapt-
This ramping up of the energy allows better follow- ing to hyper-burst mode. Keeping in mind that you will E]VXd:cZg\nHVkZY
ability of the nuclear pieces and less chatter at the phaco '*%bhZXdc '*%bhZXd[[ '*%bhZXdc '*%bhZXd[[ be controlling the interval between identical bursts via
=:6I 8DDA =:6I 8DDA
tip, and it results in less energy and less heat delivered %hZX :mVbeaZVi'EjahZh$HZXdcY &hZX
the third position, you should keep the maximum phaco
into the eye. There are situations where it is difficult to '*%bhZXdc
power level'*%bhZXd[[
relatively '*%bhZXdc
low. You will'*%bhZXd[[
be
8DDAunable to vary
6YkVcXZhEdlZgBdYjaVi^dc^hVGZfj^gZbZci
=:6I 8DDA =:6I GVbeZY"JeEjahZh
use a variable rise time, such as when the pulse width %hZXthe percentage power level with
:mVbeaZVi'EjahZh$HZXdcY your foot pedal,
&hZX so set-

24 • WORLD REPORT CME SERIES phaco fundamentals • 25

LESSON 10 Figures 2, 3, 4, 5, 6

Creating
about half to two-thirds of corneal depth and well cen-
HiZeeZYkhHigV^\]i>cX^h^dch 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç >DE;dgXZh>cX^h^dcH]ji
tered on the incision. The tension should be enough to
H]dgiIjccZa seal the incision well, yet not so much as to induce a

A Clear-Corneal
™bdgZVhi^\bVi^X large astigmatic effect. [ Figure 5 ]
™cdÈdVg"adX`^c\É
™bdgZaZV`^c\ >DEejh]Zhi]Z^cX^h^dch]ji
For managing astigmatism, keep in mind that longer
tunnels have less effect and are considered astigma-

Cataract Incision
BniVg\Zi>DE2'*id(%bb=\
:cigVcXZ^cid68^hidd tism-neutral, while the shorter incision cause flattening
("hiZeh '"hiZeh higV^\]i edhiZg^dg#iddXadhZid^g^h
and therefore are astigmatism-inducing. [ Figure 6 ]
DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I=
8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç Due to theL]Zc^cYdjWi/EaVXZVHjijgZ
increased surface area created from a longer
tunnel length, the longer incisions tend to seal much
For phacoemulsification, the use of clear-corneal incisions has become BZY^jbIjccZa better. [ Figure 7 ]
™b^aYVhi^\bVi^XZ[[ZXi
very common for many reasons: they are easy to construct, ™a^iiaZÈdVg"adX`^c\É
they provide good access to the cataract, and they seal well. ™aZhhaZV`^c\ The intra-ocular pressure at the end of the surgery ex-
erts an outward force which pushes on the inner part of
the incision and keeps the corneal layers tightly sealed.
&%"%cnadcdg&%"%k^Xgna
Patients may experience some initial post-operative
hypotony, so ensuring a long tunnel length will help
prevent any incisional leakage. Phaco surgery is com-
8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç monly referred to as “sutureless,” but the prudent sur-
geon knows the value of a well-placed suture when the

I
n a typical phacoemulsification, two incisions are
created: the main incision and a secondary incision,
the paracentesis. These are typically placed ap-
proximately 60 to 90 degrees apart, with the non-domi-
nant (usually left) hand at the paracentesis, while the
dominant (usually right) hand is at the main incision.
In addition, the main incision can be made at the steep
axis so as to help reduce astigmatism at this meridian.
Incisions can be made stepped or straight: a stepped inci-
sion has 2 or 3 different planes, while the straight inci-
sion has just one plane. There may be advantages with Adc\IjccZa situation dictates. [ Figure 8 ]
™cdVhi^\bVi^XZ[[ZXi
the stepped incisions, particularly if a hinge is created. [ ™bdgZÈdVg"adX`^c\É
™cdaZV`^c\
Figure 1 ] Well-constructed clear corneal incisions are an integral
part of modern-day phacoemulsification and a tech-
However, all of these incisions have one thing on com- nique that cataract surgeons should know.
mon: they have long tunnel lengths. [ Figure 2 ]
Figures 7, 8
The longer tunnel lengths allow better sealing of the
H]dgiZgIjccZah2BdgZ;aViiZc^c\
HiZeeZYkhHigV^\]i>cX^h^dch
incision and less induction of astigmatism, and for 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç
))#%%.% ))#*%.%
>DE;dgXZh>cX^h^dcH]ji
these reasons, making a more square incision is rec-
ommended. The longer tunnels may have more of an H]dgiIjccZa
™bdgZVhi^\bVi^X
))#%%&-% )(#*%&-%

“oar-lock” feeling, where maneuverability within the ™cdÈdVg"adX`^c\É

eye is somewhat limited, however this is usually quite ™bdgZaZV`^c\ >DEejh]Zhi]Z^cX^h^dch]ji
Figure 1 manageable. [ Figure 3 ]

HiZeeZYkhHigV^\]i>cX^h^dch The shorter 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç

("hiZehlengths cause
tunnel '"hiZeh higV^\]iflat-
more astigmatic >DE;dgXZh>cX^h^dcH]ji
:cigVcXZ^cid68^hidd
Bed][hJkdd[bi2AZhh;aViiZc^c\
edhiZg^dg#iddXadhZid^g^h
6hi^\bVi^hbCZjigVa>cX^h^dch
I^ehj[hJkdd[bi2BdgZ;aViiZc^c\
6hi^\bVi^hb>cYjX^c\>cX^h^dch BniVg\Zi>DE2'*id(%bb=\
tening at that meridian and they do not seal nearly as
H]dgiIjccZa
DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I=
well. While there is less “oar-lock” effect, the more Adc\ZgIjccZah27ZiiZgHZVa^c\
L]Zc^cYdjWi/EaVXZVHjijgZ
™bdgZVhi^\bVi^X
posterior entrance into™cdÈdVg"adX`^c\É
the anterior chamber may be 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç
™bdgZaZV`^c\
prone to iris prolapse through the incision. [ Figure 4 ] If >DEejh]Zhi]Z^cX^h^dch]ji
BZY^jbIjccZa
there is any doubt as to the water-tightness of the inci- ™b^aYVhi^\bVi^XZ[[ZXi
sion, it is better:cigVcXZ^cid68^hidd
to place a suture to close the incision. ™a^iiaZÈdVg"adX`^c\É
("hiZeh '"hiZeh higV^\]i edhiZg^dg#iddXadhZid^g^h BniVg\Zi>DE2'*id(%bb=\
™aZhhaZV`^c\

To suture the corneal incision, 10-0 nylon or 10-0 vic-

DcZi]^c\^cXdbbdc/ADC<IJCC:AA:C<I= ryl is typically used, with the knot rotated to bury it
8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç
within the corneal stroma. The suture should be placed L]Zc^cYdjWi/EaVXZVHjijgZ
Bed][hJkdd[bi27ZiiZghZVa^c\
6hi^\bVi^hbCZjigVa>cX^h^dch
I^ehj[hJkdd[bi2BdgZAZV`^c\
6hi^\bVi^hb>cYjX^c\>cX^h^dch
&%"%cnadcdg&%"%k^Xgna
BZY^jbIjccZa
™b^aYVhi^\bVi^XZ[[ZXi
26 • WORLD REPORT CME SERIES ™a^iiaZÈdVg"adX`^c\É 8aZVg@>cX^h^dcÆIjccZaAZc\i]Ç phaco fundamentals • 27
™aZhhaZV`^c\

LESSON 11
Hand Position
& Pivoting
WE SPEND MANY YEARS WRITING AND DEVELOPING THE NEURAL PATHWAYS FOR
FINE HAND MOTOR CONTROL BEFORE WE EVER PICK UP A PHACO PROBE.
IT IS EASIER AND MORE NATURAL FOR MOST PHACO SURGEONS TO HOLD THE PHACO
PROBE LIKE A PEN, PARTICULARLY GIVEN THE probe’s PEN-LIKE SHAPE.
I
f you look closely at the phaco tip—at the phaco
needle itself—you will see that it is cut at an angle,
thus giving a bevel. Most phaco needles that are
used today have a bevel to increase their utility and
usefulness during cataract surgery.
The strength of the grip is inversely related to the fine
motor control: the lighter the grip, the better the control.
If I had a stack of ten sheets of paper interspersed with
sheets of carbon paper, and then I asked you to write
forcefully enough so that even the bottom carbon copy
was legible, you would utilize a very strong grip. But
the quality of the writing would be very poor. On the
other hand, if I asked you to write as neatly as possible
on a single sheet of paper with your prettiest calligra-
phy writing, you would use a very fine, light grip. This
fine, light grip is best suited for the phaco probe and
for intra-ocular surgery.
The position of the hands should be at the patient’s eye
level, with both hands resting comfortably with the
shoulders relaxed. The hands can lightly rest on the
patient’s draped face/head or on a separate wrist-rest.
The control of the phaco probe and intra-ocular instru-
28 • WORLD REPORT CME SERIES
Pivot Action with Oars in a Rowboat
Figures 2, 3, 4
the cornea and impair the view within the eye. With
the delicate balance of fluidics in phacoemulsification, Hand Control : do NOT push down!
distortion of the incision can lead to excessive leak-
age and an unstable chamber leading to a high risk of
capsule rupture. Finally, remember that the ultrasonic
Lose Viscoelastic
energy from the phaco probe can produce a significant and Fluid
amount of heat and that forcefully pushing the phaco
needle against the edge of the incision can burn the
Very Shallow
cornea in a matter of seconds. Floating within the inci-
Anterior Chamber
sion is critical.
In order to maneuver within the eye without pushing
on the incision, we need to pivot our instruments. The
action is very similar to the rowing action in a row boat:
the paddle is placed within an oarlock (analogous to our Hand Control : PIVOT in the incision
incision), and in order to push water away from us with
the paddle, we pull the handles toward us. [ Figure 1 ]
In the eye, when you want to move the phaco tip down- Keeps Viscoelastic
And Fluid in Eye
ward, you do not push down on the incision. Rather, you
lift the back end of the phaco probe upward, which will
Good, Deep
pivot the probe within the incision, and the phaco tip Anterior Chamber
will move downward. [ Figures 2, 3 ] This is accomplished
without deforming the incision; thus, the chamber stays
Figure 1
formed and the cornea remains undistorted. [ Figure 4 ]
Hand Control : Pivot in the incision
Keeping the eye in primary gaze
With two incisions, the main incision and the paracen-
tesis, and two instruments within the eye, the patient Hand Control : PIVOT in the incision
will not be able to move the eye even under topical Corneal Distortion Cornea is Clear
anesthesia. This two-point fixation is another advan- and Wrinkling and Undistorted
tage of two-handed surgery. One-handed techniques
Oar lock of phacoemulsification are relatively out-dated, and, as
such, I do not teach them to my residents or students.
The surgeon’s best view and most maneuverable state
Pivot Action with Oars in a Rowboat
is when the eye is in primary gaze while the patient is PUSHING PIVOTING
in the supine position. By floating in the incision, we
=BAD =GOOD
ments is primarily from the fingers and somewhat from can keep the eye in this primary position. Any forceful
the wrists; gross movements of the forearms, arms, pushing of the instruments within the eye will cause
elbows, and shoulders are not well suited for ocular the eye to move away from the force vector—usually esthesia, the patient can assist you further by looking
surgery. towards the medical canthus. This is dangerous since directly at the microscope light.
it limits the surgeon’s view and maneuverability within
Hand Control : do NOT push down!
Pivoting the eye. In summary, keep the hand position relaxed and com-
The instruments, particularly the phaco probe, should fortable, keep the instrument grip fine and delicate,
float within the incision. There should be no forceful Adjust your hand position so that there is no pushing keep the instruments floating gently within the inci-
pushing on any aspect or edge of the incision. With on any aspect of the incision and you will find that the sion, and keep the eye in primary gaze by pivoting the
Lose Viscoelastic
any
andinstrument,
Fluid distortion of the incision can deform eye will return to primary gaze. In cases of topical an- instruments.
Very Shallow
phaco fundamentals • 29
Anterior Chamber
 Bevel UP - “Regular” Hand Control : Bevel Up & Down
30
Pivot Tip with Bevel UP
30 Good for Sculpting / Grooving
Bevel DOWN - “Upside Down”

LESSON 12 Figure 2

Bevel Position;
The paracentesis can be made flat and parallel to the iris
Hand Control : Bevel Up & Down since it is such a small incision. While we could certainly
Pivot Tip with Bevel UP make it in the corneal plane to achieve a longer tunnel
Good for Sculpting / Grooving

Incision Spacing
length,
Hand this could
Controllimit movement
: BevelofUp our & second
Downinstru-
ment within the eye. Because the main clear corneal
Bevel UP Bevel DOWN
incision is much
Occlusion NOT wider, it becomes more important to
Achieved Occlusion IS Achieved
have a longer
POOR tunnel
grip for length, therefore
chopping GOOD grip it for
is made while
chopping
aiming up in the plane of the cornea.
IF YOU LOOK CLOSELY AT THE PHACO TIP—AT THE PHACO NEEDLE ITSELF—
Having the correct placement of the incisions and the
YOU WILL SEE THAT IS CUT AT AN ANGLE, THUS GIVING A BEVEL. MOST PHACO Figure 3 correct bevel positioning of the phaco probe within the
NEEDLES THAT ARE USED TODAY HAVE A BEVEL TO INCREASE THEIR UTILITY AND eye, can make our surgery safer and more efficient.
efficiency DURING CATARACT SURGERY. Hand Control : Bevel Up & Down
Bevel UP Bevel DOWN Figure 4
Occlusion NOT Achieved Occlusion IS Achieved
POOR grip for chopping GOOD grip for chopping Make
Paracentesis

The approach from a typical clear corneal incision down

towards the cataract nucleus is an angle of 30 degrees
Make
– perfectly suited for our 30 degree phaco needle in the
Paracentesis
bevel-down position. As soon as the phaco needle ap- Figure 5

T Make
he most common bevel is a 30 degree bevel,
which means that the angle at which it is cut is
30 degrees relative to the long axis of the needle.
There are also 45 and 90 degree tips available, and other
varieties where the shaft itself may be bent or the tip may
have a flare. These varieties provide different options
during nucleus removal, but I still recommend starting
with a traditional 30 degree tip during the earlier stages
of the learning.
Figure 1
The beveled phaco needle can be positioned in a bevel-
up, bevel-sideways, or bevel-down orientation. The
bevel-up position is best suited to grooving techniques,
where the phaco needle’s action is similar to that of an
ice cream scoop. The goal is to only partially fill the tip
of the needle with nuclear material as the groove is made.
The bevel-sideways position is effective for quadrant
removal, with the opening directed towards the largest
part of the quadrant so that the energy is applied into the
cataractous material which would then tend to carousel
into the phaco tip. The bevel-down position is best suited
proaches the cataract, it is very easy to achieve occlusion,
and firmly hold the nucleus in preparation for chopping.
Corneal Incision
The bevel-up position would not achieve occlusion and,
thus, the holding power would be weak as the vacuum
level would never reach the preset maximum with our
peristaltic pump.
By holding the phaco probe like a pen, with a light and
delicate grip, you should be able to maneuver it easily
Make
from the bevel-down to the bevel-up position by simply
Corneal
rolling Incision
the tip between your fingers. Figure 6

to achieving maximum grip of the nucleus. Cataract Surgery

Hand Control : Bevel Up & Down Incision Spacing Incisions
To use a household vacuum cleaner to pick up a piece In a previous lesson we explained the method of making
About 60º Between Incisions
of paper, you know that it is helpful to fully occlude the a proper clear corneal incision for our phaco probe. Keep
tip in order to achieve maximum holding power. The in mind that we need to actually create two incision in
same is true for phacoemulsification with a peristaltic the eye: a small paracentesis of approximately 1.0mm (or 60
pump—occlusion is required in order to achieve the less) in width, and a main incision with a width of about Paracentesis
Bevel UP - “Regular” AIM *FLAT*
30 preset maximum vacuum level and effectively hold the 2.5-2.8mm. For ease of hand position and maximum (plane of iris) Main Incision
AIM *UP*
nucleus. Once the nucleus is held firmly, it becomes maneuverability within the eye, I prefer to have these (plane of cornea)
30 relatively easy to perform phaco chop or other methods
Cataract Surgery
incisions about 60 degrees apart, with the main incision
Bevel DOWN - “Upside Down”
of nucleus disassembly.
Incisions
for my dominant right hand and the paracentesis incision
About
for my 60ºhand.
left Between Incisions

60
30 • WORLD REPORT CME SERIES phaco fundamentals • 31
Paracentesis
Hand Control : Bevel Up & Down AIM *FLAT*
LESSON 13
Foot Pedal Control
During Steps Of
Surgery
During surgery we clearly need precise control of both hands to hold
instruments and operate within the confines of the anterior segment.
We also need to coordinate fine control of both feet, as they play a
crucial role in controlling the foot pedals.
The traditional placement is to have the left foot control
the microscope foot pedal while the right foot controls
the phaco foot pedal.
Figure 1
T
he primary microscope controls are focus,
zoom, and centration. Additional functions in-
clude the ability to turn the microscope light
Phaco Foot Pedal Function
on/off as well as to adjust the brightness. The micro-
scope should be reset and centered at the beginning of
the case in order to provide a full range of adjustability.
Avoid high magnification for routine cases as this will
unnecessarily limit your field of view.
The more important pedal during phacoemulsification
is the phaco foot-pedal as it controls the irrigation, as-
piration, as well as ultrasonic power delivery. Fine con-
trol of fluidics and power can be achieved with prac-
tice. The three positions of the phaco foot-pedal are:
1-irrigation, 2-aspiration, and 3-ultrasound. Each step
is additive, so when we are in position 2, we have irri-
gation plus aspiration, and in position 3, we have irriga-
tion, aspiration, and ultrasound power delivery.
The irrigation in position 1 is either on or off—there
is no ability to titrate the amount of irrigation via the
foot-pedal. You will recall that the irrigation inflow is
determined by the bottle height and the size of the inflow
tubing. Taking the foot off the pedal completely is called
position zero since the phaco probe is doing nothing.
32 • WORLD REPORT CME SERIES
Figures 2, 3, 4, 5, 6
The aspiration in position 2 can be controlled in a linear
Before Entering the Eye
Phaco Foot Pedal Function manner: the beginning of position 2 gives lower aspira-
tion and as you depress the pedal further into position
2, you get more and more aspiration. This is quite simi-
lar to the gas pedal on cars, where the acceleration is
Irrigation = 1 Irrigation = 1
proportional to the amount of pedal depression.
Aspiration = 2
Position 3 also has the ability for linear control, where-
by progressively greater depression of the pedal gives
Ultrasound = 3 more phaco energy. Depending on the type of phaco
power modulation used, the foot pedal depression in
Ultrasound on Forward Stroke
position 3 will give more ultrasound energy. In both
phaco continuous and phaco pulse mode, further de-
pression increases stroke length of the phaco needle.
In phaco burst mode, further depression increases the
Ultrasound = 3
number of bursts per second by limiting the rest inter-
val between bursts.
Foot-pedal position
during steps of surgery
Only Aspiration on Backstroke Before entering the eye with the phaco probe, the foot-
pedal should be in position 1 so that the irrigation fluid
will prevent the eye from collapsing as the main inci-
sion is opened and the phaco needle is introduced into
Before Entering the Eye the eye. A soft nucleus may be removed with simple
Aspiration = 2
aspiration in position 2; however, any cataract with
significant nuclear density will require ultrasound en-
ergy. To emulsify the cataract, the phaco probe should
Irrigation = 1 Irrigation = 1 deliver energy during the forward stroke. Then when
retracting the phaco probe, there is no need to deliver
Aspiration = 2 Aspiration to bring cataract to phaco tip energy, so we can go back to position 2 for aspiration,
or even position 1 for simple irrigation only.
Ultrasound = 3 Once we have a nuclear fragment or piece, we can use
Ultrasound on Forward Stroke aspiration in foot position 2 to bring the piece to the
Aspiration = 2
tip in preparation for emulsification. Once the cataract
piece is right at the phaco tip, application of ultrasound
energy in position 3 will emulsify it.
Ultrasound = 3
The goal of modern cataract surgery is ultrasound-as-
Ultrasound when cataract is at phaco tip sisted aspiration of the lens, where the primary means
of lens removal is aspiration, and ultrasound phaco en-
ergy is only given to assist. This will allow us to mini-
mize the amount of energy that is placed into the eye
Only Aspiration on Backstroke
Ultrasound = 3
and will result in better outcomes. Accurate foot pedal
control requires patience to master, but once learned,
it allows an increased margin of safety and efficiency
during phacoemulsification.
Aspiration = 2
phaco fundamentals • 33
LESSON 14 Figure 1 Figure 2

Viscoelastics: Filling The AC

With Viscoelastic
Spectrum of
Viscoelastics
Dispersive & Cohesive Ability to Maintain Space & Pressure

Viscoelastics, also referred to as ophthalmic viscosurgical

devices (OVDs), are viscous substances that allow us to make
phacoemulsification easier and safer. Once the very first incision is Ability to Coat & Protect
made, the eye has a tendency to collapse as the aqueous leaks out. The
larger the incision, the greater the propensity for the eye to collapse,
and the greater the risk to the patient. By replacing the aqueous with a
thicker viscoelastic, we can prevent the eye’s collapse.

Dispersive Moderate Cohesive Super Cohesive

More Liquid More Solid

forcing the aqueous to exit from the anterior chamber IOL injector system and allow lubrication that will
through the same incision. [ Figure 1 ] facilitate IOL delivery.

Ideal viscoelastic • Expand the empty capsular bag for

characteristics during surgery: IOL insertion: cohesive
• Maintain AC depth during Again, to maintain space and keep the empty capsular
capsulorhexis creation: cohesive bag open, the cohesive OVDs work very well. Avoid
To maintain space and keep the anterior lens capsule the super-cohesive OVDs here as they may be so solid

T
here are two main classes of viscoelastics: dis-
persive and cohesive, and they behave differ-
ently. Dispersive OVDs have the consistency of
syrup or molasses and they are able to flow like very
thick liquids. This gives dispersive OVDs the ability
to coat ocular structures quite well, and this coating is
not easily washed away by the flow of balanced salt so-
lution during surgery. This coating of dispersive OVD
is helpful to protect the corneal endothelium from the
ultrasonic waves during surgery.
Cohesive OVDs are more solid than liquid and they
have the consistency of gelatin, which means that they
cannot coat or flow very well. However, because they
are much thicker, they are able to maintain space and
pressurize the eye quite well. This is very useful to
keep the anterior chamber formed, to keep the anterior
capsule flat during capsulorhexis creation, to move and
manipulate iris or other tissues, and to keep the empty
capsular bag open for IOL insertion. It’s important to
understand that there is a spectrum of viscoelastics and
that a moderate OVD may have some dispersive prop-
erties as well as some cohesive properties. For many
surgeons, using a moderate OVD has the best of both,
and they are able to use it as their exclusive viscoelastic
for the entire surgery. Other surgeons may prefer hav-
ing two viscoelastics, one cohesive and one dispersive,
for different stages during a single surgery.
At the beginning of surgery, when the viscoelastic is
placed into the eye, the goal is to perform an exchange:
inject the OVD while the aqueous is forced out of the
eye. This is accomplished by placing the cannula across
the anterior chamber and injecting distally, thereby
flat, the cohesive viscoelastics are the most helpful
during this step.
• Corneal endothelial protection during
phacoemulsification: dispersive
Because they have the ability to coat, the dispersive
viscoelastics work very well to keep the corneal
endothelium protected during phaco.
• Prevent iris prolapse during surgery: cohesive
The ability to pressurize and maintain space is best
accomplished with a cohesive. Therefore, prolapse of
iris tissue usually may be prevented or treated with a
cohesive viscoelastic.
• Lubricate the IOL injector system: dispersive
The thinner dispersive OVDs can lightly coat the
that they can deflect the IOL as it is inserted.
At the end of surgery it is important to thoroughly re-
move the viscoelastic from the eye, otherwise it can
block the trabecular meshwork and the patient will ex-
perience very high intra-ocular pressures after surgery.
The dispersive viscoelastics can be harder to remove
since they have a tendency to spread out and coat the
ocular structures. The cohesive viscoelastics tend to
stick together as a single mass and are therefore usually
easier to fully remove.
Use of a viscoelastic can make phacoemulsification
easier for the surgeon as well as safer for the patient. It
is for this reason that is has become an integral part of
our surgeries.

34 • WORLD REPORT CME SERIES phaco fundamentals • 35

LESSON 15 Figures 2, 3, 4, 5

Capsulorhexis
terior chamber. You will remember from previous les-
Step 1 sons the importance of floating within the incision, not
Float within the Incision Dashed line is
the intended distorting the eye, and pivoting the instruments.

Creation
Capsulohexis
Size of 5.0 mm
Do not allow the anterior chamber Step 1 To start the capsulorhexis, a single puncture
is made in the central part of the anterior lens capsule.
to shallow or collapse. Poke sharp tips of forceps
into the center of the This can be done using a bent needle, called a cysto-
anterior lens capsule. The tome, or by using the tips of the capsulorhexis forceps.
first hash mark (2.5mm)
My capsulorhexis forceps are marked with two lines, at
Decades ago, the method for cataract surgery was intra-capsular represents the radius of your
intended 5.0mm 2.5mm and at 5mm, to facilitate creation of a capsu-
extraction, where the entire cataract and its capsule where removed capsulorhexis.
lorhexis with an exact 5mm diameter every time. When
from the eye. our Technique has advanced dramatically, and now more the sharp tips of the forceps are poked into the center
than 99% of the time we remove just the cataractous material, of the anterior lens capsule, the 2.5mm mark delineates
while leaving the capsule and zonular structures intact. Step 2 the radius of our intended capsulorhexis.
hence the name extra-capsular extraction.
Step 2 To propagate the tearing of the capsulorhex-
is, it is important to keep the torn capsule folded over
as this allows the tear to proceed in a more controlled
manner. I recommend understanding the force vectors
required for capsulorhexis creation by practicing using
Figure 1 Start the capsulorhexis, your fingers to tear large 10cm circles in newspaper.

T
keeping in mind the intial
he evolution of capsulorhexis began with the This will highlight the importance of keeping the torn
use of a needle to make multiple punctures in Step 1 position of the first (2.5mm)

Float within the Incision capsule folded over.

hash mark as a guide.
Dashed line is
the anterior lens capsule to create an opening the intended
through which to access the cataract nucleus. While Capsulohexis
Size of 5.0 mm
Step 3 As we proceed to tear the circular capsu-
this works, it makes for an unstable capsular bag and
predisposes to a higher complication rate. Today, our
Do not allow the anterior chamber Step 3 lorhexis, we will notice that half way through the
rhexis, the 2.5mm hash mark of the forceps tip should
to shallow or collapse. Poke sharp tips of forceps
preferred method is creation of the continuous curvilin- into the center of the be in the exact center of the anterior capsule, and the
ear capsulorhexis (CCC). anterior lens capsule. The 5mm hash mark should be at the outer edge of the cap-
first hash mark (2.5mm)
represents the radius of your sulorhexis. This ensures that we are tearing the proper
For most cases, our ideal capsulorhexis is a well-cen- Half way5.0mm
intended through the size capsulorhexis.
rhexis, the 2.5mm hash
capsulorhexis.
tered, round opening of the anterior capsule with a di- mark should be in the
ameter of about 5mm. This allows sufficient access to exact center, and the Step 4 We complete the capsulorhexis using the same
5.0mm hash mark should
the nuclear material, and at the end of the case it al- technique, and the torn central remnant is removed
Step 2
be at the outer edge of
lows secure placement of a standard posterior chamber your capsulorhexis. from the eye and discarded. If capsulorhexis radializes,
IOL within the capsular bag. The typical IOL has an it is important to stop, inject more cohesive viscoelas-
optic diameter of 6mm and our 5mm capsulorhexis is tic, and try to bring it centrally once again. If it extends
therefore able to cover the edge of the optic and hold it too far radial and out to the zonules, you may not be
securely in position after the completion of surgery. Step 4 able to retrieve it, and in this case you can finish by go-
ing in the opposite direction with the capsulorhexis, or
It is important to keep the anterior chamber well by using the bent needle cystotome to place a series of
Start the capsulorhexis,
formed and the anterior lens capsule flattened during keeping in mind the intial
punctures in the intended areas.
the creation of capsulorhexis. This allows for greater position of the first (2.5mm)
control and prevents run-off and radicalization of the hash mark as a guide. Because it is a complete circle, the capsulorhexis pro-
capsulorhexis and allows for more control. The two End of the procedure - now vides a high degree of strength and stability to the cap-
keys to achieving this stable AC and flat capsule are: the capsulohexis has the sular bag and keeps the IOL secured centrally. This
Step 3
ideal 5.0mm diameter for
use a good cohesive viscoelastic and float within the cataract surgery.
assures a consistent post-operative refractive outcome
incision. These measures prevents collapse of the an- and happy patients.

36 • WORLD REPORT CME SERIES phaco fundamentals • 37

Half way through the

LESSON 16
Hydrodissection and
Hydrodelineation
Once the capsulorhexis has been created, it is helpful to use balanced
salt solution to loosen and separate the cataract in order to facilitate
its removal. The two primary techniques are hydrodissection and
hydrodelineation, both of which are performed using a blunt 27 gauge
cannula on a 3cc syringe filled with balanced salt solution.
Figure 1
H
ydrodissection is performed between the cap-
sule and the cataract cortex in order to free
the adhesions of the cataract from the cap-
sular bag and allow it to rotate fully. Care is taken to
place the blunt cannula under the edge of the anterior
capsulorhexis and directed toward the lens equator.
You should stop shy of the lens equator as you do not
want to puncture the lens capsule or damage the zon-
ules. Keep the cannula steady so that it forms a tight
seal between the capsule edge and the cataract. If you
move too much and loosen this seal, the fluid will re-
flux back along the path of the cannula rather than dis-
secting forward.
Next, gently press on the plunger of the syringe in order
to send the balanced salt solution around the posterior
aspect of the cataract. You want to see at least one fluid
wave propagated around the cataract, and more waves
are better. As the waves propagate, they will loosen the
cataract from the capsular bag and some fluid may be-
come trapped between the lens and the posterior cap-
sule. To release this fluid, use the cannula to gently tap
on the center of the nucleus and the fluid will be pushed
anteriorly. The key here is to be gentle so that no undue
force is used as this could cause the capsule to rupture
and the nucleus to sublux into the vitreous.
38 • WORLD REPORT CME SERIES
a forward fluid wave.
Figure 2
Hydro - dissection
Between the Capsule
and the Cortex
Create a tight seal
How much force is used? Very little, since the key is
slow and steady. To give you an idea of the force re-
quired, if you take the 3cc syringe with the 27-gauge
cannula and inject it outside of the eye, it would form
a gentle arc of fluid that would extend only a few
inches. If your application of force causes the fluid to
shoot across the room, you are being much too force-
ful. This requires a steady hand and a good sense of
fluid control.
Hydrodelineation is employed by some surgeons to
separate the endo-nucleus from the epi-nucleus. The
central endo-nucleus is of a higher density and re-
quires more ultrasound energy to remove, while the
With a tight seal, epi-nuclear shell is softer and easier to remove. This
the fluid should create is an optional step that is performed with the idea that
the epi-nuclear shell can act to protect the posterior
a forward fluid wave. capsule during phacoemulsification of the endo-nu-
cleus. Many surgeons do not perform this step, and
instead prefer to remove the entire nucleus without
Figure 3
Hydro - delineation
Between the Nucleus
and the Epi-nucleus / Cortex
separating it into these layers.
To prevent the fluid from the cannula from going be-
tween the capsule and the nucleus during hydrodelin-
eation (which was already accomplished during hy-
drodissection), the tip of the cannula should be placed
central relative to the edge of the capsulorhexis and
not beyond it. Dig the tip of the cannula into the nu-
clear material while keeping it within the confines of
the 5mm capsulorhexis. This will allow proper hydro-
delineation, and a successful fluid wave will result in
the “golden ring” appearance at the area of separation
between the epi-nucleus and the endo-nucleus.
Once the cataract has been freed from the capsule
with hydrodissection and split into endo-nuclear and
epi-nuclear sections with hydrodelineation, we are
ready to perform nucleus removal using aspiration
and ultrasound energy from the phaco probe.
phaco fundamentals • 39
LESSON 17
Concepts Of
Nucleus Removal
The ultrasonic phaco probe is used for just a single part of the surgery:
removal of the cataract nucleus. The rest of the procedure can be
performed with much simpler instrumentation.
But these other steps of the surgery are critical,
and without performing them correctly, the task of nucleus
removal becomes quite difficult.
C
ataract surgery is a delicate pyramid, where
each previous step provides the foundation
upon which the next step is performed. When
everything goes well, the result is a beautiful surgery,
an excellent visual outcome, and a very happy patient.
The cataract surgery success pyramid starts with good
patient selection, good anesthesia, good exposure and
draping of the eye, and good preparation by the sur-
geon. Our next level is making proper incisions of the
right size in order to keep the anterior chamber deep
Figure 1
Apply ultrasound energy
when the nuclear pieces are at the tip.
40 • WORLD REPORT CME SERIES
and inflated during surgery. With a well-formed ante-
rior chamber, a round, well-centered capsulorhexis can
be created with minimal stress to the zonules. This al-
lows for efficient nucleus and cortex removal and IOL
insertion. These incisions will then seal very well and
will be astigmatically neutral. With all of this together,
we end up with good vision and a happy patient.
The cataract surgery complication pyramid is not so
pretty and not so happy. If we start with poor patient
selection, ineffective anesthesia, and inadequate ex-
Figure 2
Cataract Surgery
Success Pyramid
20/20
Happy Patient
Well sealed neutral incisions
Efficient Nucleus/Cortex Removal
Round Capsulorhexis/No Zonule Stress
Well made incision/Deep and Maintained AC
Good Anesthesia/Good Exposure/Prior Preparation
posure of the surgical field, we will run into problems.
These can be issues such as an improperly constructed
incision that leaks during surgery and causes anterior
chamber instability and flattening. This makes the
capsulorhexis difficult and irregular with stress placed
on the zonules. We are then at much higher risk of a
broken capsule and vitreous loss. Then vitreous gets
trapped in the patient’s leaky incision. The patient de-
velops cystoid macular edema and a vision of 20/200
or worse. Both the patient and the surgeon are disap-
pointed.
Clearly, it’s important to make sure we are building
a cataract surgery success pyramid. Since most sur-
geons who read this lesson will already have signifi-
cant experience with patient selection, anesthesia, and
draping of the surgical field, we can focus our teach-
ings on concepts of nucleus removal.
The primary concept to remember is that we are per-
forming ultrasound-assisted aspiration of the cataract.
The phaco energy should only be applied when there
is actual cataract material at the tip of the phaco nee-
dle. Being in foot-pedal position 3 without having the
Figure 3
Cataract Surgery
Complication Pyramid
20/200
Chronic CME
Vitreous to the leaky wound
Broken Capsule and Vitreous Loss
Radialized Capsulorhexis/Broken Zonules
Short Leaky Incision and a Flat Anterior Chamber
Ineffective Block/Poor Exposure/Poor Patient Selection
phaco tip in cataract material will result in transmis-
sion of the ultrasound energy through the aqueous and
to the corneal endothelium resulting in post-operative
corneal edema.
The fluidic control of the phaco machine is used to
draw the cataract pieces toward the phaco tip. Re-
member that in a peristaltic machine, the maximum
pre-set vacuum level is not reached until the phaco
tip is occluded. This is in contrast to a venturi system
where the maximum pre-set vacuum can be created
instantly and occlusion is not required. A common
mistake novice surgeons make is trying to use ultra-
sound power to draw cataract pieces to the tip, when,
in fact, the ultrasound energy can be repulsive.
In order to facilitate removal of the cataract nucleus
with the phaco probe, it is helpful to break the nucleus
into quadrants or fragments. The techniques of nucle-
us disassembly include divide-and-conquer, stop-and-
chop, and quick-chop. Most surgeons start learning
them in that order and eventually choose some form
of phaco chop as their primary technique. In our next
set of lessons, we will explore each of these methods.
phaco fundamentals • 41
LESSON 18 Figures 1, 2, 3

Divide-and- Starting the Grooves

Start the groove as close to the incision as
OncePlace

Deep
Instruments
the nucleus
quadrants, thein
Deep
is fully cracked and separated into four
thesettings
phaco
placement
Groove
allows
should be changed. The
for comlete

Conquer Technique
possible for a longer groove length phaco power settings can be changed to a lower pulse
cracking and separation of the nuclear pieces
rate, between 10 and 30 pulses per second, a somewhat
lower duty cycle of 30-50%, and a lower
SHALLOW DEEP maximum
power setting of approximately half of what was used

of Nucleus Removal
for grooving. For fluidics, it is important to have more
holding power, which means more vacuum. Depending
on the phaco needle size, the vacuum level should be
between 200 and 400 mmHg, and the flow rate should be
between 30 and 50cc/min. Make sure to raise the bottle
To facilitate removal of the cataract nucleus with the phaco probe, height to ensure that the inflow of fluid into the anterior
it is helpful to divide it into quadrants or segments, which are more chamber exceeds the outflow of fluid in order to main-
easily extracted. The traditional method of ‘one-handed’ phaco involves
TYPICAL BETTER tain a stable chamber.
using the ultrasound energy to bowl out the nucleus. however,
this requires a lot of energy and is rather slow and cumbersome. Use the phaco probe’s vacuum to bring the pieces out
Using a method to mechanically disassemble the nucleus allows
Widen the Grooves of the capsular bag and to the iris plane. This is the
Allows more room for placement of the ideal location to phaco-aspirate the nuclear fragments,
for easier removal. as it is far from
phaco probe and second instrument. BADboth the corneal endothelium
GOOD and the
capsular bag. Continue
incomplete crack to bring the quadrants to the iris
complete crack
plane and phaco-aspirate them. This is the technique of
Divide-and-Conquer for nucleus removal.

Figure 4

A
simple and effective approach to nucleus re-
moval is the divide-and-conquer technique, in
which the phaco probe is first used to sculpt
grooves into the nucleus, and then a second instrument
is used to crack the nucleus into pieces, which can then
be easily removed.
To create the groove, the phaco settings should be op-
timized for sculpting. Use a high pulse rate of between
60 and 120 pulses per second, a duty cycle of 50% or
more, and a maximum power setting of 20-60% de-
pending on the density of the nucleus. If your phaco
machine does not have the ability to do a high pulse
rate and a variable duty cycle, then it is acceptable to
use continuous phaco energy. Be aware that the con-
tinuous phaco energy mode will put more energy into
the eye and may lead to a high rate of corneal endothe-
lial cell loss. For fluidics, the goal is to simply keep the
anterior chamber deep and well formed while provid-
ing a small amount of flow and vacuum to aspirate the
sculpted cataract material.
Start the groove as close to the sub-incisional area
as possible so that the groove has the longest length Starting the Grooves Place Instruments
possible. Be careful not to hit the edge of the capsu- Start the groove as close to the incision as Deep in the Groove
lorhexis with the phaco probe, and continue to sculpt Deep placement allows for comlete
possibleNARROW WIDER
for a longer groove length
the grooves deeper into the lens material. The average cracking and separation of the nuclear pieces
GROOVE GROOVE
lens is approximaately 4mm deep centrally and shal-
SHALLOW DEEP
lows peripherally. You should create grooves that are
at least half the depth of the nucleus in order to fa- Rotate & Create 4 Quadrants
cilitate cracking. [ Figures 1, 2 ] Use the phaco probe and Maintain the Squared Grooves to facilitate
the second instrument to rotate the nucleus 90 degrees
cracking of the nucleus into quadrants.
and make a second groove orthogonal to the first. Once
completed, the two intersecting grooves will form a +
sign and will segment the nucleus into four quadrants.
To crack the nucleus into quadrants, a second instru- TYPICAL BETTER
ment is placed into the groove along with the phaco
probe tip. If the instruments are placed too shallow,
the crack will be incomplete and the pieces will not Widen the Grooves
separate. The proper method is to place the instru-
Allows more room for placement of the
ments deep within the grooves then pull apart. This
phaco probe and second instrument. BAD GOOD
will result in a complete crack with separation of the 2 HALVES 4 QUADRANTS incomplete crack complete crack
nucleus into distinct pieces. [ Figures 3, 4 ]

42 • WORLD REPORT CME SERIES phaco fundamentals • 43


LESSON 19
Stop-and-Chop
Technique of
Nucleus Removal
While divide-and-conquer is an effective technique for nucleus
removal, it does tend to require more phaco energy since the creation
of the grooves and disassembly of the nucleus is accomplished with
ultrasound energy. Making the jump from divide-and-conquer
to a full chop technique is not simple for many surgeons,
so Paul Koch, MD, invented Stop-and-Chop.
Figure 1
T
he technique of Stop-and-Chop uses a groov-
ing technique to make a single linear trench in
the cataract nucleus. The surgeon then stops,
divides it into two halves, and then chops each half fur-
ther. This is an easier transition for most surgeons and
results in more efficient surgery. Once the technique of
Stop-and-Chop is mastered, many surgeons feel more
comfortable transitioning to a full chop technique.
When sculpting the initial groove into the nucleus, it
is important to make a sufficiently long trench that ex-
tends from the sub-incisional region to the area under
the anterior capsular rim. The groove is deeper cen-
trally than peripherally, due to the natural shape of the
cataractous lens. The width of the groove should be
sufficient to allow placement of both the phaco tip as
well as the chopping instrument deep within the trench.
The initial phaco settings here should be a high pulse
mode (80 PPS or more), with a 40-60% duty cycle,
and a maximum phaco power of 40-60%. The fluidics
should allow for a low vacuum and low flow setting to
simply evacuate any emulsified cataract bits from the
excavated trench.
44 • WORLD REPORT CME SERIES
Crack into Halves
Figure 2
Step 2.
Now Chop Each Half
Step 1.
Make a groove & crack Once the instruments are placed deep within the trench,
and opposing forces can be gently applied so that the
Allows more room for placement of the nuclear halves are separated. Care should be taken to
phaco probe and second instrument separate centrally as well as peripherally in the groove
in order to get complete separation of the two halves.
If division is incomplete, then the individual nuclear
halves will not be easily chopped.
To chop each half, we need to change the phaco and
fluidic settings: here a burst mode is my preference as
it affords using very little energy. A short burst width
of 4-20 milliseconds and a power of 10-40% works
well. For those surgeons preferring a pulse mode, try
Make a Groove 10-20 PPS (pulses per second), 30-50% duty cycle,
and a maximum power of 20-50%.
The fluidics must also be changed to increase the hold-
ing power of the nucleus. Try using a higher vacuum
level (200-400 mmHg depending on your phaco needle
Crack into Halves size), and a higher flow rate (30-50 cc/min) with a cor-
responding higher bottle height to ensure that the in-
flow is greater than the outflow. To hold the nucleus
in place, the phaco probe should be embedded into the
nuclear half using ultrasound energy, and then the foot
pedal returned to position 2 with just vacuum. Now that
the nuclear half is stuck on the phaco tip, bring it up
to the iris plane, place the chopper around the edge of
the piece, and bring the two instruments together. Once
the chopper has cut through the nuclear half and is in
close proximity to the phaco tip, pull the instruments
apart, towards the left and right to separate the chopped
segment. The first chopped segment can be phaco-aspi-
rated and the chopping steps repeated to further break
both remaining nuclear halves into pieces.
Stop-and-Chop is an important step on the road to
performing phaco chop. It’s a technique that can be
mastered by all surgeons, regardless of their level of
prior experience. For those surgeons who eventually
transition to a pure phaco chop technique, it is still
helpful to have Stop-and-Chop as a back-up plan for
nucleus removal.
phaco fundamentals • 45
LESSON 20 Figures 1, 2, 3

Quick Chop
phaco tip together that does the chopping. When this is
Horizontal Chop accomplished, the pieces need to be separated by pull-
ing the two instruments apart. For most surgeons, this

Techniques of
means bringing the chopper towards the left, while the
phaco probe is pushed towards the right. A complete
separation of the two pieces is required for complete
mobilization of the halves and for further chopping into

Nucleus Removal
segments. [ Figure 1 ]

Vertical Chopping
In a dense nucleus, vertical chopping is a very effec-
tive and safe technique. The phaco tip is embedded into
The most efficient technique of nucleus disassembly is a purely the nucleus and a high vacuum level is used to fixate
mechanical one where the nucleus can be chopped into segments within a it securely. The chopper is then placed vertically into
few seconds, hence the name Quick Chop. the center of the nucleus, well within the confines of
These segments can then be easily removed with relatively little phaco the capsulorhexis. Once the chopper and phaco tip are
energy. Compare this to the divide and conquer technique, both fully buried in the center of the nucleus, the two
where a tremendous amount of ultrasonic energy is required to create Vertical Chop instruments are pulled apart: the chopper to the left and
the phaco probe to the right, thereby separating the two
the grooves that are used to create the quadrants. A simple analogy is
nuclear halves. These nuclear halves can then be further
the splitting of firewood: a grooving technique is similar to using chopped into smaller segments and emulsified. [ Figure 2 ]
a saw to cut through the piece of wood, whereas a chop technique is
similar to using an axe to chop and split the firewood along the grain. Tilt and Chop
To minimize the stress on the capsular bag, which is par-
ticularly helpful in cases of pseudoexfoliation or trauma
where there is zonular weakness, the nucleus can be
tilted out of the capsular bag. A relatively large capsu-
lorhexis of 5 mm or more, combined with hydrodissec-
tion or viscodissection, will aid in partially prolapsing
the nucleus out of the capsular bag. With the nucleus
tilted out of the capsular bag, it is very easy to place

T
he basic concept of chopping is holding the nu-
cleus with the phaco probe while the chopping
instrument splits it into pieces. The most com-
mon difficulty that beginning surgeons encounter when
attempting chopping techniques is failure to adequately
fixate the nucleus so that it can be chopped. If you’re
going to use a fork and knife to cut a piece of meat,
you must first hold and immobilize the meat with the
fork so that the knife can do the cutting. Similarly, the
phaco probe must achieve a high enough vacuum level
to firmly fixate the nucleus so that the chopper can do
the mechanical splitting of the cataract.
A high vacuum level is required to achieve the hold-
ing power that we desire for chopping. Depending on
the phaco needle size that you are using, the vacuum
level should be between 250 and 400mmHg, and if
you are using a peristaltic fluid pump, remember that
total occlusion of the phaco tip is required to achieve
the maximum preset vacuum level. With the vacuum
setting high, bury the phaco tip into the nucleus using
phaco power (foot pedal position 3), then once you have
full occlusion of the tip, back off the pedal into position
2 so that the nucleus is being held by the high vacuum
level. Now the cataract is well-fixated and we are ready
to employ a chop technique.
Horizontal Chopping
The original technique of chopping described by Naga-
hara is a horizontal chop. The phaco probe is embedded
into the nucleus and the chopper is passed under the
capsulorhexis and towards the lens equator. Once at the
lens equator, the chopper is brought towards the pha-
co tip. It is this action of moving the chopper and the
the chopper around the lens equator or even behind the
nucleus. The chopper is brought towards the phaco tip
and the two instruments are pulled apart to create the
Tilt & Chop two nuclear halves. The tilt and chop technique is my
preferred technique for very dense cataracts, where a
significant amount of force is required to propagate the
chop through the nucleus. By placing the chopper be-
hind the nucleus, with the phaco probe in front of it, I
am able to exert a powerful chopping force while still
being very gentle to the zonules and other intra-ocular
structures. [ Figure 3 ]
Chopping techniques are quickly becoming the pre-
ferred method for cataract surgery due to their inherent
efficiency and greater safety. While the technical skill
required for chopping is high, the great majority of oph-
thalmologists can master with practice.

46 • WORLD REPORT CME SERIES phaco fundamentals • 47

LESSON 21
Cortex Removal
Once the nucleus is removed, the remaining lens cortical material
must be thoroughly cleaned from the capsular bag.
It is not acceptable to leave a significant amount of lens cortex in the
eye at the end of the cataract surgery since it will induce inflammation
and may affect the patient’s quality of vision and level of comfort.
Cortex removal requires a delicate touch since we are working in direct
proximity to the fragile capsular bag.
Figure 1
T
he amount of cortex adherent to the capsular
bag is proportional to the effectiveness of the
hydrodissection performed prior to nucleus re- Grab cortex from
within the capsule
moval. As much of the nucleus and epi-nucleus as pos-
sible should be removed with the phaco probe prior to
switching to the irrigation/aspiration (I/A) hand-piece.
The I/A hand-piece has a much smaller opening as
compared to the phaco needle, which allows for more
control and a higher vacuum level while maintaining
the stability of the anterior chamber.
Any small, stray nuclear fragments can be removed by
using the I/A tip in combination with a second instru-
ment, either a chopper or a spatula, via the paracentesis.
When the small nuclear chips become stuck at the I/A
tip opening, simply use the second instrument to push
them into the port. The action is similar to using a fork
to mash potatoes, and is a mechanical means to force
the nuclear chips into the small I/A suction port.
For cortex removal, the I/A probe is placed under the
edge of the capsulorhexis and the cortex is grabbed
from within the capsule, near the lens equator [ Figure 1 ].
The key for efficient cortex removal is to move in a cir-
cumferential manner. You should aim to grab at least a
few clock hours of cortex by moving circumferentially
prior to bringing the probe radially towards the center
of the anterior chamber. The goal is to remove a few
large sheets of cortex material instead of pulling many
small strips of cortex. Removing a large sheet of cor-
tex allows for safer and more efficient cortical clean-up
48 • WORLD REPORT CME SERIES
Figures 2, 3
and is less likely to result in residual cortical material
Grab cortex from
in the capsular bag. Aspirate 3 clock hours
of cortexin a circumferential
within
hours of cortex atthe capsule
My preferred technique is to remove about three clock
a time with the circumferential tech- manner
nique [ Figure 2 ]. When it comes to the sub-incisional
cortex, the I/A tip can be positioned so that it is fac-
ing inferiorly, towards the underlying capsular bag.
Once the cortical piece is held via the suction of the I/A
tip, move the probe towards the center of the anterior
chamber and bring the port upwards to complete the
aspiration.
If the posterior capsule is inadvertently suctioned
during the removal of the lens cortex, care should be
taken to stop and release it. The foot pedal has a posi-
tion called ‘reflux’ where the vacuum is stopped and
the fluid pump is reversed to release any trapped ma-
terial. This reflux position is typically used to reverse
Aspirate 3 clock hours
the aspiration of fluid and to release the tissue, such as
of cortexin a circumferential
posterior capsule or iris that was inadvertently grabbed.
If spider-like wrinkles [ Figure 3 ] appear on the posterior
mannercapsule, the cause is most likely aspiration of the cap-
sule and you should immediately release the vacuum
by going to foot-position 1. If that does not release the
capsule, go to reflux position.
Spider-like radial lines
When small, residual cortex fragments are left on the
posterior capsule, a gentler irrigation and aspiration set- indicate dangerous
ting can be programmed into the phaco machine. Using aspiration of the capsule
a setting such as ‘capsule polish’ or ‘capsule vacuum’,
we can use low flow and low vacuum to remove these
last few bits of cortex while being very careful not to
damage the posterior capsule.
In small pupil cases, remember that the cortex needs to
be removed from the equatorial region of the capsular
bag, which may be out of view, blocked by the iris tissue.
Care should be taken to remove as much cortex as pos-
sible so that post-op inflammation and posterior capsule
opacification are minimized. Use of the new silicone-
coated soft irrigation/aspiration tips allows a higher mar-
gin of safety since no metal will come in contact with the
Spider-like radial lines
posterior capsule.
indicate
Our goal dangerous
at the end of cortex removal is to have a clean
aspirationcapsular
and clear of the capsule
bag, ready to accept our intra-ocular
lens implant.
phaco fundamentals • 49
LESSON 22 Figure 2 Figure 3

IOL Insertion
Once the capsular bag is clean and clear, it should be filled with
Insert IOL
into Capsular Bag
Remove
All Viscoelastic

viscoelastic. Inject viscoelastic as you insert the canula into the eye so
that there is never any direct contact of the canula with the posterior
capsule. Once the anterior chamber is inflated, pass the canula under
the capsulorhexis edge and completely fill the capsular bag. [ Figure 1 ]
You want the eye to be firm and ready to accept its new lens implant.

Figure 1

T
he recent advances in IOL technology have
been a tremendous benefit to surgeons and pa-
tients alike—with better optics and improved
bio-compatibility, and with the introduction of new
lens materials that permit insertion through smaller and
smaller incisions. The three main IOL classifications
for insertion are: rigid IOLs, foldable IOLs, and inject-
able IOLs. Each is inserted differently.
Rigid IOLs are typically made of polymethyl methac-
rylate (PMMA) which is a well-tolerated non-flexible
plastic. These IOLs tend to be single piece, made en-
tirely of PMMA, and, due to their rigid nature, they
require a larger incision for insertion, typically 0.5mm
greater than the optic size. Most 6.0mm optic PMMA
IOLs can be passed through a 6.5mm incision. An inci-
sion as large as this should not routinely be made in
the cornea; rather, a scleral tunnel incision should be
created. This larger incision will cause a long-term as-
tigmatic effect, which can often be lessened by proper
closure with sutures. Due to the large incision size, the
PMMA IOLs tend to be used rarely in most modern
practices.
Foldable IOLs are often made of acrylic or silicone,
and are designed to be folded in half, held with forceps,
and then placed within the eye. This allows an IOL with
an optic size of 6.0mm to be inserted through an inci-
50 • WORLD REPORT CME SERIES
Inject Viscoelastic
in Capsular Bag
mild to moderate astigmatic effect, and it can be closed
without sutures.
Injectable IOLs are also made of acrylic or silicone,
and are designed to work with a specific IOL injector
system. This allows the IOL to be completely shielded
from contacting the ocular surface during insertion, and
it allows for smaller incisions of less than 3.0mm, and
sometimes even less than 2.0mm. Once the IOL is in-
jected into the eye, it opens up and resumes its full size
and shape, and the injector can be removed from the
incision. These smaller incisions have the least astig-
matic effect and tend to seal the best, and the future
trends will be to move towards smaller and smaller in-
cisions and less invasive surgery.
The technique for inserting all of these IOLs is similar:
the leading haptic is placed into the capsular bag, fol-
sion of about 3.0-3.5mm, which can be made safely in lowed by the optic, then finally the trailing haptic is also
the cornea. Once the IOL is inserted within the eye, the placed into the bag. Note that IOLs have a proper front
forceps are opened, the IOL is released, and the forceps and back surface, and they should not be placed into
canInsert IOL
be removed. An incision of 3.0mm or so has only a Remove
the eye upside down. The normal configuration is with
into Capsular Bag All Viscoelastic
the haptics in the same orientation as the letter “Z”, and
not in the “S” formation. [ Figure 2 shows the proper “Z” ori-
entation of the haptics. ] Once the IOL is completely within
the capsular bag, it can be gently rotated with a second
instrument to ensure that it is well-positioned. In some
situations, such as with a compromised posterior cap-
sule, the IOL may be intentionally placed with the cili-
ary sulcus – the space between the posterior surface of
the iris and the anterior lens capsule.
With a typical 5.0mm capsulorhexis, a 6.0mm optic
will be held in place by the edge of the anterior capsule
for 360 degrees, and the long-term stability of the IOL
is ensured. With the lens completely within the capsu-
lar bag, the viscoelastic needs to be removed from the
eye. [ Figure 3 ] Using high flow and high vacuum, the
viscoelastic should be aspirated, with care taken to tilt
the IOL to the sides to remove any viscoelastic that is
sequestered behind the IOL optic. At this point the an-
terior chamber can be filled with balanced salt solution,
and the incisions can be sealed.
phaco fundamentals • 51
 Circular Path of the Needle

LESSON 23 To pass a suture with aFigures 1, 2, 3needle, the movement is like

semi-circular

Incision Closure &

turning a screwdriver in circular motion. Excessive pushing in a linear
length, and tensile force is an art and an integral part
Figure 1.
manner will cause the needle to bend and the tissues to distort.
of ophthalmic surgical technique. The incisions can
Circular Path of the Needle now be checked for leakage by using a small sponge
Figure 2.

Dressings
For beginning phaco surgeons, I recommend suturing the incisions at
the end of the surgery. This gives better sealing of the incisions, and it
gives the surgeon an opportunity to enhance the fine motor skills that Symmetrical suture placement (B) results in optimal power
are involved in microscopic suturing. These tiny sutures, typically 10-0 inand wound closure. (A) and (C) do not provide the same security.
size, can be challenging to use given their low tensile strength and the
small circular needles.
and pressing on the lip of the wound. Any leakage will
Symmetrical Suture Placement cause the sponge to swell and absorb the fluid. This is
an indication of insufficient wound closure, and addi-
tional sutures may be needed. Note that if two or more
sutures are placed in the same incision, they must be at
the same tension. If there are normal tension sutures on
To pass a suture with a semi-circular needle, the movement is like
turning a screwdriver in circular motion. Excessive pushing in a linear either side of a tight suture, then these normal tension
A. B. cause the needle toC.bend and the tissues to distort.
manner will
sutures will appear to be loose. Only when the tight
suture is removed will the tension on the other sutures
Figure 2. appear normal again. The balance in throwing a suture
Symmetrical Suture Placement to close a corneal incision is: too tight and there is a lot
Figure 3. of induced astigmatism; too loose and the incision will
leak. Finding the right balance only comes with prac-
Entry Angle Determines Depth
tice and experience.

A. B. C.
Figures 4, 5
A. B.
Symmetrical C. (B) results in optimal power
suture placement
Acute Angle < 90˚
Shallow Depth
and wound
Right Angle =closure.
Nomal Depth
90˚ (A) and (C)
Obtuse do not
Angle provide the same security.
> 90˚
Excessive Depth
Figure 4.
The entry angle of the needle will determine the depth of the suture Suture Holding Power
placement. (A) Acute angles result in shallower sutures. (B) Right
Figure 3.
angles result in nomal depth, equal to the radius of the needle.
(C) Obtuse angle result may result in excessively deep suture passes. Incision / Wound
Entry Angle Determines Depth

T
he sutures typically come with semi-circular The suture holding power is greatest directly under the
needles, which create circular paths when they suture itself, and this diminishes as you move further
Suture
are passed through tissue. There should be no away. The resulting forces from the suture result in a A. B. C.
linear pushing with these needles, otherwise they will diamond-like distribution pattern. [ Figure 4 ] Acute Angle < 90˚ Right Angle = 90˚ Obtuse Angle > 90˚ Figure 4.
bend and distort the tissues. Rather, the movement used Shallow Depth Nomal Depth Excessive Depth The holding power is strongest under the suture and
The entry angle of the needle will determine the depth of the suture Suture
it decreases as you move Holding
futher Power the
away, distributing
to pass these sutures is similar to turning a screwdriver Shorter sutures distribute their force over a smaller placement. (A) Acute angles result in shallower sutures. (B) Right
in a circular motion. [ Figure 1 ] Sutures should be placed area, and therefore more sutures are required to close angles result in nomal depth, equal to the radius of the needle. forces in a diamond shape.
(C) Obtuse angle result may result in excessively deep suture passes. Incision / Wound
symmetrically so that an even amount of tissue on ei- the incision or wound. This may be helpful in situations
ther side of the incision is captured by the suture. This where higher strength closure of the wound is required. Figure 5.
results in optimum holding power of the incision, better Sutures that are placed at a more ideal length will pro- should be unlocked before passing the suture. When ty- Suture Length and Spacing
long term stability, and a lower likelihood of cheese- vide good holding power at the incision while minimiz- ing nylon monofilament sutures, it is customary to tie
A. B. C.
wiring through the tissues. [ Figure 2 ] ing the number of sutures required for a given length interrupted sutures with three knots in a 3-1-1 manner: Suture
of incision. Overly long sutures tend to distribute the the first knot should be three throws, and the second
The entry angle of the suture plays a large role in de- closure force over too broad an area, and, as a result, and third knots should be one throw. These three knots The holding power is strongest under the sutur
termining the depth of the suture. Since needle creates they may give less effective holding power for the inci- are placed in alternating directions in order to create it decreases as you move futher away, distributi
a circular path, acute angles of less than 90 degrees re- sion. [ Figure 5 ]. square knots. Sutures placed in the cornea can then short forcesideal
in a diamond shape.
long
sult in shallow passes, and obtuse angles of more than typically be rotated so that the knots are buried within (A) Short sutures distribute their force over a smaller area, and
90 degrees result in deeper passes. If the needle entry Suture placement in clear corneal incisions should be the corneal stroma, which aids in patient comfort while therefore more suturesFigure 5.to close the incision.
are requird
(B) The ideal balance of suture length and spacing, where the
angle is 90 degrees, then the circular path of the needle radial, much like the spokes of a bicycle wheel. The helping to prevent unraveling of the knots. Suture
forces provide good holding powerLength andincision.
for the entire Spacing
will result in a depth equal to the radius of curvature of needle should be grasped at about one-third the distance (C) An overly long suture may distribute the forces over too
large an area and therefore give less effective holding power
the needle. [ Figure 3 ] from the swaged end to the point, and the needle-holder Placing a suture with good depth, symmetry, spacing, for the incision. A. B. C.

52 • WORLD REPORT CME SERIES phaco fundamentals • 53

LESSON 24
Post-op Medications
& Follow-up
After routine phacoemulsification surgery,
the two primary concerns are resolution of the surgically
induced inflammation and prevention of infection. The patient’s
comfort and return of sharp vision are also dependent on a
successful post-op course and recovery.
T
o prevent the dreaded complication of endo-
phthalmitis, topical antibiotics are often pre-
scribed during the immediate post-op period.
The most commonly used topical antibiotics have
broad-spectrum coverage, such as the case with fluoro-
quinolones, and they are administered before surgery
and then for the first week or so after surgery.
To ensure optimum patient recovery of good, clear
vision, the inflammation must be controlled with po-
tent topical medications such as corticosteroids and
NSAIDs (non-steroidal anti-inflammatory drugs). The
most commonly prescribed corticosteroids are pred-
nisolone acetate and dexamethasone, which are dosed
for at least 2 weeks after surgery, and sometimes for
as long as 8 week after more complex cases. While
the steroids are efficacious at reducing the inflamma-
tion, they can induce a glaucomatous state as a side
effect. The intra-ocular pressures should be monitored
in post-op patients to ensure that this does not hap-
pen. NSAIDs are also a useful adjunct to steroids since
they can help reduce inflammation further, offer pain
relief, and help to prevent the development of cystoid
macular edema.
54 • WORLD REPORT CME SERIES
The routine post-op care of phacoemulsification pa-
tients involves seeing them the day after surgery to
monitor the initial healing response. On post-op day
1, the incisions should be sealed and water-tight, the
anterior chamber should be deep and formed, and the
IOL should be in good position. The intra-ocular pres-
sure should be normal to mildly elevated. A high intra-
ocular pressure typically indicates that some residual
viscoelastic was left in the eye at the end of the case
and should be treated with topical or oral IOP-lower-
ing medications. The vision on post-op day 1 is depen-
dent on the clarity of the cornea—the less ultrasound
energy that was placed in the eye, the clearer the cor-
nea and the better the vision. Most cases of corneal
edema will resolve within a few weeks.
The patients are typically seen again at post-op week
1 or 2, at which point the vision should be better, the
inflammation should be less, and the patient should be
happy with the surgical result. IOP is monitored to make
sure that it is within normal range, and the antibiotic
medication can be stopped. The next visit will be at ap-
proximately 4-6 weeks after surgery, where the retina
can be checked for any macular or peripheral lesions.
Course Summary
We are truly fortunate
to be ophthalmologists
—it’s rewarding and challenging to perform
complex microsurgery to restore the gift of
sight to our patients, and it’s a pleasure to
put the technical art and science of surgery
into practice. I’m sure that many others share
my passion and pride, and I hope that we can
spread it to future generations – to the people
who will one day perform cataract surgery on
our eyes.
This 24 part series can serve as a good foun-
dation for the principles of phacoemulsification
surgery for ophthalmologists. It takes years of
practice and scores of cases to become profi-
cient at phaco, and a lifetime to truly master
it. I encourage you to pursue further training,
studies, and mentoring in cataract surgery and
to truly enjoy the process. I would like to thank
the people who have worked so hard to put
this project together, including Mridula Chettri
Singh and her team, Bausch & Lomb for their
support, and the other important people behind
the scenes that have made this idea a success.
- Uday Devgan, MD, FACS
Los Angeles, California, USA
phaco fundamentals • 55
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Global editorial board Chief Medical Editor, India Edition Dr. P. Namperumalsamy, MD Chief Medical Editor, China Edition Dr. Zhang Kang, MD, PhD Executive Editors Dr. Rajvardhan Azad, MD
• Dr. Robert Gale Martin, MD • Dr. He Wei, MD Senior Advisory Board Dr. Ge Jian, MD • Dr. Lingam Gopal, MD • Dr. Kulin Kothari, MD • Dr. Li Xiaoxin, MD • Dr. Gullapalli N. Rao, MD • Dr. Xie
Lixin, MD Consulting Editor Shashi Kapoor, MD Global Column Editors Cataract Dr. Debasish Bhattacharya, MS • Dr. Mahipal Sachdev, MD • Dr. Ye Zilong, MD Retina Dr. Manish Nagpal, MS
• Dr. Biju Raju, MS • Dr. Tang Shibo, MD Refractive Dr. Lu Wenxiu, MD • Dr. D. Ramamurthy, MD Cornea Dr. Rajesh Fogla, DNB, FRCS • Dr. Liu Zuguo, MD Dr. Sheng Minjie, MD Glaucoma Dr.
Tanuj Dada,MD • Dr. He Mingguang, MD Occuloplasty/ Ophthalmic Education Dr. A.K. Grover, MD Uvea Dr. Vishali Gupta, MD • Dr. Yang Peizeng, MD Orbit/Oncology Dr. Santosh Honavar, MD
Medical Ophthalmology Dr. Mallika Goyal, MS Neuro Ophthalmology Dr. Satya Karna, DO, DNB Contributing Editors Dr. Au Eong Kah-Guan, MD • Dr. David F. Chang, MD • Dr. Debraj Shome,
DO, DNB • Dr. Gaurav Shah, MD • Dr. Geoffrey Tabin, MD • Dr. Sanghamitra Burman, MD • Dr. Parijat Chandra, MD • Dr. J.E. McDonald, MD • Dr. John S.M. Chang, MD • Dr. Luther Fry, MD • Dr.
R. Ramakrishnan, MD • Dr. Y. Ralph Chu, MD • Dr. Rohit Saxena, MD • Dr. Rishi Swarup, MD • Dr. Savari Desai, MD • Dr. Suhas Haldipurkar, MD • Dr. Seenu Hariprasad, MD • Dr. Uday Devgan,
MD • Dr. Usha Raman, PhD • Dr. Zhang Zhenping, MD Editorial Editorial Director Jeffrey K. Parker Managing Editor, India Edition Mridula Chettri Singh International Editor Larry Schuster
News and Supplements Editor Stephanie Schweimnitz Assistant Managing Editor, China Edition Anny Xiao Editors Dr. Hao Xiaojun • Chelsea Zhao Publishing &Advertising Group Publisher
Grant J. Prigge gjprigge@ilxmedia.com +86 21 6359 3631 X 888 Business Development Director Jaideep Bajaj jaideep@ilxmedia.com +91 98101 83544 Group News Editor Lea Zang CME
Specialist Steven Tresker News Reporter Myra Colis Copy Editor Yang Li Art Direction, India Seoyoung Kang. skang@ilxmedia.com Circulation Associate Eunice Zhang

Published By ILX MEDIA GROUP

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56 • WORLD REPORT CME SERIES